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ment can certainly serve to enhance and compliment the services
provided by the private physician.

GIVEN THE IMPORTANCE OF PRENATAL MEDICAL CARE AND
EDUCATION, EACH COUNTY SHOULD MAKE A CONCERTED EFFORT
TO HAVE PRENATAL EDUCATION AVAILABLE IN SOME CAPACITY



1
Better Health For Our Children: A National Strategy DHHS
Publication #79-55071. ~ ^^



25



Prenatal Care

IN THEIR COUNTY. TO FACILITATE THIS, COOPERATION WITH
THE LOCAL MEDICAL SOCIETY AND COUNTY COMMISSIONERS IS
ESSENTIAL. PUBLIC HEALTH NURSES SHOULD BE GIVEN ASSIS-
TANCE FROM SDHES IN WORKING WITH PRIVATE PHYSICIANS
AND COUNTY COMMISSIONERS IN THE ESTABLISHMENT OF A
PRENATAL PROGRAM.

A third concern is that some women are financially unable to
seek early and frequent prenatal care. Several counties cited the
financial inability of some county residents to obtain adequate
prenatal care. Several things can be done to ease this problem.



■Some counties already have a "petty cash" fund of sufficient
amount that allows the public health nurse, at her discretion,
to provide for this special need. In some special instances,
this "petty cash" fund could be used as a last option to
provide prenatal care for women who are unable to seek any
prenatal care at all.

■The Improved Pregnancy Outcome Project provides a service
to a group of women and infants unserved by any other
program. Without the option of transporting high risk women
to higher level medical centers or provision of needed labora-
tory or x-ray services, both the maternal and infant death
rate could be expected to increase. Most individuals and
counties would be unable to finance this needed service.
THEREFORE, IT IS RECOMMENDED THAT SDHES ASSURE
CONTINUED STATE-WIDE FUNDING FOR THE TRANSPORTS
OF HIGH RISK LOW INCOME WOMEN AND INFANTS.

■The inability of low income women to pay for prenatal services
by private physicians is increasing. This is particularly
evident in areas of high concentrations of low income women,
including urban Native American and refugee women. To
alleviate this problem, alternative sources of prenatal care
should be made more accessible. THEREFORE, IT IS RECOM-
MENDED THAT SDHES WORK TO ACTIVELY ATTRACT LICENSED
NURSE-MIDWIVES AND NURSE PRACTITIONERS FROM OTHER
PARTS OF THE COUNTRY TO BE AVAILABLE FOR HIRE BY
THE MEDICAL COMMUNITY THROUGHOUT MONTANA.



26 -



Prenatal Care

Currently, the Board of Nurse Examiners is in the process of
writing rules to regulate these practices. Once the services are in
place, public health departments should work to inform women of
the service.

IN ADDITION, SDHES SHOULD INVESTIGATE THE FEASIBILITY
OF ESTABLISHING PRENATAL CLINICS IN AREAS OF HIGH CON-
CENTRATIONS OF LOW INCOME WOMEN AND CERTAIN RURAL
AREAS. ONE POSSIBLE SOURCE OF SUCH SERVICE TO BE
EXPLORED IS THE LINKAGE OF PRENATAL SERVICES WITH
EXISTING FAMILY PLANNING PROGRAMS.

The fourth identifiable need is the area of providing prenatal
services to urban Native American women. Infant mortality rates
are one measure of the adequacy of prenatal care and medical
services. When birth and death certificate information is compared
for non-reservation and reservation Native Americans, a statistically
significant difference is found. Non-reservation Native Americans
have significantly more deaths than the reservation Native Americans
in the neonatal period for infants weighing more than 2,500 grams
at birth. While using caution not to extrapolate conclusions from
the data, the higher infant death rate may be one indicator of
inadequate prenatal care within the Native American non-reservation
population. The data on the following pages provide documenta-
tion.



1
In order to compare the infant mortality rates for non-reservation

and reservation infants, the counties in Montana with reservations
were designated Reservation Counties and counties without reser-
vations were designated Non-Reservation Counties. It is assumed
that all Native American births in Reservation Counties occurred at
Indian Health Service Hospitals and all Caucasian births in Reserva-
tion Counties occurred in non-IHS facilities.



- 27



Prenatal Care



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28 -



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29



Prenatal Care

It is generally accepted that the urban Native Americans do
not receive health services in the same capacity as their non-Indian
counterparts. Although services are as available to low income
urban Native Americans as any other low income individual, cultural
barriers frequently hinder Native American women from seeking
these services.

TO ASSURE THAT URBAN NATIVE AMERICAN WOMEN HAVE
EQUAL ACCESS TO PRENATAL SERVICES, IT IS RECOMMENDED
THAT SDHES WORK WITH URBAN NATIVE AMERICAN GROUPS
AND OTHER LOCAL ORGANIZATIONS TO ERODE THE CULTURAL
BARRIERS THAT EXIST FOR NATIVE AMERICAN WOMEN SEEKING
HEALTH CARE.

SECOND, TO HELP THE TRANSITION INTO URBAN LIVING
AND URBAN HEALTH CARE SYSTEMS FOR THE NATIVE AMERICAN
WOMEN, IT IS RECOMMENDED THAT SDHES SUPPORT THE EXIST-
ING URBAN INDIAN HEALTH CLINICS IN SEEKING FUNDS FOR
MEDICAL SERVICES FOR PRENATAL CARE FOR NATIVE AMERICAN
WOMEN WHO HAVE RECENTLY LEFT THE RESERVATION AND THE
SUPPORT AND IHS FACILITIES IT HAD PROVIDED.

An additional concern lies in the area of the WIC program. If
the goal of the WIC program were only to supply nutritious food
supplements to low income women, infants, and children at nutri-
tional risk, the goal is perhaps easy to attain. But if the goal of
the program includes providing education to permanently change
the nutritional patterns of clients to assure the maintenance of
good health, the goal is much more elusive.



30 -



Prenatal Care

To attain this second goal, local WIC programs may need the
assistance of trained nutritionists in identifying and counseling
high risk women within the program. In many high risk cases,
one-to-one counseling may provide the only viable means to effect
change in the nutritional patterns of the woman and her children.
TO ASSURE THAT HIGH RISK WOMEN ARE IDENTIFIED AND
PERTINENT EDUCATION AND COUNSELING TO PERMANENTLY
CHANGE NUTRITIONAL PATTERNS TAKES PLACE, IT IS RECOM-
MENDED THAT SDHES MOVE TOWARD THE REGIONALIZATION OF
THE SERVICES OF NUTRITIONAL CONSULTANTS, THEREBY
BEING MORE AVAILABLE TO ALL LOCAL WIC PROGRAMS.



- 31 -



PREVENTION OF INFANT MORTALITY

Prenatal care is clearly related to positive pregnancy outcome.
Many of the risks associated with low birth weight infants can be
identified in a first prenatal visit and steps can be taken to prevent
or correct them. Conversely, late care or no care is associated

with low birth weight, increased prematurity rates, increased

1
stillbirths, and increased newborn mortality.

There are approximately four million pregnancies a year in
the United States; over one million are intentionally terminated,
one percent of these pregnancies result in fetal deaths, approxi-
mately one percent of infants die within the first month of life;
and seven percent are low birth weight, and nearly five percent
have significant congenital malformations, birth defects, or genetic
disorders.

Infant mortality fell in the United States from 20 deaths per
1,000 live births in 1970 to 14.1 in 1977 - almost a 30 percent drop
in 7 years. Yet, despite these declines in infant mortality, the
United States still has a higher death rate than fourteen other
industrialized nations.



1
Better Health For Our Children: A National Strategy . A report

of the select panel for the promotion of child health. U.S. Depart-
ment of Health and Human Services, Public Health Service, DHHS
Public #79-55071.

2
National Center for Health Statistics, National Center for Health

Statistics and Research, in Health, U.S. 1978, DHHS Publication

#79-1232.



32



Infant Mortality

In Montana in 1977-80, the infant mortality rate was 11.6 or
1.1 percent of total births. Montana's infant mortality rate has
generally been comparable to the United States' rate, except for a
greater decline in recent years. In 1980, the Montana infant
mortality rate rose to 12.4, while the United States rate was 12.5
for the same time period. Although provisional, the 1981 Montana
mortality rate is expected to drop to 9.5.



TABLE 1
INFANT AND NEONATAL MORTALITY







(Rate/1,


,000 Live Bir


ths) By


Place of Residence






Montana




United


States






Infant




Neonata


1


Infant


Neonatal




De


ath Rate




Death Rate


Death Rate


Death Rate


Year


(Und


er 1 Year)


(Under 28


Days)


(Under 1 Year)


(Under 28 Days)


1970




21.5




16.0




20.1


15.1


1971




21.6




15.0




19.1


14.2


1972




19.7




14.5




18.5


13.6


1973




19.5




13.6




17.7


13.0


1974




16.5




12.5




16.7


12.3


1975




15.5




10.7




16.1


11.8


1976




16.6




11.7




15.1


10.7


1977




13.8




8.9




14.0


9.9


1978




11.4




7.3




13.6


9.5


1979




10.7




7.1




13.0


8.8


1980




12.4




7.7




12.5


8.5



Source: Bureau of Records and Statistics, Department of Health and
Environmental Sciences.



Low birth weight is the greatest single hazard for infants,
increasing vulnerability to developmental problems and death. In
Healthy People , the Surgeon General reported the following statistics
regarding low birth weight:



■-Of all infant deaths, two-thirds occur in those infants weighing
less than 5.5 pounds at birth.

■-Given no prenatal care, an expectant mother is three times as
likely to have a low birth weight baby.



- 33 -



Infant Mortality



- Smoking slows fetal growth and doubles the chances of low
birth weight.

- Teenage mothers are twice as likely to have a low birth
weight infant.



The Montana low birth weight rate for 1977-80 was 58.8 or
5.8 percent of all live births. This compares to a national average
of 6.9 percent of all live births.

SERVICES
State

Once a child is born, low birth weight and infant deaths
become basically a medical problem. Subsequently, services that
are provided for these problems evolve around the private physicians
and hospitals. It is in this setting that the Improved Pregnancy
Project (IPO) plays a major role.

One of the major objectives of the IPO Project is to provide
for the continuing education of health care professionals. This
education is focused on the early recognition of high risk preg-
nancies, management of high risk pregnancies, newborn risk
assessments, and the evaluation and management of long-term
problems resulting from a high risk pregnancy. In 1981, 531
health professionals participated in continuing education programs
sponsored or partially funded by IPO.



1
Healthy People , Surgeon General Report and Health Promotion and

Disease Prevention 1979, Public Health Service, DHHS Publication

#79-55071, July 1979.



- 34 -



Infant Mortality

As already discussed, the program also provides for payment
of necessary transports of high risk mothers and infants, in
addition to the procedures and tests used to evaluate the status of
a high risk pregnancy for genetic and medical problems.

Inborn Errors of Metabolism

Inborn errors of metabolism represent metabolic disorders that
can be present in newborns. If these disorders are present at birth
and go undetected, profound mental retardation and sometimes death
can follow. The most common metabolic disorder is phenylketonuria
(PKU). Recognizing this, the Montana Legislature, in 1965, mandated
that the Montana State Laboratory screen all newborns for PKU. In
1973, the Legislature passed a second bill expanding the program to
include screening for hypothyroidism, galactosemia, homocystinuria,
maple syrup urine disease, hypermethionemia, and tyrosinemia. In
1975 the Legislature approved SDHES' contracting with the Oregon
Public Health Laboratory for the service. This has continued to
date.

Since 1975 a total of five cases of PKU, ten cases of hypo-
thyroidism, and one case of galactosemia have been detected in new-
born infants by the screening program. All these cases were
detected in the first few days of life and have been successfully
treated with diet and appropriate medication. All the children are
currently developing normally.

Under state direction, guidelines have been established and
all newborn infants are screened at the time of birth or within a
few days thereafter. The screening is done by obtaining a drop of



35



Infant Mortality

blood from the newborn which is sent to the Oregon Laboratory
where it is tested. The results of all these tests are returned to
the Maternal and Child Health Bureau which assumes responsibility
for notifying the hospitals and physicians of the test results. In
cases found to be positive or suspected of being positive, the
Oregon Laboratory telephones the MCH Bureau. The MCH Bureau,
in turn, notifies the attending physician immediately by telephone
so appropriate therapy can be instituted promptly.

The Legislature makes an appropriation of general fund monies
each biennium for continuation of the screening program for these
seven disorders at a cost of $3.25 per infant.

County

Follow-up programs for high risk infants are an important
part of the home visits of the public health nurse. Any infant
that has been identified through the IPO Project is referred to the
local public health nurse. Some counties rely on a private physician's
order to provide follow-up care. Other counties have sophisticated
mechanisms to locate all high risk infants.

Gallatin County works closely with the medical society and
nursing staff at the local hospital to identify high risk infants
prior to dismissal from the hospital. Any infant identified as high
risk, from a comprehensive list of criteria by the attending physician,
is referred to the public health nurse for follow-up.

A copy of the forms used to identify the high risk infants is
located in Appendix F. Plans are now underway in the Improved
Pregnancy Outcome Project to reproduce the entire high risk



- 36



Infant Mortality

registry system of Gallatin County for statewide distribution.
Plans are also being made to institute a statewide referral system
for high risk infants, with information coordinated with the attending
physician, SDHES, and county health departments.

Custer County has a policy of personally visiting every
woman who has given birth within 48 hours of her dismissal from
the hospital. In addition, the department has a special follow-up
program for all nursing mothers. Missoula County has a high risk
program similar to that of Gallatin County.

In addition to follow-up services for newborns in their com-
munities, 24 counties provide well child clinics for children ages 0-6
years. (A complete discussion on this service is described later in
this chapter under "Health Assessments for Children and Adoles-
cents. ")

Concerns

Because low birth weight and infant mortality are so closely
related to prenatal care, the service needs for women and infants
are approximately the same as those described in the last section.


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Online LibrarySheryl MotlMaternal and child health needs assessment (Volume 1982) → online text (page 3 of 21)