A.6

Prototype Indicator Set: Infant Health

BACKGROUND

During childhood, infancy is the most vulnerable period. Important determinants of infant health operate even before a child is conceived. A woman's general health, her socioeconomic and family circumstances, and her intentions regarding pregnancy all influence the health of the children she bears. During pregnancy, maternal health, nutrition, lifestyle, and socioeconomic and physical environments have an even more immediate influence on infant health. Once children are born, their healthy physical and psychosocial development continues to be subject to a variety of influences.

The most widely used indicator of infant health is the infant mortality rate: deaths of children less than 1 year of age per 1,000 live births. In the United States in 1993, the infant mortality rate was 8.4 (Gardner and Hudson, 1996). Most infant deaths occur in the neonatal period (within 28 days of birth), and low birth weight infants—those weighing less than 2,500 grams (5 pounds, 8 ounces)—are at greatest risk (McCormick, 1985; Paneth, 1995). The risk of death is especially high for infants born weighing less than 1,500 grams (3 pounds, 5 ounces). Low birth weight is also associated with increased risk of long-term health impairments (Hack et al., 1995). Thus, prevention of low birth weight is an important goal. The target set by Healthy People



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring A.6 Prototype Indicator Set: Infant Health BACKGROUND During childhood, infancy is the most vulnerable period. Important determinants of infant health operate even before a child is conceived. A woman's general health, her socioeconomic and family circumstances, and her intentions regarding pregnancy all influence the health of the children she bears. During pregnancy, maternal health, nutrition, lifestyle, and socioeconomic and physical environments have an even more immediate influence on infant health. Once children are born, their healthy physical and psychosocial development continues to be subject to a variety of influences. The most widely used indicator of infant health is the infant mortality rate: deaths of children less than 1 year of age per 1,000 live births. In the United States in 1993, the infant mortality rate was 8.4 (Gardner and Hudson, 1996). Most infant deaths occur in the neonatal period (within 28 days of birth), and low birth weight infants—those weighing less than 2,500 grams (5 pounds, 8 ounces)—are at greatest risk (McCormick, 1985; Paneth, 1995). The risk of death is especially high for infants born weighing less than 1,500 grams (3 pounds, 5 ounces). Low birth weight is also associated with increased risk of long-term health impairments (Hack et al., 1995). Thus, prevention of low birth weight is an important goal. The target set by Healthy People

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring 2000 is for a low-birth weight rate of no more than 5 percent of live births (USDHHS, 1991). In the United States, 7.3 percent of babies born in 1994 weighed less than 2,500 grams, and about 1.3 percent weighed less than 1,500 grams (Ventura et al., 1996). The incidence of low birth weight varies by race and ethnicity. Among African Americans, 13.2 percent of infants born in 1994 weighed less than 2,500 grams. In addition, factors such as poverty, lower levels of maternal education, unintended pregnancy, and delayed prenatal care are associated with increased rates of low birth weight (Hughes and Simpson, 1995). Many low birth weight infants require costly medical care. An estimate for 1988 (which does not capture the impact of new technologies) suggests added medical care costs of $15,000 per low birth weight infant during the first year of life (Lewit et al., 1995). Low birth weight can occur because of an early, preterm birth or slow growth during a normal period of gestation (Paneth, 1995). Steps such as cessation of maternal smoking and adequate maternal nutrition have been shown to reduce the risk of slow fetal growth (USDHEW, 1973; IOM, 1990). The risk of mortality is higher for preterm births, but evidence for interventions that can reduce their occurrence is mixed (Paneth, 1995). Some evidence suggests that vaginal or intrauterine infections may be contributing to preterm births (Fiscella, 1996; Goldenberg and Andrews, 1996). Early and continuing prenatal care can help identify risks for low birth weight and may help ensure that both mothers and infants receive care that can improve survival even if low birth weight cannot be averted (Alexander and Korenbrot, 1995). Prenatal care can also provide benefits to mothers and infants that do not translate into changes in birth weight. After the neonatal period, infant health is influenced strongly by family resources. A loving and caring home with educated parents makes an important contribution to healthy infant development and, therefore, future capacity to become a well-functioning adult (Carnegie Task Force on Meeting the Needs of Young Children, 1994). Among factors affecting physical health, injury is a leading preventable cause of mortality and morbidity. Parental knowledge of and attention to injury prevention have documented benefits for children (Bass et al., 1993; Gielen et al., 1995). Immunization also is a well-recognized means of protecting health and is a marker for adequate use of well child care (Rodewald et al., 1995). Promoting healthy psychosocial development is also important. For example, factors influencing the home environ-

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring ment, such as increased parental workforce participation that creates a need for nonparental child care, can have important consequences for infant well-being. Children are the future of a community, and their well-being depends on a variety of factors. Protecting and improving infant health is a complex task that involves individual families plus health care, public health programs, and social programs that support families. Communities may also want to address factors such as educational attainment and employment of parents. Coordination of these various efforts can encourage optimal use of resources on behalf of infants. ''FIELD" SET OF PERFORMANCE INDICATORS Each of the domains of the health field model addresses relevant determinants of infant health, many of which suggest specific health improvement interventions. These domains can be used to organize a field set of potential performance indicators for community efforts to protect and improve infant health. Although some of the proposed indicators address concerns that are not easily operationalized as quantitative measures, they help illustrate issues that might benefit from additional effort to develop suitable measures or data sources. Disease Leading causes of death during the neonatal period (within 28 days of birth) are congenital anomalies, respiratory distress syndrome, consequences of preterm birth, and effects of maternal complications. In the postneonatal period (28 days to 1 year of age), the principal causes of death are sudden infant death syndrome (SIDS), congenital anomalies, injury, and infection (USDHHS, 1991). In the United States in 1993, the neonatal mortality rate was 5.3 deaths per 1,000 live births and the post-neonatal rate was 3.1 (Gardner and Hudson, 1996). Disease influences infant health directly and through its impact on the health of the mother before, during, and after pregnancy. Maternal conditions that pose particular risks for infant health include hypertension and diabetes (either preexisting or emerging during pregnancy), vaginal infection, and preeclampsia (CDC, 1993; Ananth et al., 1995; McGregor et al., 1995). Conditions such as these can lead to preterm delivery and to intrapartum fetal distress. Early detection and careful management of

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring these diseases before and during pregnancy can reduce their negative effects. The adverse effect of some maternal infections (e.g., HIV, hepatitis B, group B streptococcus) occurs with their transmission to infants before or during birth. In some cases, treatment of the mother or early treatment of the infant can reduce these adverse effects. When preterm delivery cannot be prevented, infants are at increased risk for a variety of conditions including respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Improved treatment has increased survival, but treatment itself carries risks for conditions such as bronchopulmonary dysplasia and retinopathy of prematurity (Horbar and Lucey, 1995). Although proper management of these conditions in the appropriate intensive care nursery setting can improve outcomes, these infants are at greater risk than full-term, normal weight infants for neurologic and other impairments at later ages. The most significant diseases after the first month of life are infections of various sorts. Appropriate immunization provides protection against conditions such as diphtheria, tetanus, pertussis, polio, hepatitis B, and Haemophilus influenzae type b disease. Effective therapies are available to treat many other infections such as otitis media, pneumonia, and gastroenteritis. Infants in group day care have a higher incidence of common respiratory and gastrointestinal infections compared with babies not in day care settings. The causes of SIDS are not fully understood, but evidence suggests that placing infants on their back or side to sleep, not on their stomach, may reduce its incidence (Willinger, 1995). Indicators that might be considered include the following: Number (or rate) of neonatal infant deaths. Number (or rate) of postneonatal deaths. Infant deaths are widely used as an indicator of infant health. Although some deaths are due to injuries rather than disease and to factors for which preventive interventions are not presently available (e.g., congenital anomalies), changes in the number of deaths relative to the number of births may help a community determine whether conditions affecting infant health are improving or worsening. The overall infant mortality rate is included in the community health profile indicators proposed by the committee (see Chapter 5). Examining early and later infant deaths separately makes it easier to assess the differing factors that operate in these periods. In many communities, the number of deaths

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring will be small, making it necessary to aggregate data over multiple years to calculate stable rates. Percentage of babies born weighing less than 1,500 grams. Percentage of babies born weighing less than 1,000 grams. Low birth weight is a marker for high risk of death or serious morbidity in the near and longer term. Communities might also use these very low weight births as the basis for a review of factors in maternal health that could be contributing to preterm birth or slow fetal growth. Hospitalizations of pregnant women per 100 deliveries. Healthy People 2000 uses this measure as an indicator of severe complications of pregnancy and has set a national target of no more than 15 such hospitalizations per 100 deliveries (USDHHS, 1991). This indicator is intended to reflect the extent of serious problems in maternal health that might contribute to infant health problems. Communities would hope to reduce such health problems, but for some women, hospitalization will represent the most appropriate form of care. A state's hospital discharge record system, which includes an indication of community of residence (e.g., zip code), would facilitate collecting information on hospitalizations outside a given community. Hospitalizations of infants for illness during the postneonatal period. Hospitalizations of infants 28 days to 1 year of age would be an indicator of severe illness among infants in a community. A rate might be based on the number of hospitalizations per 1,000 births. Data for multiple years may be needed to have enough cases to calculate a stable rate. Individual Response An infant's response to its environment will have some influence on its health, but a much greater influence will be the behavior and responses of others. A mother's behavior and lifestyle will be of particular importance because of the close biological linkage of pregnancy and the traditionally dominant role of the mother in child care. Fathers and other family members, as well as care givers in settings such as day care, will also have an influence. Good maternal nutrition before and during pregnancy plays an important role in promoting proper fetal growth (IOM, 1990),

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring and consumption of appropriate nutrients appears to lessen the risk of some birth defects (e.g., adequate levels of folic acid may reduce the risk of neural tube defects). Smoking has been linked to 20–30 percent of low-weight births (primarily through growth retardation) and also increases the risk of fetal and infant death (Kleinman and Madans, 1985). Exposure to environmental tobacco smoke increases the risk of respiratory and ear infections in infants and may increase the risk of SIDS (EPA, 1992). Heavy alcohol use during pregnancy can result in physical and mental impairments, which are labeled fetal alcohol syndrome in their most severe form (IOM, 1996), and alcohol abuse among adults can lead to behavioral problems that pose a health risk for infants in their care. Other substance abuse can affect maternal health before pregnancy, fetal health during pregnancy, and infant health after birth (Chomitz et al., 1995). Exposure before or during pregnancy to intravenous drug use, multiple sexual partners, or continuing sexual partners with high risk for infection can increase the risk of acquiring infections such as HIV and various sexually transmitted diseases (STDs) that can endanger the health of the baby. A woman's contraceptive practices can contribute to success in avoiding an unintended pregnancy, which is associated with poorer outcomes for the baby (IOM, 1995). Nearly 60 percent of pregnancies are unintended, either mistimed or unwanted. Once pregnancy occurs, early use of prenatal care services and having at least half of the recommended number of prenatal visits are associated with lower rates of low birth weight (Kotelchuck, 1994) and may serve as a marker for other healthful practices (Alexander and Korenbrot, 1995). Following birth, breast feeding is associated with reduced infant illness, particularly in the first three to six months of life. Maternal employment has mixed implications for infant health. It can increase a family's economic resources and improve a mother's sense of well-being. At the same time, it generally creates a need for day care services, which can be costly or of questionable quality and may increase an infant's exposure to common infectious diseases. Within the family, child abuse or neglect and other forms of domestic violence also pose a threat to an infant's physical and psychological health, even if the baby is not the immediate victim. Indicators that might be considered include the following:

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Percentage of women giving birth who used tobacco during pregnancy. Percentage of women giving birth who used illicit drugs during pregnancy. Both smoking and illicit drug use during pregnancy contribute to slow fetal growth, but pregnant women can adopt (and be guided in adopting) more healthful behaviors. Smoking status is recorded on most states' birth certificates, and some states record the use of illicit drugs. Underreporting may, however, limit the accuracy of birth certificate data. A community focusing on infant health issues might make a special effort to collect the data needed for these indicators. Percentage of pregnant women who obtain first-trimester prenatal care. Early prenatal care gives women access to care and advice that can promote better birth outcomes, including detecting high-risk conditions that may require special attention. Individual decision making may have a greater influence on when prenatal care is started than on how many visits are made, which may reflect special health risks (many visits) or limited service (few visits), as well as individual behavior in seeking care. Whether prenatal care was initiated in the first trimester is generally recorded on the birth certificate. Percentage of new mothers who breast feed their babies for at least four weeks. Breast feeding provides infants with nutritional, immunologic, and psychosocial benefits. It also reduces the need to purchase or prepare formula for infants and therefore provides practical benefits to the family. Percentage of pregnancies identified as unintended. Unintended pregnancy is widespread and increases the health risks for the babies that are born (IOM, 1995). To reduce unintended pregnancy, women (and men) may need better information about family planning, better access to family planning services, and better skills in practicing family planning. Information on unintended pregnancy could help communities assess whether family planning services might be improved or whether specific services could be offered when unintended pregnancies have occurred.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Number of reported and number of substantiated cases of violence against pregnant women in the community. Number of reported and number of substantiated cases of child abuse and neglect for children under 1 year of age. Reporting and substantiation of cases are incomplete, but these data give an indication of the amount of family violence occurring in the community. In assessing changes over time in the numbers of cases, consideration must be given to whether they reflect true changes in the number of cases or changes in the completeness of reporting and substantiation of cases. Both issues should be important to the community. Changes in the numbers of infants and pregnant women in the community could also affect the apparent incidence of violence. Genetic Endowment The genetic endowment of the parents, as well as the infant, can affect infant health. Parental intelligence, ability, and health shape the environment into which the infant is conceived and born. Genetic factors play a role in some birth defects and also are responsible for disorders such as cystic fibrosis and sickle cell disease. These conditions range in severity from almost immediately fatal to having little impact on normal life span. Preconceptional counseling for couples with known genetic risks can guide decisions regarding pregnancy. Prenatal screening for conditions such as Down syndrome and neural tube defects can inform families that a serious disorder is likely, giving them an opportunity to prepare for the care that the child will need or to decide not to continue the pregnancy. Many states now have birth defects registries, and all states have neonatal screening programs for at least some important genetic defects for which early intervention can reduce morbidity and mortality. Among these conditions are phenylketonuria (PKU), hypothyroidism, galactosemia, and sickle cell disease. Other genetic diseases such as cystic fibrosis and Tay-Sachs disease can now be detected at very early ages, but treatment cannot yet fully prevent the morbidity. For many genetic disorders, infants who survive will have special health care needs throughout their lives. Indicators that might be considered include the following: Number and type of birth defects identified in children born during the previous year. A community might wish to monitor the number and types of

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring birth defects to determine whether specific risk factors can be identified and addressed. This information may also help determine the need for genetic counseling within the community. Particular attention should be focused on those birth defects that might be prevented through prenatal care or through control of toxic exposures. For example, instances of neural tube defects might suggest the need to improve folic acid supplementation before and during pregnancy. Evidence of fetal alcohol syndrome would support efforts to address alcohol abuse among women of childbearing age. Number of infants with conditions for which neonatal testing is possible but for which no routine screening is offered. Communities might monitor the incidence of these conditions to assess whether a screening program at the local or state level could be beneficial. With earlier discharge after delivery, there may also be a need to ensure that infants receive screening tests that are already offered and that follow-up after testing is appropriate, since early treatment can mitigate some adverse effects. Social Environment The social environment exerts a strong influence on infant health, especially through factors such as education, social networks, employment, and income. For both the pregnant woman and the infant, a nurturing family environment and broader social supports can improve health. Family, friends, health care providers, and outreach workers may be sources of this support. Ensuring that other infant caretakers, such as relatives and day care workers, have adequate social supports and nurturing environments is also important to infant health. General support in the community for the well-being of women and families sets the stage for a positive environment for infant health. Educational and employment opportunities for girls and women increase their capacity to provide for their infants. Maternal education has an enduring association with improved pregnancy outcomes and infant health. Employment policies shape opportunities for parental leave, as well as time available for prenatal care and for sick and well child care. Employment can create a need for day care services, and the quality of those services can have an effect on an infant's health. Day care can also create an economic burden. Poverty has been shown to have a distinct, adverse impact on infant health (CDC, 1995).

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Programs that address economic disadvantage have included Aid to Families with Dependent Children (AFDC),1 WIC (Special Supplemental Food Program for Women, Infants, and Children), and Medicaid. Changes in state and federal welfare programs that limit benefit periods and emphasize employment requirements will have an as yet undetermined impact on the financial resources available to families and on the demand for day care services. The cost and quality of those services may have implications for infant health. Many of the points discussed in the domain of individual response are part of an infant's social environment because parental behavior, in large measure, defines the social environment. In this regard, nutrition, smoking, domestic violence, and other behavioral factors influence the social environment. Indicators that might be considered include the following: Of pregnant women and women who have a child less than 1 year of age and who are eligible for AFDC, WIC, or related programs, percentage who are enrolled in those programs. Programs such as WIC and AFDC provide nutritional and income support to low-income families in the community. WIC participation has been associated with improved pregnancy outcomes (Mayer et al., 1992). Percentage of low-income pregnant adolescents served by home visiting programs. Percentage of families with preterm or low birth weight infants or with infants with chronic illness or disabilities served by home visiting programs. Programs addressed by these two indicators can provide a range of assistance that, for mothers or families at special risk, contributes to better pregnancy outcomes and better infant health (Olds and Kitzman, 1993). A community would want to ensure that programs are culturally appropriate for the families they serve. 1   In August 1996, as this report neared completion, federal legislation—the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104–193)—substantially modified many public assistance programs. Under this legislation, Aid to Families with Dependent Children (AFDC) is replaced by a new program designated Temporary Assistance to Needy Families (TANF).

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Percentage of mothers less than 18 years of age who are enrolled in school. Pregnancy during adolescence can interrupt a mother's completion of high school, which can have long-term adverse implications for her health and that of her child and for her economic opportunities in the future (Zill, 1996). In some communities, special child care services are available to help teenage mothers return to school. Percentage of children less than 1 year of age living in single-parent homes. In general, single-parent homes have more limited financial resources, which can make it more difficult to meet the needs of an infant. Therefore, the health of these children may be at special risk. Percentage of women with children less than 1 year of age who are employed outside the home. A mother's employment could have positive or negative implications for a child's health. Added financial resources might be beneficial but could be offset by the cost of day care services. Similarly, some mothers may find that employment improves their personal well-being and, therefore, their ability to care for their child; other women may find that the added stress of employment and requirements for day care are a negative influence on them and their infants. Percentage of employees who report that they can use paid leave for prenatal, well child, and sick child care. For parents of infants and other children, the availability of paid leave time for health care visits can encourage appropriate and timely use of services. Employee perceptions, in contrast to employer policies, may provide a more realistic assessment of the practical availability of paid leave. Percentage of employees with health insurance that covers at least 80 percent of the costs of prenatal care, delivery, and well child care. Health insurance can reduce financial barriers to care needed to promote good infant health. Some employers, however, may offer plans that provide limited coverage for these services or may not offer any coverage for employee's families.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Percentage of infants living in families below 200 percent of the poverty level. Families that are below the poverty level will have extremely limited financial resources for food, housing, and other essential aspects of daily living. For some families, assistance programs can mitigate some of the adverse effects of such limited financial resources. Even less extreme financial deprivation still poses a risk for infant health. Thus, communities might want to determine the proportion of infants in families with low but not poverty-level incomes. Health Care Many issues related to appropriate health care for mothers and infants have been alluded to above. Access to family planning services can help limit unintended pregnancy. Timely access to prenatal care services that include both suitable health behavior advice and prenatal care procedures has been shown to contribute to lower rates of low-weight births (Kogan et al., 1994; Kotelchuck, 1994). Guidance on the appropriate content of prenatal care can be provided by a source such as Caring for Our Future: The Content of Prenatal Care (U.S. Public Health Service, 1989). Many states and communities have established systems to screen pregnant women to ensure that high-risk pregnancies are cared for in facilities capable of dealing with problems that might arise. Mothers at high risk for delivering very low birth weight babies can be transferred to facilities with neonatal intensive care nursery services. The appropriate application of neonatal intensive care can improve survival for those babies born prematurely or with serious health problems. Neonatal screening programs, discussed above, are an important health care service for dealing with treatable congenital defects. Screening can also identify problems such as hearing impairments. In addition, access is needed to well child care, including immunizations, and to sick child care in the event of illness. Within well child care, support for breast feeding can affect the likelihood that mothers initiate and continue this healthful process. The content of infant health care can be guided by sources such as the American Academy of Pediatrics and Bright Futures (Green, 1994). Indicators that might be considered include the following:

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Percentage of women 15 to 45 years of age who can identify a regular source of health care. Women of reproductive age who do not have a regular source of health care may fail to receive preconceptional care that could promote a successful pregnancy and birth outcome. These women may also be more likely to delay the start of prenatal care or may have difficulty obtaining appropriate care during the course of their pregnancy. A mother's lack of a routine source of care might signal a risk that a routine source of infant care will not be established. Percentage of women 15 to 45 years of age who report access to affordable family planning services. This measure would reflect perceived availability of family planning services. Communities might want to examine ways to improve the availability of services to women who do not feel that they have access to them. Percentage of mothers who gave birth during the past year who received the number of prenatal visits recommended by the American College of Obstetricians and Gynecologists. This measure is similar to one proposed for inclusion in HEDIS 3.0 for Medicaid members (NCQA, 1996). The HEDIS measure adjusts the recommended number of visits downward if the initial prenatal visit is delayed or if an infant is born prematurely, both of which shorten the period during which visits could occur. Percentage of infants weighing less than 1,500 grams at birth who are born in facilities designated as Level II or III perinatal care centers. Such facilities have resources to provide specialized care for high-risk mothers and infants. Health care providers and hospitals should have procedures for identifying women at risk for low weight births and arranging for deliveries in appropriate facilities. Although it may not be possible for all such births to occur in Level II or III facilities, communities might want to examine whether the rate is as high as possible and address referral practices if it declines. HEDIS 3.0 (NCQA, 1996) proposes a measure of this type for Medicaid enrollees served by health plans. Percentage of 1-year-olds who have received all age-appropriate immunizations recommended by the Advisory Committee on Immunization Practices.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Provider practices play an important role in ensuring that children are up to date on recommended immunizations. The committee's community profile includes immunization rates at 2 years of age, the age by which the initial series of recommended immunizations should be completed. In fact, however, recommendations call for most of these immunizations to be administered by 1 year of age (CDC, 1996). Currently this includes three doses of diphtheria-tetanus-pertussis (DTP) vaccine; three doses of Haemophilus influenzae type b (Hib) vaccine; two or three doses of polio vaccine; and two or three doses of hepatitis B vaccine. Unless an immunization registry is operating, a specialized data collection process would be needed. Health and Function, Well-Being It is difficult to assess the well-being and functional status of an infant. Because infants cannot report on their status, assessments must be based on observation by others. Measures of growth and developmental progress can be used as proxies. Although most children are basically healthy, as many as 10 percent of all children have two or more chronic physical conditions, and emotional and developmental problems affect an additional portion of the child population (Newacheck and Taylor, 1992). Early developmental progress may not, however, predict longer-term outcomes. Interventions may compensate for early deficits or latent problems may emerge. An indicator that might be considered is 1. Percentage of 1-year-olds that have been identified as having a developmental delay, physical impairment, or chronic illness such as cystic fibrosis or kidney disease. These children should be receiving appropriate care to promote optimal physical and psychosocial development. Criteria to be used to identify these children would require further specification. SAMPLE INDICATOR SET From this range of possible indicators, a more limited set is proposed for community-level performance monitoring. Reducing infant deaths is likely to be a priority for every community, but they will be rare enough that the infant mortality rate will not be a reliable measure in most communities unless data are aggregated

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring over multiple years. Preventing or limiting long-term morbidity that has its origins in the prenatal or infant period is also likely to be a priority, and a variety of activities in the community could be expected to make contributions toward this end. For indicators that are adopted, communities will have to establish clear operational definitions and identify sources of relevant data. The committee proposes the following indicators. Percentage of babies born weighing less than 1,500 grams. Percentage of babies born weighing less than 1,000 grams. Low birth weight is a marker for increased risk of morbidity and mortality. It reflects the combined effect of a variety of factors including the mother's health and lifestyle, the infant's genetic endowment, socioeconomic circumstances, and the quality of prenatal health care services. Therefore, responsibility and accountability are diffused throughout the community. Data on birth weight would be available from birth certificates. State vital records systems should be able to provide information on the basis on a mother's place of residence rather than the location of the birth. In communities with small numbers of births, data should be aggregated over multiple years to produce a stable measurement. Of pregnant women and women who have a child less than 1 year of age and who are eligible for AFDC, WIC or related programs, percentage who are enrolled in those programs. Programs such as WIC and AFDC provide nutritional and income support to low income families in the community, which can benefit the health of pregnant women and their infants. These public assistance programs are a response by federal, state, and local governments to needs created by economic deprivation. Program records at the state or local level should be able to provide data on the number of enrollees and are likely to have methods of estimating the percentage of those eligible who are enrolled. Alternatively, a community survey could be used to collect information. Percentage of mothers less than 18 years of age who are enrolled in school. Since higher levels of education are associated with better health, communities may want to encourage adolescent mothers to complete high school. Schools can play a major role by providing child care and programs designed specifically to meet the

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring needs of mothers. A special community survey or follow-up program for teen births would probably be needed to obtain this information. Percentage of employees who report that they can use paid leave for prenatal, well child, and sick child care. With an increase in the proportion of infants with parents who work, employers have an important influence on access to necessary health care. Policies that provide paid leave time can reduce financial barriers to care that loss of paid work time might create. A community survey would probably be needed to obtain information from employees. A companion survey of employer policies might reveal discrepancies in the way policies are applied or the extent to which employees have been informed about those policies. Percentage of employees with health insurance that covers at least 80 percent of the costs of prenatal care, delivery, and well child care. Health insurance is another means of reducing financial barriers to appropriate health care. The terms of coverage reflect decisions by employers and insurers. This information would help communities determine the extent to which infants in families with working parents are, nevertheless, without insurance coverage because their family cannot afford available coverage or because employers do not offer it. A community survey or a survey of employers might be used to obtain this information. Percentage of smokers living in homes with pregnant women or children less than 1 year of age. Exposure to environmental tobacco smoke is an avoidable health risk for infants, even prenatally. Information on whether smokers live with pregnant women and small children can help a community formulate smoking cessation programs appropriate for that audience. This could include not only parents but also grandparents, siblings, and others. Health care providers might, for example, raise this issue with their patients. Data might be collected through special community-level sampling for a state survey for the Behavioral Risk Factor Surveillance System (BRFSS). Currently, the BRFSS includes questions on smoking, and it might be possible to add a question on household composition. Percentage of infants weighing less than 1,500 grams at

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring birth who are born in facilities designated as Level II or III perinatal care centers. Given current limitations in our understanding of how to prevent preterm (and therefore low-weight) births, it is important that high-risk births take place in facilities that can care for both the mother and the infant. Health care providers and hospitals play a primary role in directing women to appropriate facilities. With the development of a HEDIS 3.0 measure for Medicaid enrollees, health plans are likely to develop the capacity to provide this information. Other sources of data might be hospital discharge data systems. Percentage of 1-year-olds who have received all age-appropriate immunizations recommended by the Advisory Committee on Immunization Practices. The value of immunizations is clear, but currently few communities have a system to track immunizations or produce information that can help ensure that children are immunized on time. Recent data collection efforts have focused on the immunization status of 2-year-olds. Similar approaches might be used to obtain information on 1-year-olds. Because children can be immunized in many different places, it can be difficult to aggregate the information across a community to be sure every child is up to date. Some communities are developing immunization registries, which should make it possible to assess immunization status for any age group. Techniques being developed by health plans to produce HEDIS data for 2-year-olds could be adapted for 1-year-olds. Once systems are functioning, inadequately immunized children can be identified more easily and consistently, and responsibility for their immunization can be established and followed. Achieving improved immunization rates will require concerted cooperation across many segments of the community. The indicators selected to provide an overall tool for assessing efforts in a community to improve infant health are a small segment of what might be a very large collection. These indicators bring together measures of health risk (birth weight, environmental tobacco smoke, and immunization) and actions in the community that can help reduce health risks (assistance programs, school enrollment, paid leave, insurance coverage, and referral for delivery). These indicators address infant health both directly and through the health of mothers. They also address how various community stakeholders are

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring doing in providing prenatal and well infant care and setting reasonable policies at work to encourage the use of appropriate well infant and prenatal services. In addition, they point to a role for schools and social services in promoting the health of mothers and infants. Communities with specific infant health concerns or resources could find it useful to include indicators tailored to their particular circumstances. REFERENCES Alexander, G.R., and Korenbrot, C.C. 1995. The Role of Prenatal Care in Preventing Low Birth Weight. The Future of Children 5(1):103–121. Ananth, C.V., Peedicayil, A., and Savitz, D.A. 1995. Effect of Hypertensive Diseases in Pregnancy on Birthweight, Gestational Duration, and Small-for-Gestational-Age Births. Epidemiology 6:391–395. Bass, J.L., Christoffel, K.K., Widome, M., et al. 1993. Childhood Injury Prevention Counseling in Primary Care Settings: A Critical Review of the Literature. Pediatrics 92:544–550. Carnegie Task Force on Meeting the Needs of Young Children. 1994. Starting Points: Meeting the Needs of Our Youngest Children. New York: Carnegie Corporation of New York. CDC (Centers for Disease Control and Prevention). 1993. Prenatal Care and Pregnancies Complicated by Diabetes—U.S. Reporting Areas, 1989. Morbidity and Mortality Weekly Report 42:119–122. CDC. 1995. Poverty and Infant Mortality—United States, 1988. Morbidity and Mortality Weekly Report 44:922–927. CDC. 1996. Immunization Schedule—United States, January–June V 1996. Morbidity and Mortality Weekly Report 44:940–943. Chomitz, V.R., Cheung, L.W.Y., and Lieberman, E. 1995. The Role of Lifestyle in Preventing Low Birth Weight. The Future of Children 5(1):121–138. EPA (Environmental Protection Agency). 1992. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Pub. No. EPA-600/6-90/006F. Washington, D.C.: EPA, Office of Health and Environmental Assessment. Erdmann, T.C., Feldman, K.W., Rivara, F.P., Heimbach, D.M., and Wall, H.A. 1991. Tap Water Burn Prevention: The Effect of Legislation. Pediatrics 88:572–577. Fiscella, K. 1996. Racial Disparities in Preterm Births: The Role of Urogenital Infections. Public Health Reports 111:104–113. Gardner, P., and Hudson, B.L. 1996. Advance Report of Final Mortality Statistics, 1993. Monthly Vital Statistics Report 44 (No. 7, supplement). Hyattsville, Md.: National Center for Health Statistics. Gielen, A.C., Wilson, M.E., Faden, R.R., Wissow, L., and Harvilchuck, J.D. 1995. In-Home Injury Prevention Practices for Infants and Toddlers: the Role of Parental Beliefs, Barriers, and Housing Quality. Health Education Quarterly 22:85–95. Goldenberg, R.L., and Andrews, W.W. 1996. Intrauterine Infection and Why Preterm Prevention Programs Have Failed. American Journal of Public Health 86:781–783.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Green, M., ed. 1994. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health. Hack, M., Klein, N.K., and Taylor, H.G. 1995. Long-Term Developmental Outcomes of Low Birth Weight Infants. The Future of Children. V 5(1):177–196. Horbar, J.D., and Lucey, J.F. 1995. Evaluation of Neonatal Intensive Care Technologies. The Future of Children 5(1):139–161. Hughes, D., and Simpson, L. 1995. The Role of Social Change in Preventing Low Birth Weight . The Future of Children 5(1):87–120. IOM (Institute of Medicine). 1990. Nutrition During Pregnancy. Washington, D.C.: National Academy Press. IOM. 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. S.S. Brown and L. Eisenberg, eds. Washington, D.C.: National Academy Press. IOM. 1996. Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. K. Stratton, C. Howe, and F. Battaglia, eds. Washington, D.C.: National Academy Press. Kleinman, J., and Madans, J.H. 1985. The Effects of Maternal Smoking, Physical Stature, and Educational Attainment on the Incidence of Low Birth Weight. American Journal of Epidemiology 121:832–855. Kogan, M.D., Alexander, G.R., Kotelchuck, M., and Nagey, D.A. 1994. Relation of the Content of Prenatal Care to the Risk of Low Birth Weight: Maternal Reports of Health Behavior Advice and Initial Prenatal Care Procedures. Journal of the American Medical Association 271:1340–1345. Kotelchuck, M. 1994. The Adequacy of Prenatal Care Utilization Index: Its U.S. Distribution and Association with Low Birthweight. American Journal of Public Health 84:1486–1489. Lewit, E.M., Baker, L.S., Corman, H., and Shiono, P.H. 1995. The Direct Cost of Low Birth Weight. The Future of Children 5(1):35–56. Mayer, J.P., Emshoff, J.G., and Avruch, S. 1992. Health Promotion in Maternity Care. In A Pound of Prevention: The Case of Universal Maternity Care in the U.S. J.B. Kotch, C.H. Blakely, S.S. Brown, and F.Y. Wong, eds. Washington, D.C.: American Public Health Association. McCormick, M.C. 1985. The Contribution of Low Birth Weight to Infant Mortality and Childhood Morbidity. New England Journal of Medicine V 312:82–90. McGregor, J.A., French, J.I., Parker, R., et al. 1995. Prevention of Premature Birth by Screening and Treatment for Common Genital Tract Infections: Results of a Prospective Controlled Evaluation. American Journal of Obstetrics and Gynecology 173:157–167. NCQA (National Committee for Quality Assurance). 1996. HEDIS 3.0 Draft for Public Comment. Washington, D.C.: NCQA. Newacheck, P.W., and Taylor, W.R. 1992. Childhood Chronic Illness: Prevalence, Severity, and Impact. American Journal of Public Health V 82:364–371. Olds, D.L., and Kitzman, H. 1993. Review of Research on Home Visiting for Pregnant Women and Parents of Young Children. The Future of Children 3(3):53–92. Paneth, N. 1995. The Problem of Low Birth Weight. The Future of Children 5(1):19–34.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring Rodewald, L.E., Szilagyi, P.G., Shiuh, T., Humiston, S.G., LeBaron, C., and Hall, C.B. 1995. Is Underimmunization a Marker for Insufficient Utilization of Preventive and Primary Care? Archives of Pediatric and Adolescent Medicine 149:393–397. USDHEW (U.S. Department of Health, Education, and Welfare). 1973. The Health Consequences of Smoking. DHEW/HSM 73-8704. Washington, D.C.: USDHEW. USDHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . DHHS Pub. No. (PHS) 91-50212. Washington, D.C.: Office of the Assistant Secretary for Health. U.S. Public Health Service. 1989. Caring for Our Future: The Content of Prenatal Care. A Report of the Public Health Service Expert Panel on the Content of Prenatal Care. Washington, D.C.: U.S. Department of Health and Human Services. Ventura, S.J., Martin, J.A., Mathews, T.J., and Clarke, S.C. 1996. Advance Report of Final Natality Statistics, 1994. Monthly Vital Statistics Report 44 (No. 11, supplement). Hyattsville, Md.: National Center for Health Statistics. Willinger, M. 1995. SIDS Prevention. Pediatric Annals 24:358–364. Zill, N. 1996. Parental Schooling and Children's Health. Public Health Reports 111:34–43.

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring TABLE A.6-1 Field Model Mapping for Sample Indicator Set: Infant Health Field Model Domain Construct Sample Indicators Data Sources Stakeholders Disease Reduce low birth weight and its adverse effects Percentage of babies born weighing <1,500 grams Percentage of babies born weighing <1,000 grams Birth certificates, vital statistics Health care providers Health care plans State health agencies Local health agencies Community organizations Special health risk groups General public Social Environment Reduce the health impact of economic and nutritional deprivation Percentage of eligible women and infants enrolled in AFDC, WIC, or related programs Program records; community survey State health agencies Local health agencies Social service agencies Local government Special health risk groups   Encourage better education for adolescent mothers Percentage of mothers less than 18 years of age who are enrolled in school Community survey; program records Local government Education agencies, institutions Community organizations General public   Reduce workplace barriers to use of health care services Percentage of employees who report that they can use paid leave for prenatal, well child, and sick child care Community survey; employer survey and insurance licensing authority Local government Business, industry General public

OCR for page 276
Improving Health in the Community: A Role for Performance Monitoring   Reduce financial barriers to health care services Percentage of employees with health insurance that covers at least 80 percent of costs of prenatal care, delivery, and well child care Community survey; employer survey Health care plans Local government Business, industry General public Physical Environment Reduce exposure to environmental tobacco smoke Percentage of smokers living in homes with pregnant women or children <1 year of age Community survey General public Health Care Ensure access to specialty care for high-risk births Percentage of infants weighing <1,500 grams at birth born in facilities designated level II or III perinatal care centers Health plan records; hospital discharge records Health care providers Health care plans State health agencies Local health agencies Special health risk groups General public   Ensure timely preventive care Percentage of 1-year-olds who have received all recommended immunizations Immunization registry or medical charts Health care providers Health care plans State health agencies Local health agencies General public NOTE: AFDC, Aid to Families with Dependent Children; WIC, Special Supplemental Food Program for Women, Infants, and Children.