MAY 26, 1988 WILLIAM A. NEAL, M.D. PROFESSOR AND CHAIRMAN DEPARTMENT OF PEDIATRICS

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1 NATIONAL PERINATAL ASSOCIATION National Headquarters 101V2 S. Union Street Alexandria, Virginia "A non-profit organization... deaicatsd to promoting perinatal health through fostering delivery of optimal care, education, research and ordering of national priorities." (703) The National Perinatal Association Officers and Board of Directors Officers: President: John V. Hartline, MD Kalamazoo, Michigan President-Elect: Micki Cabaniss. MD Mobile. Alabama Secretary: Carol K. Mahan. ACSW Cleveland, Ohio Treasurer Everett A. Beguin. Jr., MD LaCrosse. Wisconsin Immediate Past President: Sister Jeanne Meurer. CNM, MS Tampa. Florida Board of Directors: Frank W. Bowen. Jr.. MD Philadelphia. Pennsylvania Robert Cicco MD Pittsburgh. Pennsylvania Maureen H Greer. BA Indianapolis. Indiana Larry D. Jones. MA Jefferson City. Missouri David A. Nagey MD. PhD.. PE Baltimore. Maryland Jeffrey Pomerance. MD. MPH Los Angeles California Judith L B Roeoke PhD. RD Muncie. Indiana Linda F. Samson. RNC. MN Cherry Hill. New Jersey Patricia Sealing R\. MS Alexandria. Virginia Brenda. C SumraH. ACSW Jackson. Mississippi Pat Wagner. RNC BSN Mobile. Alabama Julie West. RNC BSN Little Rock. Arkansas Frederick H. Wirth, MD Virginia Beach. Virginia Mardelie K. Wuerger. RN. MS Madison, Wisconsin Nancy Young. RN. MSN Spokane. Washington TESTIMONY BEFORE INFANT MORTALITY IN THE UNITED STATES: THE NEED FOR UNIFORM COMPREHENSIVE PRENATAL CARE WILLIAM A. NEAL, M.D. PROFESSOR AND CHAIRMAN DEPARTMENT OF PEDIATRICS WEST VIRGINIA UNIVERSITY SCHOOL OF MEDICINE PAST PRESIDENT, NATIONAL PERINATAL ASSOCIATION Headquarters Sandra Butler Whyte Executive Director 1988 NPA Clinical Conference and Exhibition October Sheraton Harbor Island San Diego. CA

2 NATIONAL PERINATAL ASSOCIATION National Headquarters 101 1/2 S. Union Street Alexandria, Virginia "A non-profit organization... dedicated to promoting perinatal health through fostering delivery of optimal care, education, research and ordering of national priorities." (703) The National Perinatal Association Officers and Board of Directors SUMMARY Officers: President: John V. Hartline. MD Kalamazoo. Michigan President-Elect: Micki Cabaniss, MD Mobile. Alabama Secretary: Carol K. Mahan. ACSW Cleveland. Ohio Treasurer Everett A. Beguin, Jr.. MD LaCrosse. Wisconsin Immediate Past President: Sister Jeanne Meurer, CNM, MS Tampa Florida Board of Directors: Franc, W Bo<ften. Jr. MD Philadelphia. Pennsylvania Robert Cicco. MD Pittsburgh. Pennsylvania Maureen H Greer. BA Indianapolis. Indiana Larry D Jones MA Jefferson City. Missouri David A Nagey. MD. PhD.. PE Baltimore. Maryland Jeffrey Pomerance. MD. MPH Los Angeles. Ca : i'or"ia Jud'th L B Roepke. PhD. RD Muncie. Indiana Linda F. Samson. RNC MN Cherry Hill. New Jersfy Patricia Sealing. RN. MS Alexandria. Virginia Brenda C. Sumrali. ACSW Jackson. Mississippi Pat Wagner. RNC BSN Mobile. Alabama Julie West. RNC BSN Little Rock. Arkansas Frederick H Wi-th. MD Virginia Beach. Virginia Mardelie K Wuerger RN. MS Madison. Wisconsin Nancy Young. RN. MSN Spokane. Washington Headquarters Sandra Butler Whyte Executive Director The need to develop newborn intensive care at West Virginia University Hospital in 1974 to support pediatric cardiology services lead to participation in a state-wide program to regionalize perinatal care throughout the state. White infant mortality fell from worst in the nation to below the national average by the end of the decade. Further reduction of infant mortality to the irreducible minimum is possible only if all women in the country have access to prenatal care and receive it during the first trimester. To accomplish this goal it must become a consistent national priority of the highest order. The fifty different Medicaid systems in this country must become one system administered by the federal regulatory process. Funding must become more uniform NPA Clinical Conference and Exhibition October Sheraton Harbor Island San Diego. CA Our children, the future of our society, depend upon our will as a nation to provide for their welfare. i: EM ATE FIliJUJCE COMMITTEE MAY 26, 19S8

3 It is a privilege to speak with you today about the health and well being of the children of this nation. I represent the National Perinatal Association (NPA), a provider and consumer organization dedicated to this goal by fostering optimal care, education, research and ordering of national priorities. As a practicing pediatric cardiologist and Professor and Chairman of the Department of Pediatrics at West Virginia University, I am honored to also represent my native state and its Land Grant Institution of higher education. My involvement with the perinatal health care issues at the state and national level began from a rather narrow initial focus. I joined the faculty at. West Virginia University in 1974 upon completion of graduate training at the University of Minnesota. As a newly trained pediatric cardiologist I was apprehensive about the ability to practice my speciality in West Virginia because of the absence of newborn intensive care unit at the University Hospital and throughout the rest of the state. I was offered and accepted the responsibility for developing such a facility at the University Hospital. When I requested seed money for needed equipment from the federally funded Regional Medical Program I was frankly

4 disappointed by their response. They were not willing to fund equipment, but they would and did fund a planning grant for the regionalization of perinatal care in the state. This resulted in the formation of the West Virginia Perinatal Committee, a working committee with no statutory authority comprised of pediatricians, obstetricians, nurses, hospital administrators, consumers, family practitioners and health planners from throughout the state. The result was development of an integrated system which fostered cooperative efforts among the tertiary centers so that- they would provide uniform outreach education to every hospital in the state with an obstetrical service; a system which would standardize the level of care provided by each hospital, as well as indications for maternal and neonatal transport; a system which included the implementation of ground and air transport of high risk infants and mothers funded by the State Health Department by legislative line item; a system which provided seed money for creation of a badly needed tertiary care facility in the southern part of the state, and secondary centers in strategic location. I elaborate on this significant development for a reason: It worked! Cooperative effort by the various sectors of our state to forge a rational system to address a problem was effective

5 beyond expectation. Neonatal mortality in West Virginia plummeted more rapidly than in any other state to slightly below the national average. Physicians, nurses and educators working within this state system were called upon to provide leadership at the regional and national level in matters related to perinatal health. Effective political leadership and State and Federal agency support were vital to the success of this effort, beginning with the thoughtful decision of the Regional Medical Program to look beyond short term needs. Was it divine providence that the very first premature infant to be transported to the University Hospital by the new system was the grandson of a state legislator: Whether or not this was the case, line item budgeting of the system was the immediate result. The expansion of the statewide program was later funded by Title V Infant Intensive Care Funds. We received written commitment for the continuation of funding by then Governor Rockefeller. Governor Rockefeller showed great leadership toward the end of his second term by taking the bold initiative to divest the University Hospital from direct state control so that a state-of-the-art.,.!.. aw****^ facility incorporating a Children's Hospital within a hospital could be constructed. This truly magnificent facility will be

6 ready for patients next month. Mr. Rockefeller has provided us the chance to provide exemplary tertiary care for our citizens. He has done his part. My part is only beginning: that is to further reduce the still unacceptably high perinatal mortality and morbidity in West Virginia. As we are well aware the United States ranks last among industrialized nations in the percentage of our infants who survive beyond one year of age. If we are to correct this matter, if we are to decrease infant mortality to its irreducible minimum, every woman in this country must have not only uniform access to prenatal care, but every woman must in fact receive prenatal care beginning in the first trimester. I submit that the issue of access must be federally mandated and funded. Implementation of a workable system to accomplish universal prenatal care must be developed and administered by state government. Therein lies part of the problem. In reality we have 50 different Medicaid systems with different priorities. The economic and social characteristics of each state are different. The economic capacity of each state to appropriate funds eligible for federal match is highly variable. I am sad to

7 report that the Medicaid system in West Virginia is virtually bankrupt. Bankrupt though we may be, we are not despondent nor have we given up the fight. Medicaid is doing all it can within its limited budget to extend eligibility criteria for women. The Centers for Disease Control is providing funds for a pregnancy risk assessment program, referred to as PRAMS. The Robert Wood Johnson Foundation has awarded 1.2 million dollars to establish a case management system. The challenge to West Virginia, indeed every state, is to see that these funds accomplish their intended purpose: the documentable incorporation of every pregnant mother into the prenatal care delivery system. No exceptions. We must guard against excessive administration at the expense of actual health care delivery. Such is our responsiblity at the local level. What is the responsibility of the Federal government? Our elected leadership must first establish participation in prenatal care as a national goal. To suggest that the same order of commitment this country devoted to placing a man on the moon is called for may sound melodramatic. But is it: The health of

8 our children is a gauge of the moral fiber of our society. They are our future. It makes economic sense as well. Every dollar spent upon this preventive measure will save more than three dollars otherwise required for newborn intensive care. If one adds the cost of long term disability resulting from no prenatal care the savings become enormous. I had intended to raise other issues related to maternal and child health care for your consideration: the potential for total disruption of already established regionalized systems of perinatal care by alternative care delivery programs; the potentially destructive and costly competitive environment created by prospective reimbursement and an oversupply of physicians; the liability crisis as it effects obstetrical care in this country; the problem of catastrophic and chronic health care for children; and finally, the threat to tertiary hospitals, especially rural ones, resulting from the problem of uncompensated care and technical problems with Medicare and Medicaid reimbursement. In the interest of saving your valuable time I will leave these issues for discussion by my capable colleagues here today.

9 My message shall remain simple. Every woman in this country must receive prenatal care as a preventive health measure if we really intend to further reduce infant mortality and morbidity. If I were you, I would ask: Will it work? The answer is yes. European countries have proven it. As a fiscal conservative I ask myself: Can we afford it? The answer is always the same. We cannot afford not to invest in the future of our society. A prominent child health advocate, and good friend of mine, recently pointed out, "This is basically not a medical problem. It is a social problem with medical consequences." I am grateful for your attention.

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