Remarks to the Secretary’s Advisory Committee on Infant Mortality

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by HRSA Administrator Mary K. Wakefield

August 3, 2011
Bethesda, MD

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Thank you all for agreeing to serve on this important advisory committee – with a special thanks to our new chairman, Dr. Michael Lu.  I am familiar with your individual expertise, and given the opportunities and challenges we face, you are exactly the kind of board of advisors we need at this important time.

Before I get into a look forward, I want to take a look back and ask you to assist us with that.

A lot has happened since SACIM last met.  I asked that your briefing books include the recommendations of the prior committee members, and I can tell you that we are very much interested in having you reach back, take a second look at those reports, and advise us on which ones you think we should be pursuing.

I want to be sure we’re capitalizing on your best advice – yours and your predecessors, as well.   

For this Administration – this President and Secretary Sebelius, personally – the health of America’s children and the on-going challenge of infant mortality is a high priority.

Remember that one of President Obama’s first actions upon taking office was to push for and sign the reauthorization and expansion of the Children’s Health Insurance Program.  That act has boosted insurance coverage for children from low-income families from 7 million then to 11 million children now.

And by overseeing passage last year of the Affordable Care Act, he has guided U.S. health care into a new focus on expanding access, improving quality, and promoting wellness and prevention for all Americans, most certainly the youngest among us.
All of America benefits from the Affordable Care Act, but parts of the legislation contain a clear focus on the health of mothers, infants and school-aged children.

My main reason for coming today is to give you a better sense of HRSA’s role in this arena – the range and reach of our services, and how they link up with the specific programs you’ve been hearing about from our staff experts in the Maternal and Child Health Bureau, as well as our colleagues in the CDC and CMS.

But first, I’d like to note a couple of fine points about the Affordable Care Act.  

Written into the Act are three powerful incentives aimed directly at attacking infant mortality head-on, in a much more systematic and global way than, perhaps, it has been done in years. These three provisions are:

• First, this week, HHS announced new historic guidelines which will ensure that women receive preventive health services at no additional costs beginning next year – these include breastfeeding support, domestic violence counseling and routine screening for gestational diabetes, HPV, and a range of other conditions associated with poor birth outcomes;
• Second, the Act encourages grantees in the CDC’s Community Health Worker program to target areas and communities with high incidents of infant mortality by giving those grantees a “priority” in awarding funds;
• Finally, under the Home Visiting program run by HRSA in collaboration with the Administration for Children and Families, all potential grantees were required to conduct statewide needs assessments last year to qualify for funding – these include data on “premature births, low-birth weights, infant deaths due to neglect, or other indicators of at-risk prenatal, maternal, newborn, or child health.”

In a moment, you’ll be hearing in detail about the Home Visiting provision of the Act from Audrey Yowell of MCHB.  But this needs assessment – coupled with a separate assessment required every five years for states to qualify for Title V block grants – will give HHS and all of you a more comprehensive mosaic of nationwide data.

This year, the Home Visiting program gets underway nationwide, supported by a first installment of $227 million of an anticipated $1.5 billion over five years.  This is one of the most significant investments in years in the fight against infant mortality.

As Secretary Sebelius said last year: “This initiative will give children a healthier start and give parents the help they need to succeed in the most important job in the world – parenting. This effort builds on impressive research findings and is one more piece of our strategy to invest in prevention and early interventions that pay off.”

The Act also targets infant mortality by expanding the primary care safety net in many of the very communities where we tend to see the social and economic conditions commonly associated with infant mortality.

For example, HHS recently awarded $95 million to 278 school-based health center programs across the country to renovate, refit and expand their facilities to provide health care services to nearly a half-million more children.

This represents the first installment of $200 million for the years 2010 through 2013 for the School-Based Health Center Capital Program – including significant awards in 42 states, the District of Columbia and Puerto Rico.

Together with the 790,000 students already being served in federally supported school-based clinics, these additional funds will make it possible for more than 1.2 million young people to receive primary and preventive care where they go to school – approximately a third of them of high school age.

Teenage girls, as we all know, are in a particularly vulnerable stage of their lives with regard to their reproductive health.  The CDC, for example, estimates that 725,000 high school-aged girls become pregnant each year.

These young mothers not only are more likely to enter pre-natal care late – or not at all – they also are more likely to engage in behaviors like smoking, drinking and drug abuse that place their infants at higher risk.  Most worrisome, nearly 1 in 5 teen mothers delivers her baby prematurely.

At the time of this committee’s formation in 1991, two-thirds of infant deaths occurred in the first month of life.  Although neonatal mortality rates have declined, the incidence of preterm birth, low birth weight, and very low birth weight have not significantly improved.  And one contributing factor is the incidence of teen pregnancy.

Prematurity, low birth weight and intrauterine growth restriction are the leading causes of neonatal mortality.  However, the vast majority of infant deaths are from preventable causes such as Sudden Infant Death Syndrome, injuries and infections.

Stark racial disparities also persist.  For example, African Americans have an approximately twofold greater rate of low birth weight, a twofold greater rate of intrauterine growth restriction, and a threefold greater risk of very low birth weight than white Americans.

So it’s vitally important that young mothers have immediate access to primary care, and School-Based Health Centers and Home Visiting investments go a long way toward improving that access.

In addition to school-based health centers, the Affordable Care Act also mandates a major expansion of the Community Health Center system – a nationwide program funded by HRSA in partnership with 1,100 grantees who operate 8,100 clinics that already serve 19 million patients.

Of those 19 million patients, about 6.8 million are children ages 19 or younger.  In terms of women’s health, more than 11 million patients served in health centers are women and girls, or about 6 of every 10 patients.  Health centers provide prenatal care to a half-million expectant mothers every year – 67 percent of them in the first trimester – while tending to 178,000 births.

HRSA’s Health Centers not only offer the HPV vaccine and STD screening, but in a typical year they administer PAP tests to about 1.8 million women, tests that detect some 117,000 abnormal cervical findings.  These, of course, are the types of conditions that have been associated with difficulties in pregnancy and higher incidents of mortality.

So the expansion of the health center system should result in improved birth outcomes for many millions more women and girls – and their infants – especially those in greatest need and at greatest risk.

Beginning this month, 11 of our grantees will take on the added role of acting as Teaching Health Centers under a provision of the Affordable Care Act that aims to increase community-based residency training as a means of bolstering the ranks of primary care providers, including pediatricians.

Funds totaling $1.9 million have been awarded this year, with increased annual funding expected to provide additional residency slots in future years.  This is part of a renewed focus on community-based primary care and prevention.

In addition to these programs, we have others that directly or indirectly impact on the health of women and infants.

For example, in partnership with the National Healthy Mothers, Healthy Babies Coalition, HRSA is spreading the word about a new service called “Text4Baby.”

If you’re not familiar with this project, it allows expectant and new mothers with an infant under age 1 to sign up to receive free text messages reminding them to take care of their health and give their babies the best possible start in life.

Just go to www.text4baby.org and type in the word “Text,” the number 4, and “Baby” – all one word. Or you can send a text directly to number 511411 and type in the word BABY (or BEBE for the Spanish version) into the message field.  Again, it’s free.

Most importantly, Text4Baby provides evidence-based health information through brief messages three times a week, directly to young moms who might otherwise be hard to reach.

We also support 105 Healthy Start providers in 39 states, Puerto Rico and the District of Columbia.  These grantees provide intensive services for high-risk pregnant women and their newborns – many of them teenage mothers – in a targeted effort to reduce infant mortality.

The Affordable Care Act also extends $5 million in funding until 2015 for 41 Family-to-Family Health Information Centers.  These centers are staffed by parents of kids with special health needs, and have linked more than 170,000 families to federal and state programs, clinics, special insurance pools and rehabilitation services to give infants and children with disabilities a better chance in life.

HRSA also has unveiled a new $5 million Healthy Weight Initiative in conjunction with the First Lady’s Let’s Move campaign.  One major intervention being promoted by the First Lady and U.S. Surgeon General Regina Benjamin is breastfeeding.  HRSA has already provided extensive training and technical assistance in 30 states and jurisdictions, targeting state breastfeeding coalitions and Healthy Start sites.

Clearly, we have a growing body of evidence that has documented the benefits to babies and mothers of breastfeeding for at least the first six months of life.  But a mother’s return to work or school often is an obstacle to continued breastfeeding.

So HRSA has developed a resource kit entitled The Business Case for Breastfeeding that provides a wealth of information about this important initiative.  It’s available at www.womenshealth.gov/breastfeeding.

At the heart of any effort to reduce infant mortality is people.  To staff the expanding primary care infrastructure I described a moment ago, the President has charged HRSA with more than doubling the ranks of the National Health Service Corps.

The Corps is comprised of advanced practice nurses, physicians, psychologists and others who agree to provide primary care for at least two years in communities where health care is scarce.

In exchange, the federal government – through HRSA – gives them up to $60,000 tax free over that period to repay student loans.  For a five-year commitment, the loan repayment amount can run as high as $170,000.

Health professions shortages are an important consideration in ensuring infant health.

Just two years ago, the National Health Service Corps had only 3,600 providers in the field.  Thanks to President Obama’s leadership, we are planning for the Corps’ ranks to expand to 10,500 primary care clinicians by the end of 2011.

Most immediately, here’s what that NHSC expansion means to MCH providers:

• A 72 percent increase in nurse midwives in the past year alone – from 108 to 190;
• A 95 percent increase in nurse practitioners – from 615 to 1,200; and
• A 47 percent increase in pediatricians – from 245 to 360;

Overall, the field strength of the Corps has grown by 57 percent in just one year to more than 7,530 clinicians.

HRSA’s Maternal and Child Health Bureau continues to provide national leadership on the prevention of infant mortality and improving birth outcomes – principally through its funding authority over a $650 million budget.

About 85 cents of every dollar goes to states in the form of block grants that afford support services for over 40 million women and children nationwide, including kids with special health care needs, and their families.

It is the only program that focuses solely on improving the health of all mothers, adolescents and children – whether insured or not – through a broad array of public health and community-based programs.

By now, you’ve heard from many of our MCH staff and you’ve been given a comprehensive, data-rich breakdown of Title V funding by Michele Lawler.  As the committee digs into its work, I think you will continue to be impressed by the depth of knowledge and volume of information available from the MCH staff.

Among efforts currently underway:

• ASTHO: MCHB and the Association of State and Territorial Health Officials are collaborating on the possible development of a national strategy to reduce infant mortality, building on work already done by ASTHO in 2010 and particularly focused on the 15 predominately rural states in HHS Regions IV and VI;
• MCHB is also hard at work on formulating its five-Year strategic plan, and would welcome your input;
• We are also at a time when the SACIM Charter is up for renewal, so I imagine that will be one of your first orders of business.

My own personal convictions about infant mortality are well known by now.  I consider it one of the harshest reminders that we still have unfinished business from the last century – and that our health care system has failed to protect the smallest and most fragile members of society.

And so, today, I want to personally pledge my support for your important work, and the support of HRSA’s Maternal and Child Health Bureau, which will staff the committee and be available as a resource during your tenure.  These are committed people with an unbroken track record of service to the nation dating to the establishment of the Children’s Bureau in 1912.

I could say the same for all of you.  Assembled on this committee are some of the best minds in this field – vetted and approved at every level, up to and including the White House.  You’re here for a reason.  We need your advice, your candor and your sense of where we are in this fight: what’s working, what’s not, and what steps we should be taking next.

We may not always agree.  But from you, the people with some of the greatest expertise, we have the highest expectations.  And we owe it to the American people to deliver on that promise. 

Together, I am confident that we can make a difference in the fight against infant mortality.

If anyone on the Committee has any questions, I’d be happy to take them now.