Improving the Life Chances of Children at Risk

Cornell University Medical College Sixth Conference on Health Policy

David E. Rogers

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429722400
• Edition: 1
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

This book discusses how to identify those children who are at hazard of becoming less than they might be as adults. It explores critical policy issues in broadening access to health care services and reassessing results of major intervention efforts for improving life chances of vulnerable children.

1
Overview

Eli Ginzberg

This chapter has a twofold aim: to call attention to the major themes covered by the participants in the sixth Cornell University Medical College conference on health policy and to identify the main points of some of the discussions that led to the participants' recommendations for policy interventions.

The selection of the conference theme—improving the life chances of children at risk—was influenced by two recent events: the repeated actions of Congress since 1986 to expand Medicaid coverage for pregnant women and children living in or close to poverty; and the recently completed report of the Mayor's Commission on the Future of Child Health in New York City. But beyond these two stimuli from the political arena was the steadily mounting concern of medical, public health, and child welfare advocates with the lack of adequate attention to the health risks of infants and children, particularly those being born into low-income and other disadvantaged households.

The arrangement of the chapters that follow parallels the agenda of the conference. Addressed first are the informational and the knowledge base related to infant mortality and neonatology. Following that is a discussion of some of the developmental problems affecting vulnerable young children. The book concludes with an exploration of critical policy issues involved in broadening access to health care services and reassessing the results of major intervention efforts aimed at improving the life chances of vulnerable children.

The reader who wants to be fully exposed to the rich and varied issues that engaged the conference participants over the two days of intensive and insightful discussions should read and reflect on each of the chapters that follow. The themes that are discussed will provide all readers, both the interested specialist and those less deeply involved in the subject, with an overview of the major issues and the directions that the conferees concluded offered the best prospects for future progress.

Several major trends were discussed: the long-term significant decline in infant mortality in advanced countries from around 10 deaths per 100 infants to 1 per 100 during the course of this century; the years of moderate decline in infant mortality in the 1950s and 1960s and the renewed decline thereafter, which was mainly in response to advances in neonatology; and the renewed flattening of the curve since the early 1980s.

Considerable criticism was voiced about the poor performance of the United States in terms of infant mortality when compared to the performance of other advanced countries: The United States ranks far below the leaders, even when comparisons are limited to whites only. In terms of overall infant mortality, the United States ranks far down on the list.

Low birthweight was identified as the principal predictor of neonatal mortality, but although we have a good understanding of the causes of fetal growth retardation (race, malnutrition, drugs, smoking), we are largely in the dark about preterm delivery, the other principal cause for low birthweight. It is not surprising, therefore, that several of the participants strongly urged more research and development directed at the biological aspects of pregnancy and labor about which we know much less than we need to know to understand the factors contributing to preterm delivery and how they might be modified.

The subject of prenatal care was singled out for close attention. The point was stressed that because of inadequate or nonexisting financing arrangements, about one-third of all pregnant women receive inadequate prenatal care. But the discussion emphasized that broadened access to effective prenatal care would not by itself assure much-improved outcomes unless such care led to the reduction and cessation of such dysfunctional behavior as the heavy use of alcohol, drugs, and cigarettes; eating an inadequate diet; and other undesirable behavior. Thus, even universal access to effective prenatal care would fall short of assuring optimal birth outcomes. The United States is far behind other advanced countries in sex education, family planning, and the proper use of contraceptives. The intensity of the struggle between the pro-choice and pro-life advocacy groups suggests that a resolution will not come soon. The question is whether medical leadership can play a more active and constructive role as an advocate for comprehensive sex education and informed use of contraceptive devices.

The discussion about neonatology confirmed that new technology explained much of the recent decline in the neonatal death rate; that considerable gains could still be made from bringing the less effective hospitals up to the performance levels of the more successful; and that the gains that had been achieved through regionalization should not be jeopardized.

A disturbing account was provided about recent developments at New York City's Harlem Hospital, which is located in the midst of a low-income, severely disadvantaged black community in which the crack epidemic is raging. The neonatal facilities have become greatly overtaxed, and the nursing staff is grossly inadequate to cope with the overflow of drug-infected infants, many of whose mothers are incapable of caring for them. Because the hospital remains one of the few functioning institutions in the neighborhood, a further weakening of its capabilities to provide essential medical care would have dire effects, far beyond the medical arena.

Although most low birthweight and even very low birthweight babies that are being saved appear to have no lasting disabilities, a certain proportion of all newborns, including those with normal birthweight, encounter developmental handicaps. Neurodevelopmental dysfunctions during childhood were explored, and the point was made that much can be done to help children with these conditions if the health care system becomes more sensitive to the prevalence of their dysfunctions; if gross labeling of children is avoided; and, most particularly, if the educational system becomes more flexible so as to enable children to build on their strengths rather than penalizing them for their weaknesses.

Early testing could lead to early interventions that might result in improved cognitive, social, and behavioral outcomes; but widespread early assessments were recognized to have a downside risk. Important ethical issues are involved in large-scale testing and classification of young children, and the danger of the self-fulfilling prophecy exists.

In the policy arena, the discussion focused on two subjects: the financing of care and the assessment of early intervention. With respect to financing, the point was stressed that both private insurance and Medicaid failed to enable all pregnant women and young children to obtain access to the health care system. All of the conferees agreed that U.S. society should take early remedial action; some favored incremental changes (improving Medicaid), while others advocated major reforms (national health insurance) as the best means of providing increased access for all.

Three early intervention efforts were singled out: home visitation by nurses; preschool interventions; and a more comprehensive set of approaches through centers that provided intensive activities for young children as well as parental support. Although many intervention efforts failed to meet the criteria of controlled clinical trials, a minority passed muster and the findings were positive. Early interventions improved the cognitive and social development of children at risk. In the case of the nurse visitation program, the cost/benefit analysis suggested the program could pay for itself within a four-year period.

In retrospect it is clear that the speakers and the other conferees were in broad agreement that many opportunities exist for the United States to lower its infant mortality rate and strengthen services for young children at risk. But as important as more resources were to achieving these desirable results, they would by themselves not suffice. During the course of the discussion the following sticky points were raised and although many of them were not pursued, they warrant attention:

1. The increasing difficulties that many pregnant women on Medicaid were encountering in finding obstetricians who were willing to accept them as patients.
2. The relative lack of attention that has been paid to the recruitment, education, and use of a larger number of nurse-midwives who could help to overcome, at least in part, the growing shortages in the supply of obstetricians.
3. The need to improve the education and training of residents in obstetrics so that they become more sensitized to the commingling of socioeconomic factors with health factors in the presenting conditions of many patients from disadvantaged groups.
4. The need for improved data collection and analysis that could explore subgroup differences with respect to both infant mortality and childhood dysfunctioning to gain more insights into the role of cultural, environmental, and family constellations in affecting outcomes.
5. The potential for improved services to pregnant women and young children if the current narrow categorization of public programs were relaxed and more flexibility was gained in providing early preventive and therapeutic services.
6. New and improved ways the health care system could provide continuity of care with comprehensive services, improved coordination between the health care system and the educational system.

One final observation: All of the conferees were disturbed by the gross inequities that continue to persist in the United States between the range and quality of prenatal, delivery, and postnatal services available to middle-class families in contrast to services available to the poor, members of minority groups, legal and illegal immigrants, and groups living in medically underserved areas. In light of their discontent they searched for ways to mobilize public opinion and political action to narrow and remove these gross inequities.

No one challenged this goal or the urgency for taking actions on a broad front. But the conferees were reminded, late in the conference, of two countervailing realities that had to be recognized. The United States has one of the most unequal distributions of income of any advanced nation and there is little evidence that it plans to move at an early date to narrow the differentials between rich and poor. In addition, as long as our income distribution remains seriously skewed, additional expenditures for improved health services may be inappropriate if the poor do not have adequate housing, food, and jobs.

2
Infant Mortality

Nigel Paneth

The choice of infant mortality as a topic for the Sixth Cornell Health Policy Conference indicates the importance attached to the subject. Yet numerically, infant mortality contributes only a small amount to yearly deaths in the United States. Deaths in the first year of life currently account for less than 2 percent of all deaths in the United States, and the infant death rate is now one-fifth of what it was 50 years ago and one-tenth of the figure of 80 years ago. In contrast, the past 50 years have seen only a halving of death rates for middle-aged males. Yet it is infant mortality rates that are commonly featured in the headlines of our daily newspapers. Why this paradoxical attention to a health indicator that appears to be healthier than many others?

To some extent we are prisoners of tradition. Few health statistics have been tabulated, analyzed, and pondered over for as long as infant mortality. Studies at the turn of the twentieth century linked high infant mortality rates with declining fertility. Birthrates had dropped throughout the industrialized world, and concern was expressed that population would decline. Attention began to focus on the huge loss of life that then occurred so shortly after birth. In the United States in 1900, about 15 percent of births did not survive to age one, a figure roughly comparable to that in rural Africa today. And in the United States then (as in Africa now) infant deaths constituted about one-third of all deaths in the population.

Our present concerns are different. An important characteristic of infant mortality is its persistently strong association with social and economic circumstances. In spite of the great improvements in nutrition, sanitation, and health care that characterize this century, the relative position of the more and the less privileged in our society remains about the same as far as infant mortality is concerned. In 1950, the infant mortality rate for black infants was about double that for white infants.

TABLE 2.1 Comparison of Mortality Rates and Potential Years of Life Lost for Three Causes of Death, 1985

	Mortality Rate per 100,000 Population	Years of Potential Life Lost
Malignant neoplasms	191.7	1,813...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Tables and Figures
• Introduction: America's Children—Are We Doing Right by Them?
• 1 Overview
• 2 Infant Mortality
• 3 Prenatal Care: Who Gets It and Who Does Not?
• 4 Neonatology: Where Are We and What More Could We Do?
• 5 The Status of Neonatology in New York City: The View from Harlem
• 6 Neurodevelopmental Dysfunction During Childhood: The High Impacts and Policy Implications of Insidious Handicaps
• 7 Improving Access to Care for Expectant Mothers and Young Children
• 8 Can Home Visitation Improve the Health of Women and Children at Environmental Risk?
• 9 Identifying the Vulnerable Young Child
• 10 Promoting Healthy Development in Young Children: What Educational Interventions Work?
• 11 A Multisite Randomized Intervention Trial for Premature, Low Birthweight Infants: The Infant Health and Development Program
• 12 Focusing on Effective Measures for Saving Children at Risk
• 13 Summary
• About the Contributors
• Cornell University Medical College Sixth Conference on Health Policy
• Index