Healthy Start

Authorizing Legislation - Section 330H of the Public Health Service Act.

Program Description and Accomplishments
The Children’s Health Act of 2000 (P. L. 106-310) amended the Public Health Service Act to provide “such sums as necessary” for continuation and expansion of a distinct Healthy Start program of grants that use community-designed and evidence-supported strategies aimed at reducing infant mortality and improving perinatal outcomes in project areas with high annual rates of infant mortality.

In the United States each year, approximately six million women become pregnant. While most women have a safe pregnancy and deliver a healthy infant, that is not the experience for all women. Major and persistent racial and ethnic disparities exist in the proportion of pregnancy-related maternal death, in preterm birth, and in infant mortality. Despite considerable research efforts to understand and prevent these adverse outcomes, the factors that make some pregnancies more vulnerable than others have not been clearly defined. Emerging research indicates that environmental, biological and behavioral stressors occurring over the life span of the mother from her earliest life experiences until she delivers her own child may account for a significant portion of the disparities. Moreover, it may take specific interventions consistently provided to several generations before the factors responsible for the disparities in adverse birth outcomes have been overcome.

The interconceptional period (the time between the end of a woman’s pregnancy to the beginning of her next pregnancy) is a critical time to modify risk factors, particularly those such as tobacco use, that are causally associated with infant mortality. Interconceptional health care may improve complications from a recent pregnancy and/or prevent the development of a new health problem (obesity, diabetes, depression, and hypertension). Additionally, interconceptional healthcare provides a valuable opportunity to reduce or eliminate risks before one or more future pregnancies to ensure healthier (full term) infants and mothers.

To reduce the factors that contribute to the Nation’s high infant mortality rate, particularly among African-American and other minority groups, Healthy Start (HS) provides intensive services tailored to the needs of high risk pregnant women, infants and mothers in geographically, racially, ethnically, and linguistically diverse communities with exceptionally high rates of infant mortality.

Through the implementation of evidence-based practices and innovative community-driven interventions, HS works with individual communities to build upon their resources (outreach, health education, case management, utilization of prenatal/postnatal care) to improve the quality of and access to health care for women and infants at both service and system levels. At the service level, beginning with direct outreach by community health workers to women at high risk, HS projects ensure that the mothers and infants have ongoing sources of primary and preventive health care and that their basic needs (housing, psychosocial, nutritional and educational support and job skill building) are met. Following risk assessments and screening for perinatal depression and other risk factors, case managers provide linkages with appropriate services and health education for risk reduction and prevention. Mothers and infants are linked to a medical home and followed, at a minimum, from entry into prenatal care through two years after delivery (interconceptional). At the system level, every HS project has developed a consortium composed of neighborhood residents, perinatal care clients or consumers, medical and social service providers, as well as faith and business community representatives. Together these key stakeholders and change agents address the system barriers in their community, such as fragmentation in service delivery, lack of culturally appropriate health and social services, and barriers to accessing care. HS projects also have strong collaborative linkages with States programs including Title V MCH Block Grant, Medicaid, State Child Health Insurance Program, and with local perinatal systems such as community health centers. The close connection between these services can assist in reducing significant risk factors such as smoking and alcohol use, while promoting behaviors that can lead to healthy outcomes for women and their families. These positive relationships and effects which begin during the perinatal period continue to be monitored for both mother and baby for two years post-delivery to ensure that they remain linked to ongoing sources of primary care.

Communities in the 38 States, the Districts of Columbia, and Puerto Rico that are served by Healthy Start have large minority populations with high rates of unemployment, poverty and major crime. Parents at highest risk typically have less than a high school education, low income and limited access to safe housing. Limited medical providers are accessible, but only long commutes on crowded public transportation. Tulsa Healthy Start (THS) in Tulsa, OK typifies one of Healthy Start’s urban projects, with deep historic social and economic disparities in comparison to the City of Tulsa as a whole and the U.S. Though its commitment to providing accessible family-centered, high-quality pre- and postnatal care that is unique to the their community needs, Tulsa Healthy Start serves pregnant women who are at most risk of poor birth outcomes. Eighty-nine percent live below 100% of the FPL, and 7% lived 100-185% below. (Total 96%) Of the 7,880 Tulsa Healthy Start clients that were case managed from September 1998 to August 31, 2006, 11.0% were found to use illicit drugs, 9% were found to drink alcoholic beverages, 19% smoked, 12% were in domestic violence situations, and 11% were found to have depression. Depression was a co-factor with domestic violence in 256 cases, illicit drug use in 176 cases, drinking in 168 cases, and smoking in 306 cases. Despite the high-risk level of THS clients, infant outcomes continue to improve. THS client infant mortality rate (IMR) has decreased over time from (14.2/1000 in 1998 to 9.17 in 2006). In contrast, the Tulsa County rate is 10.58 per 1000 live births.

Healthy Start continues to make significant contributions to improving birth outcomes and the health of our nation’s families in other communities. The infant mortality rate (IMR) has plummeted since the initiation of the Central Harlem Healthy Start project in 1990 when it was 27.7 infant deaths per 1,000 live births. By 2004, the IMR was 5.1, a drop of 83%. This rate was better than the IMR for the United States which was 6.79 in 2004. Again this is a high risk community where the median household income is $19,920, about half that of New York City ($38,293) and less than half of the nation ($41,994).

There are achievements linked to the HS program in other communities as well. Thirteen Healthy Start communities reported no infant deaths among program participants for the past four years (2002-2005): Mobile , AL; Oakland, CA; Fresno, CA; Atlanta, GA; Hawaii County, HA; Kalamazoo, MI; Louisville, KY; Las Cruces, NM; Brooklyn, NY; Downstate, NY (Nassau, Queens and Suffolk Counties NY); Portland, OR; Philadelphia, PA ; San Antonio, TX; Fort Worth, TX; Brownsville, TX. Thirty seven sites reported no infant deaths among program participants for the past year. The Twin Cities Healthy Start infant mortality rate for Native Americans in Minneapolis and St. Paul (the area served by Twin Cities Healthy Start) dropped from 19.42 in 1996-1998 which are the three years prior to receiving federal funding to 7.97 in 2002-2004. During the years 1996-1998, Native American infants in the Twin Cities area experienced a postneonatal rate as high as their neonatal rate. This is a trend different from all other racial groups for whom the neonatal rate is always larger. This trend has reversed and the American Indian postneonatal rate is now much smaller than the neonatal, going from 9.71 in 1996-98, prior to federal funding to 3.42 in 2002-2004. The infant mortality rate for the Jacksonville Healthy Start, a program that focuses on high risk interconceptional women, reported an infant mortality rate of 15.6 per 1,000 live births in 2001. By 2004 there was a dramatic improvement with no infant deaths among Healthy Start project program participants.

Low birthweight (LBW), a major contributor to infant mortality has been dramatically reduced. In 2004, the national LBW rate was 8.1%, the highest level recorded since the early 1970s (National Center for Health Statistics, Births: Final Data for 2004, September 29, 2006). In 1998, the National LBW was 7.6% and 65% of all infant deaths were attributed to LBW (Source: NVSS, NCHS, 2000). At the same time, the LBW rate in the Healthy Start projects averaged 12.1%. By 2005, in contrast to the upward trend in the nation, HS projects had reduced LBW to an average rate of 10.1%. This is particularly significant because the national LBW rate for African-Americans was 13.7% (National Center for Health Statistics, Births: Final Data for 2004, September 29, 2006). HS communities demonstrating remarkable successes in reducing low birth weight include: Baltimore Healthy Start, where the very low birth weight (VLBW) rate is 2.0% (17 of 852) among HS enrolled participants (99% African-American) with singleton births, compared to a 3.7% citywide African-American VLBW rate. The percent of African-American babies born VLBW in Baltimore is now approaching that of white babies citywide VLBW (1.5%). In the Fresno California Healthy Start, entitled Babies First, the low birthweight rate among African-American participants was 9.9%, compared to 14.9% for all African Americans in the Babies First project area. The Houston Healthy Start reported a low birth weight rate of 26% for 2001 in 2004, however, the low birth weight rate was 3.3 % for their program participants.

Another risk factor for infant mortality is late entry into prenatal care. In 2004, the mortality rate for infants of mothers who began prenatal care after the first trimester of pregnancy or not at all was 8.35 per 1,000. This rate was 37 percent higher than the rate for infants of mothers who began care in the first trimester (NVSS, NCHS, 2007). While nationally, 82.8% of pregnant women received prenatal care in the first trimester in 1998, first trimester entry into prenatal care for Healthy Start projects was only 41.8% in 1998. By 2005, the projects had increased first trimester entry into prenatal care to 66% - a 61% increase. The Great Lakes Intertribal-Council Honoring Our Children Healthy Start project serves eight tribes in Wisconsin. Eighty percent of their program participants enrolled in prenatal care in the first trimester, compared to 71% of all Native American women in Wisconsin. The Pee Dee Healthy Start a rural project in South Carolina reported for 2006 that 85% of their program participants enrolled within the first trimester.

Focusing on systems development and coordination improves maternal and infant outcomes. Baltimore Healthy Start reduced the percent of short (< 12 months) inter-pregnancy intervals, from 30% to 17% with the addition of a family planning nurse practitioner as part of their case management services. Decreasing the inter pregnancy interval increases a woman’s chances of having a better birth outcome with a subsequent pregnancy. Healthy Start, Chester, PA, identified that lack of health insurance is a significant barrier to utilizing care resulting in delayed initiation of prenatal care and pediatric care. This financial barrier to care is compounded by the extremely limited health care services for the under/uninsured in the project area. Prenatal and pediatric care is provided by private practice groups. Many of these groups are reluctant to see uninsured women and children. During the most recent project period (FY 2001 - 2005), 74% of the pregnant women enrolled in Healthy Start had no health insurance at the time of enrollment. Healthy Start staff completed Medicaid or SCHIP applications on all uninsured Healthy Start participants. 969 (98%) of 991 Medicaid/SCHIP applications submitted by Healthy Start were approved for Medicaid or SCHIP coverage. By reducing a significant barrier to utilizing appropriate health care, Healthy Start projects have made important strides in helping at-risk mothers have healthy babies and families.

Healthy Start was designed to bring vital services to the pregnant and parenting women who need it most. There have been measurable successes in the Healthy Start program. Most significantly, a decrease in the number of infant deaths among Healthy Start participants.

The Healthy Start program received a PART review rating in 2006 of Moderately Effective. The review cited that the program resources are effectively targeted, and that independent evaluations are conducted. Some issues with grantee-reported data were cited. The HS program has undertaken several steps, including providing training for grantees to assure the quality of grantee-reported data. The program is also identifying and synthesizing evidence-based practices that contribute to improved perinatal outcomes that it will disseminate to HS communities.

Funding includes costs associated with grant reviews, processing of grants through the Grants Administration Tracking and Evaluation System (GATES) and HRSA’s electronic handbook, and follow-up performance reviews.

Funding History

Budget Request
The FY 2009 Request of $99,744,000 is the same as the FY 2008 Enacted level. Seventy seven Healthy Start projects will end in FY 2009. The request will support 76 competing renewals, and 22 non competing continuation grants. Each of the Healthy Start projects has committed to reducing disparities in perinatal health and infant mortality by transforming their communities, strengthening community-based systems to enhance perinatal care and improving the health of the young women and infant in their vulnerable communities. To assist projects, the Healthy Start program will provide support for peer mentoring, technical assistance, the Healthy Start Leadership Training Institute, eight to ten webcasts, site visits and sharing of best practices among projects. Additionally the program has undertaken a learning collaborative to enhance projects ability to unify the varied systems of care in their community and increase the capacity of local providers to incorporate emerging evidence-based health guidelines on preconceptional and interconceptional care. The FY 2009 target for percent of low birth weight births among HS women is 9.6%, reflecting experience in the field and the upward national trend. Nationally, the percentage of infants born low birthweight increased in 2005, to 8.2 percent of all births, from 8.1 percent in 2004. The percentage of infants born low birthweight (less than 2,500 grams) has increased more than 20 percent since the mid-1980s (from 6.7); the 2005 level is the highest level reported since 1968. The target for the percent of women participating in HS who have a prenatal care visit in the first trimester is 75%.

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