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Effect of Healthy Start on Infant Mortality and Birth Outcomes

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Effect of Healthy Start on Infant Mortality and Birth Outcomes Contract No.: 240-93-0050 MPR Reference No.: 8166-111 EFFECT OF HEALTHY START ON INFANT MORTALITY AND BIRTH OUTCOMES July 2000 Lorenzo Moreno Barbara Devaney Dexter Chu Melissa Seeley Submitted to: Submitted by: Health Resources and Services Administration Mathematica Policy Research, Inc. Parklawn Building, Room 14-36 P.O. Box 2393 5600 Fishers Lane Princeton, NJ 08543-2393 Rockville, Maryland 20857 (609) 799-3535 Project Officer: Project Director: Karen T. Raykovich Embry Howell ACKNOWLEDGMENTS The authors thank the following federal and state entities for providing the vital records for this report: C Alabama Department of Public Health C Baltimore City Department of Health C California Department of Health Services C District of Columbia State Center for Health Statistics C Illinois Department of Public Health C Indian Health Service (IHS), Public Health Service, U.S. Department of Health and Human Services C Indiana State Department of Health C Louisiana Department of Health and Hospitals C Massachusetts Department of Health and Hospitals C Michigan Department of Health C New York City Department of Health C Ohio Department of Health C Pennsylvania Department of Health C South Carolina Department of Health and Environmental Control The authors also thank Patricia Ciaccio, Roy Grisham, and Walter Brower of Mathematica Policy Research, Inc. for editing the report; and Cindy McClure, Marjorie Mitchell, and Jane Nelson of Mathematica Policy Research for producing it. iii CONTENTS Chapter Page EXECUTIVE SUMMARY ......................................... xi I INTRODUCTION .................................................1 A. PROGRAM BACKGROUND ....................................2 B. THE NATIONAL HEALTHY START EVALUATION ................5 II STUDY METHODOLOGY .........................................7 A. SELECTION OF COMPARISON AREAS ..........................7 1. Selection Process ............................................9 2. Comparison Areas Selected ...................................11 3. Comparability of Project and Comparison Areas ..................11 B. ANALYSIS VARIABLES ......................................14 C. ANALYSIS METHODS ........................................16 1. Data .....................................................19 2. Model Specification and Statistical Analysis .....................20 III EFFECTS OF HEALTHY START ...................................25 A. PRENATAL CARE ADEQUACY ................................25 1. Any Prenatal Care ..........................................26 2. Trimester When Prenatal Care Began ...........................26 3. Number of Prenatal Care Visits ................................28 4. Kotelchuck Index of Adequacy of Receipt of Prenatal Care and Its Components .........................................28 B. BIRTH OUTCOMES AND INFANT MORTALITY ..................32 1. Preterm Birth Rate ..........................................32 2. Low and Very Low Birthweight Rate ...........................34 3. Infant, Neonatal, and Postneonatal Mortality .....................34 v CONTENTS (continued) Chapter Page C. SUMMARY ..................................................41 IV SUMMARY AND CONCLUSIONS .................................43 REFERENCES ..................................................47 APPENDIX A: BIRTH OUTCOMES AND INFANT MORTALITY RATES: HEALTHY START PROJECT AREAS AND MATCHED COMPARISON AREAS, 1984 TO 1996 ........................A.1 APPENDIX B: ESTIMATES OF THE EFFECTS OF HEALTHY START ON PRENATAL CARE, BIRTH OUTCOMES, AND INFANT MORTALITY .......B.1 vi TABLES Table Page I.1 CHARACTERISTICS OF THE HEALTHY START PROJECT AREAS ........4 II.1 HEALTHY START PROJECT AREAS AND COMPARISON AREAS ........12 II.2 DEFINITION OF KEY OUTCOME VARIABLES ........................17 II.3 INDIVIDUAL CHARACTERISTICS THAT AFFECT INFANT MORTALITY AND RELATED BIRTH OUTCOMES .................................18 II.4 AVAILABILITY OF BIRTH AND INFANT DEATH FILES ................21 III.1 EFFECTS OF HEALTHY START ON PRENATAL CARE INITIATION AND NUMBER OF VISITS ..........................................27 III.2 EFFECTS OF HEALTHY START ON PRENATAL CARE ADEQUACY .....31 III.3 EFFECTS OF HEALTHY START ON LOW BIRTHWEIGHT RATE AND VERY LOW BIRTHWEIGHT RATE ..............................37 III.4 EFFECTS OF HEALTHY START ON NEONATAL AND POSTNEONATAL MORTALITY .....................................42 IV.1 SUMMARY OF OUTCOMES ANALYSIS RESULTS ....................44 vii FIGURES Figure Page II.1 COMPARABILITY OF PROJECT AND COMPARISON AREAS: INFANT MORTALITY RATE ........................................13 II.2 COMPARABILITY OF PROJECT AND COMPARISON AREAS: RACE/ETHNIC COMPOSITION ......................................15 III.1 ADEQUACY OF PRENATAL CARE UTILIZATION .....................30 III.2 PRETERM BIRTH RATE ............................................33 III.3 EFFECTS OF HEALTHY START ON PRETERM BIRTH RATE ............35 III.4 LOW BIRTHWEIGHT RATE AND VERY LOW BIRTHWEIGHT RATE .....36 III.5 INFANT MORTALITY RATE ........................................39 III.6 EFFECTS OF HEALTHY START ON INFANT MORTALITY ..............40 ix EXECUTIVE SUMMARY The Healthy Start program is a major initiative to reduce infant mortality and improve maternal and infant health status in communities with high infant death rates. In fall 1991, the Health Resources and Services Administration selected 13 urban areas and 2 rural areas as Healthy Start grantees to implement a five-year demonstration of community-based approaches to reducing infant mortality. The demonstration was extended through 1997, and, in fiscal year 1999, 94 projects in total received Healthy Start funding. This report presents findings on the effects of Healthy Start on prenatal care utilization, key birth outcomes, and infant mortality in the 15 original project areas through 1996--the period of full implementation of the Healthy Start demonstration. The principal findings from the analysis of the effects of Healthy Start on birth outcomes and infant mortality are: C Prenatal Care Utilization: Healthy Start is associated with significant improvements in many of the outcome measures for prenatal care utilization. - In 8 of the 15 project areas, Healthy Start is associated with improved adequacy of prenatal care utilization: Baltimore, Birmingham, Chicago, New Orleans, New York City, Northern Plains, Oakland, and Philadelphia. - Healthy Start is associated with increases in the adequacy of prenatal care initiation in 4 of the 15 project areas: Birmingham, New Orleans, New York City, and Philadelphia. - Healthy Start is associated with improved adequacy of the number of prenatal care visits in 9 of the 15 project areas: Baltimore, Birmingham, Boston, Chicago, New Orleans, New York City, Northern Plains, Oakland, and Philadelphia. - Three project areas--New Orleans, New York City, and Philadelphia--show improvements in all measures of prenatal care as a result of Healthy Start. C Preterm Rate: Four project areas have statistically significant declines in the percentage of infants born less than 37 weeks gestation: Birmingham, New Orleans, Oakland, and Philadelphia. C Low Birthweight: Three project areas have statistically significant reductions in the percentage of infants with birthweight less than 2,500 grams: Birmingham, Detroit, and the District of Columbia. xi C Very Low Birthweight: In Birmingham, Boston, and Pittsburgh, Healthy Start is associated with a statistically significant reduction in the percentage of infants with birthweight less than 1,500 grams. C Infant Mortality Rate: In two project areas, New Orleans and Pittsburgh, Healthy Start is related to a statistically significant decline in the number of infant deaths per thousand live births. For Birmingham and Oakland, Healthy Start is associated with fairly large, but not quite statistically significant, declines in infant mortality (4.3 and 2.1 infant deaths per 1,000 live births, respectively). In summary, the Healthy Start program demonstrates improvements in several birth outcomes across the 15 original project areas and reductions in infant mortality in 2 project areas. Healthy Start is particularly successful at linking women and their families to prenatal care, as shown by improvements in the adequacy of prenatal care utilization in 8 of the 15 original project areas. xii I. INTRODUCTION Infant death is a tragedy for both families and communities. Fortunately, most infants--more than 99 percent of them--survive their first year of life. Nonetheless, with a rate of 7.1 infant deaths per 1,000 live births in 1997, the United States ranks 25th in the world, and significant disparities in infant mortality are found across communities and population subgroups (Ventura et al. 1998; National Center for Health Statistics 1998). Efforts to reduce infant mortality are important not only for reducing the number of deaths and eliminating these disparities, but also for improving the quality of life for those infants who survive. Healthy Start began as a major demonstration program sponsored by the Health Resources and Services Administration (HRSA) to reduce infant mortality by 50 percent over five years and to improve maternal and infant health in communities with high infant death rates. In fall 1991, HRSA chose 13 urban areas and 2 rural areas in which to implement a five-year demonstration of community-based approaches to reduce infant mortality. Since 1991, HRSA has continued to sponsor similar programs in other high-risk communities, reaching a total of 94 communities in 1999. However,
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