Chapter 3: Health
3.3.11 Births to Women Lacking Adequate Prenatal
Care
Definition
Births to women lacking adequate prenatal care are those births in which the mother did not obtain medical consultation prior to the last three months of the pregnancy. Rates are calculated per every 1,000 live births.
Findings
The rate of births to women lacking adequate prenatal care in New Hampshire has been cut in half over the past ten years, falling from 29.8 per 1,000 live births in 1987 to 14.6 per 1,000 in 1997.
Women who do not obtain adequate care are not distributed uniformly in the state’s population. Figure 3-1 plots the rates of these births for Cluster 1 and Cluster 5 and the state average. For each of the three plots a linear trend line has also been plotted and highlighted.1
The figure shows that:
ü the rate of inadequate care was three to four times higher in the poorer communities than in the wealthiest cluster;
ü the decline in the rate of births lacking adequate care has been greatest in the poorer communities;
ü the bulk of the decline in the poorest communities occurred between 1989 and 1992, years when Medicaid eligibility was being expanded to higher family income levels.2 For example, in the poorest cluster, the rate fell 64% between 1986 and 1997, three quarters of which occurred in the 1989-1992 period.
Figure 3-1
Significance
Tracking births to women lacking inadequate prenatal care provides insight in two critical areas: health risks to infants and children lacking health insurance.
It is well documented that women who receive early
prenatal care have fewer complications and their children have fewer health
risks.[19] late or no
prenatal care face increased risk of complications at birth. The children of women who receive late or no
prenatal care face a higher chance of low birth weight and death in
the first year of life.3 The decline in women lacking adequate
prenatal care is encouraging -- as is the news that the expansion of Medicaid
eligibility hasappears to have positively impacted this
indicator of child well -being.
But what about those women who still lack
adequate prenatal care.care? We know that the children of these mothers
are more likely to lack health insurance.4 According to a recent survey by the Department
of Health and Human Services, 25,000 children in New Hampshire lack health
insurance.5
While this information provides insight into the scope of the problem,
it does not allow analysis of the problem at a community level. Analysis of births to mothers lacking
adequate prenatal care provides a proxy by which to gauge likely uninsured
children on a community level. The fact
that the rate of inadequate prenatal care was three to four times higher in the
poorer communities than in the wealthiest cluster suggests a similar ratio in
the lack of health insurance for children in different communities.
Attention to this trend is necessary in light of what we know about the importance of health insurance for children. Lack of health insurance can result in untreated illnesses, lack of timely immunizations, untreated developmental disorders, or undetected mental illness. One recent study found that uninsured children were 25% more likely to miss school than children with health insurance, and we know that missing school contributes to higher truancy and school failure.6
The Children's Agenda 2000 calls for a
reduction in barriers to health care coverage.
An estimated 74% of the uninsured children in this
state are eligible for, but not enrolled in, state- sponsored
health insurance.7 Increased
outreach and barrier reduction efforts are needed to assure these children
appropriate access to and use of preventive and primary health care services.
Bullets:
· The rate of births to women lacking adequate prenatal care in New Hampshire has been cut in half over the past ten years.
·
The recent decline in the rate of births to women
lacking adequate prenatal care occurred during a period in which the state
greatly expanded eligibility for Medicaid-paid health services for the working
poor. It appears that this expansion of Medicaid had a significant positive
impact with respect to access to prenatal care, especially in the state’s
poorest communities.
3.2 Low Birthweight Infants
Definition
Births by
payment source is the count
(and percentage) of births by source of expected payment for the costs of
delivery.[20]
Findings
There are no complete measures of the number of
children who are covered by private health insurance, who are covered by public
funds such as Medicaid, or who lack all health coverage.[21]
Children whose birth is not covered by health insurance are unlikely to be
covered by such insurance in their early years while children whose birth costs
are covered by private insurance or Medicaid are likely to have such coverage
pay for their subsequent health care costs. Thus, the source of payment for
childbirth is a useful predictor of insurance coverage for infants and
toddlers.
We investigated the source of payment for the
medical costs of pre-natal care and delivery for a total of 40,983 births from
1995 through 1997.[22]
One out of every three births in the poorest cluster of communities is paid for
by Medicaid, a rate that is 5 times higher than in the wealthiest cluster. Blue
Cross[23]
seems to be insuring about the same percentage of mothers in each of the five
clusters. However, other health
maintenance organizations (HMOs) appear to be insuring more in the wealthier
communities.
A slightly higher percentage of births are
"self-pay" in the poorest communities than in the wealthiest.. It may
be due to lack of ability to pay for insurance coverage in these communities.
Thus self-pay and Medicaid could both be viewed as options for those who cannot
afford to purchase health insurance.
Finally, There is a strong relationship between the
"unknown" category and the economic well-being of communities. In the
wealthiest communities, 18% of births have "unknown" payment sources
but this is true of only 4% in the poorest communities.
Figure
3-4[24]
Significance
There appears to be a relationship between the
wealth of a community and whether deliveries are paid by private insurers,
including HMOs, or public insurance programs.
The data raises a question whether the lower rate of HMO insurance in
poorer communities is related to the types of employers in those communities or
whether it reflects a purposeful decision by HMOs not to sell their product in
poorer communities. Attention needs to
be paid to these figures and tracked over time to gage the impact of the
changing health insurance market in New Hampshire.
3.3 Low Birth Weight Babies
Definition
Low birthweight babiesinfants
counts births in which the infant weighed 2,500 grams (5.5 pounds) or less.
Rates are calculated per every 1,000 live births.
Findings
In New Hampshire, the incidence of low birthweight babies has been falling over the last 27 years. Figure 3-2 shows the steady decline in this indicator:8
Figure 3-2
Significance
An infant who is born weighing under 2,500 grams may be at
immediate risk of serious health and developmental complications.[25]
complications.9 Such babies are 20 times more likely to die as
infants than babies of normal birthweight.10 For low
birthweight babies who survive to the middle school years, they are 50% more
likely to require special education than their peers who were of normal birthweight.11
The incidence of low birthweight infants has always been relatively equally distributed among the economic clusters compared to inadequate prenatal care.12 The decline has been general across the clusters, and there appears to have been no discernible effect from the expansion of Medicaid eligibility in the early 1990s.
3.43.3 Births to Teen Mothers
Definition
Births to teen mothers counts births in which the mother was 19 years old or younger. Rates are calculated per every 1,000 live births.
Findings
Births to teen mothers declined statewide by 46% between 1973 and 1997, from a rate of 145.7 per thousand to a rate of 78.1 per thousand. The period of decline, however, ended in about 1992. Since that time, the percentage of births to teenage mothers has begun to inch back upward. By 1997, it was nearly 10 per thousand higher than it was in 1992, as seen in Figure 3-3.14
A strong relationship exists between births to teenagers and community economics. In 1973, at the beginning of this time series, the rate of births to teen mothers in the poorest cluster was a little more than double that in the wealthiest cluster. In the generation between 1973 and 1997, the rate had fallen 63% in the wealthiest communities and only 28% in the poorest communities, with the result that rates in the poorest communities are now more than four times those in the wealthiest communities. Further, the rate in 1997 in the poorest communities was still well above that in the wealthiest communities in 1973, a whole generation ago. This is consistent with national trends. In the United States, 83% of all births to teens occur in poor and low-income families.15
Figure 3-3
Significance
Births
to teen mothers pose a risk to both mother and child.
Ø
A teen mother faces an above
average risk of complications in pregnancy, ranging from toxemia to cervical
trauma, to premature delivery. After
birth, teen mothers face diminished economic opportunities. Seven out of ten teen mothers drop out of
high school. During their first
thirteen years of parenthood, teen mothers earn an average of $5,600 per
year -- less than 50% of the federal
poverty threshold.16
Ø
Children born to teens are
less likely to receive adequate prenatal care.
These children are more likely to experience poor health, poverty, and
school failure.17
The
recent rise in teen births is cause for alarm and a call to action. The remedy lies in targeted prevention
program.programs:
Ø
Prevention, because research
has shown that teenage pregnancy prevention
programs are effective in terms of service delivery and cost
effectiveness. For every tax dollar
spent on contraceptive services, taxpayers save about $4 that would otherwise
be required for support services and medical care.18
Ø
Targeted, because the
data reveal such striking differences among communities with respect to teen
birth rates. Educational and family
planning services need to be heavily targeted to communities with high teen
birth rates. Parenting education needs
to be available to all teen mothers.
Action recommended in the Children's Agenda 2000 includes: comprehensive health
education as an integral part of school curricula (kindergarten through high
school), support for community-based sexuality
education, and support for family education models that enhance
parent-teen communications.
Bullets
·
Poor academic
performance is a predictor of teen pregnancy.19
·
Births to teen mothers are
four times higher in the poorest communities than in the wealthiest ones.
·
Teen pregnancy may
perpetuate the cycle of poverty, as teen mothers are more likely
to drop out of school and to have reduced earning potential.
3.53.4 Substance Abuse
Definition
Substance abuse measures the percentage of youth (grades 9-12) who indicate they have used alcohol, tobacco, or illegal drugs during a specified period of time
Findings
In 1999, the NH Department of Education conducted a survey
among high school students (grades 9-12) regarding their behavior
risks.[26]risky behavior.20
Of 2,213 New Hampshire high school students who responded, 53% indicated
they had consumed alcohol within the past 30 days, 34% had smoked tobacco, 30%
had smoked marijuana, and 3% had used some form of cocaine during the same
period. The rates of ever having used these substances during their lifetimes
were 83%, 66%, 50%, and 10% respectively. These are shown in Figure 3-4.
Figure 3-4
Of 33 states surveyed in 1997, New
Hampshire ranked sixth highest for high school drinking. That figure contrasts sharply with our
ranking as the sixth lowest state nationwide for per capita expenditures on
alcohol and other drug services in the country.21
Significance
New Hampshire
must invest more resources into substance abuse prevention. The state has lagged behind other
states. In 1995, New Hampshire had the
6th lowest level of
overall per capita expenditures for alcohol and others drug services in the
country, a level unequal to the high volume of drug and alcohol problems in New
Hampshire.22New Hampshire needs to make a substantial
investment
in substance abuse prevention efforts and aggressively address the serious
challenge of drug and alcohol use by New Hampshire youth.
Prevention programs need to target children before
as well as during adolescence and focus on helping our youth develop critical
life skills and supportive relationships.26 Immediate action steps recommended in the Children's Agenda 2000 include:
Ø
Government agencies need to
identify and support best-practice models for in-school and community-based
substance abuse prevention programs, peer acceptance, and self-esteem programs.
Ø
Community-based substance
abuse support groups should be incorporated into the school setting.
Ø
Local businesses should consider ways to develop
mentoring and job-shadowing opportunities in their communities.
Ø
Local schools should encourage parental involvement.
Ø State government should make grants available to communities for violence prevention training.
Ø
State and local government should support after school
programming as a part of an adequate education.
Ø
Comprehensive health education, including information
on sexuality, drugs and alcohol, should be incorporated as an integral part of
school curricula, kindergarten through grade twelve.
3.63.5 Infant and Child Deaths
Definition
Infant deaths are the number of deaths among live-born children prior to their first birthday. The rate is calculated per 1,000 live births. Child deaths are the number of deaths among children age 0-18.
Findings
The infant death rate in New Hampshire has consistently
ranked among the lowest in the United States; in 1997, it was 4.4 per 1,000
live births. That compares to a
national rate in 1996 of 7.3 deaths per 1,000 births.23births.27
Indeed, New Hampshire's infant death rate ranks among the lowest in the
world as displayed in Table 3-1below.24.28
Table 3-1
|
|
Infant Deaths per 1,000 Live Births |
|
|
Japan |
4 |
|
|
New Hampshire, Germany, Iceland, Norway, Sweden |
5 |
|
|
Canada, Austria, Czech Republic, Finland, France, Netherlands, Australia, Switzerland |
6 |
|
|
United States, Belgium, Denmark, Ireland, United Kingdom |
7 |
|
The infant death rate has fallen over the most recent five years for which data is available, declining from 94 infant deaths in 1992 to 63 infant deaths in 1997. During that five-year period, total infant deaths were 484.
Figure 3-5
Although
socioeconomic status is often associated with higher infant mortality rates,29 our analysis of the infant death rate
over the most recent five-year period did not show a strong linkage between
economic conditions in the community and infant death rates, as set forth in
Figure 3-6.
Figure 3-6
New Hampshire’s low infant death rate is paralleled by a
child death rate lower than the national average in all age groupings as set
forth in Table 3-2below.25.30
Table 3-2
|
Deaths to Children Age 0-19, 1993-1997 |
||||
|
|
Count of Deaths |
Rate per 100,000 Children |
||
|
|
US |
NH |
US |
NH |
|
Age <1 |
151,291 |
396 |
770.9 |
534.8 |
|
Ages 1-4 |
31,708 |
74 |
40.5 |
23.7 |
|
Ages 5-9 |
18,870 |
52 |
19.7 |
12.2 |
|
Ages 10-14 |
23,239 |
87 |
24.7 |
20.9 |
|
Ages 15-19 |
74,305 |
179 |
81.9 |
48.6 |
|
Ages 0-19 |
299,413 |
788 |
79.1 |
49.3 |
As in infant deaths, we found no relationship between child deaths, certain causes of death, and economic conditions.
Significance
The absence of a correlation between infant or
child death rates and community economics contrasts sharply with the strong
relationship shown by certain birth risks to community.
Compared to
younger children,Both nationally and in New Hampshire,
adolescents have a much higher rate of mortality. Motormortality than
children (excluding infant deaths).
Nationwide, motor vehicle accidents are the leading cause of
adolescent mortality, followed by deaths from firearms and then suicide.26suicide.31 Alcohol and other drugs are major
factors in adolescent mortality caused by trauma. Nearly one-half of motor vehicle accidents and homicides among
adolescents, and 30% of adolescent suicides, are associated with the use of
alcohol and other drugs. Alcohol has
also been implicated in the majority of adolescent drownings, fire-related
deaths, and fatal falls.27
falls.32 The call for
increased investment in
We must have a
detailed analysis of reasons for mortality among our youth in the state and
then institute programs and policies that aim at prevention of needless deaths
of our young people.
substance abuse
prevention is supported by these sobering facts.
3.73.6 What
We Would Like to Know About Our Children's Health
Current data limitations preclude full analysis of a number
of topics critical to child health. The
following recommendations call for enhanced data collection by the Department
of Health and Human Services and the Department of Education. As the following
recommendations show, the state must expand its data collection, sample sizes
and analysis of existing data to better determine the current health status of
our children and to develop prevention programs in the future. While some important data exists at DHHS,
there are significant obstacles preventing its dissemination which we believe
must be overcome to attain a clearer picture of children's health in New
Hampshire.
Children without Health Insurance
Department of Health and Human
Services (DH&HS)
Access to health care is dependent in large part
upon health insurance. At the time of our data collection, only rough
estimates were available of the number of the state's children who lack health insurance. Since then, DH&HS
has completed amonumental scientific survey of health and health insurance issues.
We expect to see important data from that study that will increase knowledge of
this issue as it affects children. TheWe hope the
department should annuallywill update at least portions of the survey annually so
that trends in this critical area can be monitored closely.
KIDS COUNT New Hampshire would like to include a measure of the mental health of our children. However, detailed information on the number of children who receive mental health services-- such as breakdowns by age, gender, severity of need, duration of services, town of residence, age at first encounter, and diagnosis-- is not available at present. The Medicaid and mental health management information systems do not produce tallies, analyses, or reports of that type. The State's mental health program should be able to provide statistical information on the kinds of services it offers and provides to the state's children.
Data limitations with respect to children's health also affected our ability to report on other issues: child immunizations, lead poisoning, sexually transmitted diseases among teenagers, and obesity.
With respect to immunizations, only rough estimates of the numbers of children who do not receive necessary immunizations in New Hampshire exist at present. The National Immunization Survey-- a collaborative effort between the National Center for Health Statistics and the Centers for Disease Control and Prevention National Immunization Program-- collects information on the immunization coverage of children 19 months to 35 months of age across the United States. Because it is a national survey, the sample size in New Hampshire (about 420) results in only a rough estimate of 12-20% of toddlers lacking full immunization; it is inadequate to ascertain anything below the state level that might be used to target resources to communities most in need. DH&HS should work with the National Immunization survey to greatly expand the sample size in New Hampshire so that more useful data could be provided annually for following trends, setting state policy, and targeting public resources to ensure higher immunization levels.
With respect to lead poisoning, DH&HS collects information on all blood-lead-level tests done on children below the age of 12. Although DH&HS did provide KIDS COUNT New Hampshire with the total count of tests and children who tested positive for potentially dangerous levels of lead, it would not release information broken down by location such as town of residence. In 1999, an alarming 1 in 25 of children tested had blood lead levels indicative of learning problems. It would be useful, both for state policy-makers and for local health officials, to know the relative distribution of this problem.
Finally, with respect to sexually transmitted diseases (STDs) among teenagers, DH&HS provided statewide counts of STDs but was unwilling to provide a breakdown of this data on a town level. As with the information on lead poisoning, the data have been collected and are in the hands of the State, but are not being released for use in public policy research.
Department of Education
SubstanceAbuse
abuse is a serious threat to the health of children and families. The Youth Behavior Risk Survey of the Department of Education has collected and published aggregate tabulations on alcohol, tobacco, and drug use among some high school students. But the students were not a true random selection and it is impossible to use the results to project them to the total population of NH high school students. This type of study should be regularly repeated, but it should be conducted on either a universal or scientific sampling basis so that the results can actually be used to make year-to-year comparisons and to compare the behavior of NH students to national averages. A universal survey of all students would allow each local community to ascertain the trends and conditions among its own teens and would, therefore, be preferable. Also, if other characteristics of the students were collected at the same time, it would be possible to do cross-tabulations that would allow specific "at risk" groups to be better identified.
Obesity among children is a significant
and growing national health concern. There is no centrally collected data on
the incidence of this problem in New Hampshire. However, hundreds of school
nurses all over the state have height and weight measurements of children,
especially in elementary schools, that could be used to determine obesity
rates. If the nurses would compile this information at each school and submit
it to a central location on an annual basis, the degree to which obesity is a
public health problem affecting children in New Hampshire could be assessed and
addressed.