In 1991, the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) funded 15 urban and rural sites in communities with infant mortality rates that were 1.5 - 2.5 times the national average to begin the Healthy Start Initiative. The program began with a five-year demonstration phase to identify and develop community-based systems approaches to reducing infant mortality by 50% over the five-year period and to improve the health and well-being of women, infants, children and their families.

Since its inception, the Healthy Start Program has been located in HRSA. Healthy Start is a component of the Maternal and Child Health Bureau and resides in the Division of Perinatal Systems and Women's Health.

Originally funded under the authority of Section 301 of the Public Health Services Act, Healthy Start was recently authorized by the Congress as part of the Children's Health Act of 2000.

The common principles underlying the Healthy Start program are:

• Innovations in service delivery;

• Community commitment and involvement;

• Personal responsibility demonstrated by expectant parents;

• Integration of health and social services;

• Multi-agency participation;

• Increased access to care; and

• Public education.

Healthy Start projects address multiple issues, including:

• Providing adequate prenatal care;

• Promoting positive prenatal health behaviors;

• Meeting basic health needs (nutrition, housing, psychosocial support);

• Reducing barriers to access; and

• Enabling client empowerment.

An additional seven sites were funded in 1994 as special projects with the goal of significantly reducing infant mortality through more limited interventions. In the second, or "replication," phase, Healthy Start added 75 projects in 1998, 19 in 1999 and three more in 2000. In 2001, Healthy Start entered its third phase, and added nine new grantees. Twelve existing projects that were categorized as "approved, but not funded" in 2001 received new funding early in 2002. Presently, there are 96 federally-funded Healthy Start projects, and five main types of Healthy Start grants: Perinatal Health, Border Health, Interconceptional Care, Perinatal Depression and Family Violence, the last just awarded by the MCHB in May 2002. Some projects have more than one grant type.
(Source: Telling the Healthy Start Story: A Report on the Impact of the 22 Demonstration Projects, National Center for Education in Maternal and Child Health, 1999.)

Click Infant Mortality, Low Birthweight and Racial Disparity in Perinatal Outcomes or visit www.hrsa.gov (Maternal and Child Health Bureau) for more information about infant mortality and low birthweight.

Infant mortality and low birthweight remain major public health issues in the U.S. Infant mortality among African American women is more than twice that of white women. Low birthweight among African American women is more than twice that of white women. For Hispanics and Native Americans, the infant mortality and low birthweight rates are significantly higher than that of the white population.

Although infant mortality has decreased in the last decade, clearly the gap between whites and minorities has not been closed. Minority families, therefore, need special attention, focus and priority in perinatal health services.

Less attention has been paid to the problem of low birthweight and very low birthweight babies. In contrast to infant mortality, the last decade saw no significant drop in the rate of low birthweight. In fact, low birthweight now appears to be on the rise. The medical and social services that are required by low birthweight and very low birthweight infants are significant and the costs are high to society and the American taxpayer. Those babies that survive the first year incur medical bills averaging $93,800. First year expenses for the smallest survivors will average $273,900.

Significant savings can accrue from enabling mothers to add a few ounces to a baby's weight before birth. An increase of 250 grams (about 1/2 pound) in birth weight saves an average of $12,000 to $16,000 in first year medical expenses. Prenatal interventions that result in a normal birth (over 2500 grams or 5.5 pounds) saves $59,700 in medical expenses in the infant's first year.
(Source: March of Dimes Perinatal Data Center. Rogowski, J. (1998) Cost-effectiveness of Care for Very Low Birthweight Infants. Pediatrics 012(1):35-43.)

The long-term cost of low birthweight infants includes re-hospitalization costs, many other medical and social service costs and, when the child enters school, often large special education expenses. These public expenses can go on for a lifetime. Decreasing infant mortality rates are frequently the result of dramatically improved medical technology keeping of low birthweight infants alive who would have died 10 or 20 years ago.

Improving the low birthweight rate, on the other hand, requires improvements in the practices and behavior of the women themselves while pregnant. Risk-taking behaviors or inattention to good health practices while pregnant is undoubtedly the single major cause of low birthweight. The most effective way to change these behaviors is to engage women early in their pregnancies and to find ways to encourage them to make changes in their lifestyles and lives. Without ongoing, extensive community-based programs like Healthy Start, it is unlikely that the rate of low birthweight or the gap in racial disparity will be affected.

Healthy Start to the Rescue

Healthy Start programs are community-driven and located in the poorest neighborhoods in the United States. Since its initiation in 1991, Healthy Start has served hundreds of thousands of families. Over 90% of all Healthy Start families are African American, Hispanic, or Native American. Healthy Start specializes in outreach and home visiting — the surest way to reach the most at-risk women.

Healthy Start focuses on getting women into prenatal care as early in the pregnancy as possible. It is generally accepted by the medical and research community that early entrance into prenatal care is the single most critical factor in improving birth outcomes.

Healthy Start has pioneered the use of women living in the community as outreach workers and home visitors. This approach has three important advantages:

• It saves money (nurses' salaries are at least twice that of a paraprofessional or lay worker).

• Minority pregnant women respond better to women who have "walked in their shoes."

• It has given real jobs to hundreds of unemployed women, particularly those on welfare.

Every Healthy Start project has developed a consortium, composed of neighborhood residents, clients, medical providers, social service agencies, faith representatives and the business community. This ensures that not just Healthy Start but the whole community is committed to fight to reduce infant mortality and low birthweight. Major U.S. cities as well as urban counties have a disproportionate number of poor and minority families living within their boundaries. Yet, the amount of federal discretionary dollars going directly to these cities and counties has decreased dramatically in the last 20 years. Healthy Start represents one of the few health and social services programs that is funded directly to the localities by the federal government. Major urban cities desperately need the programs that Healthy Start provides.

Summary

The fact that African American and other minorities continue to have enormously increased rates of infant mortality and low birthweight poses a major public health issue for the U.S. The rate of low birthweight has not decreased significantly in the last decade and now appears to be rising. Low birthweight costs significant dollars, both short-term and long-term, and these costs are not well understood by the American public. Low birthweight can only be decreased by changing behavior — and behavior can only be changed by intense, ongoing interventions at the community level.