Ala. Admin. Code r. 410-2-2-.02 - Maternal And Child Health

(1) The Problem

(a) Alabama's infant mortality was 9.0 per 1,000 live births in 2005. In 2014 the provisional rate improved to 8.7 deaths per 1,000 live births, a drop from the 2005 rate. Reasons for the improvements include a number of factors related primarily to improved Medicaid coverage.

1. Medicaid has been expanded to serve more children and pregnant women who do not receive cash assistance such as Aid to Families with Dependent Children. This trend started in 1988 with expansion of eligibility to pregnant women and children up to age one (1) with incomes under 100 percent (100%) of the federal poverty level and now up to one hundred thirty-three percent (133%) of the federal poverty level.

2. As of September 1, 1991, Medicaid had workers out-stationed at hospitals, county health departments and other health facilities throughout the state to determine Medicaid eligibility for children and pregnant women who need help with payment for health care but who do not qualify for cash assistance.

3. The Alabama Medicaid Agency received a 1915(b) waiver to create the Alabama Coordinated Care Network for maternity, family planning, children, foster children, and eligible adults beginning October 1, 2019, for three (3) years. The objective is to better coordinate the care, follow-up, and follow-through for Medicaid recipients residing in any one of the seven (7) regions. Each region will have a contracted entity responsible for the coordination of care and services for Medicaid eligibles. Quality measures are key to the success of the waiver.

4. ADPH, in collaboration with the Alabama Department of Human Resources, implemented the Alabama Unwed Pregnancy Prevention Program (AUPPP) in 2001 and the Family Planning Teen Care Coordination Program in 2002. The AUPPP addresses adolescent pregnancy and unwed pregnancy by providing funding support to community-based projects, a statewide teen pregnancy prevention campaign, and media outreach. The teen care coordination program provides medical social support to teens age eighteen (18) and under receiving family planning services in local health departments.

5. Other programs implemented by ADPH that are affecting infant mortality include the Alabama Child Death Review Program legislated in 1997, a campaign addressing "back-to-sleep", a "safety for sleeping babies" brochure, and folic acid outreach. According to the Alabama Child Death Review Program, approximately eighty percent (80%) of infant deaths in Alabama are attributable to unsafe sleeping conditions.

(b) Progress has been made in Maternal and Child Health in the state. In 2005, Alabama's infant mortality rate was 0.93%, and in 2014 declined to 0.87%. In "real terms", 517 of Alabama's babies failed to reach their first birthday in 2014. Those at highest risk for infant mortality are infants born to blacks, single mothers, teenagers, and the socio-economically disadvantaged. Over thirty percent (30%) of Alabama's population is black and other. Close to one-half (1/2) of the births in 2014 (43.2%) were to unmarried women, and 8.5% of infants resulted from teenage pregnancies.

(c) Infant death is not the only problem associated with high-risk birth. Research indicates that for every baby who dies, three (3) more are born with handicapping conditions. In 2014, 10.1% of babies were born with a low birth weight, putting them at greater risk for handicapping conditions. Ensure the newborn screening component is followed as it identifies problems in newborns early in their development so interventions and therapies can be applied for long term outcomes.

(d) Alabama's women and children must receive adequate health care -- health care that is primarily preventive, appropriate for the need, and available. Barriers to care include the following:

1. Outreach Efforts. Outreach efforts at the local community level are varied and sometimes nonexistent. Some children do not receive the minimal recommended number of preventive health care visits as outlined by the American Academy of Pediatrics, thus immunization rates for these infants and young children are low, and conditions that could be identified through routine screening exams go untreated.

2. Diminishing Rural Health Services and Delivery Hospitals. Alabama continues to experience a decline in rural population and health providers. Hospitals are financially challenged due to declining population and reductions in federal reimbursement. Only twenty-nine (29) counties have a birthing hospital. Innovative means of delivering care to rural Alabama is needed for primary care, intermediate/interventional, and emergency or hospitalization.

3. Perinatal Services. Several components of the perinatal system are not available in all areas of the state. These components are obstetrical and neonatal outreach education, maternal-fetal and newborn transport systems, and high-risk infant follow-up. Case management to include tracking and follow-up for women and infants is not available in some areas. There is a need for additional social workers at the local level to provide these services.

4. Child Mental Health. A significant deficit of child mental health professionals, social workers, and residential resources continues for children under age eight (8) . The lack of residential resources in Alabama for those with pure mental and behavioral health issues puts pressure on hospitals to retain them or send them several states away for long term rehabilitation or care.

5. Adolescent Mental Health. The resource deficit for adolescent trained professionals should be noted. As important is the lack of adolescent designed residential or mental/behavioral health rehabilitation, and in particular, for those with adolescents mental/behavioral health diagnoses and physical health needs such as gastrointestinal tubes.

(2) Recommendations

(a) Improve the accessibility of services to maternity and pediatric patients through expansion and improvement of services to women and children.

1. Outreach efforts should be strengthened and targeted to maternity and pediatric patients.

2. Evaluation of case management services should be designed and implemented and management data for the Alabama Department of Public Health should be refined.

(b) Strengthen the Alabama Perinatal Program to implement programs that address recommendations issued by the State Perinatal Advisory Council (SPAC) in 2002. Provide statewide follow-up of all infants identified as high-risk. Improve maternal-fetal and neonatal transport systems.

(c) Maintain and strengthen interagency and private sector efforts directed toward decreasing the amount and effects of substance abuse in women of childbearing age and their children. Efforts to increase intervention and treatments should be encouraged. Child abuse and neglect has risen significantly with the opioid and meth usage. DHR's foster care system is burdened with babies and children of substance abuse mothers. The affected newborns will experience some health care issues long term, though what those issues may be is unknown.

(d) Encourage access in schools for perinatal testing, counseling, prenatal education, and care.

(e) The Statewide Health Coordinating Council (SHCC) is committed to maintaining and strengthening efforts to expand and improve quality pediatric health care throughout Alabama's health care delivery system. This should be achieved through pediatric-trained personnel and systems whose expertise is to care for children -- pediatric-trained physicians (family physicians, pediatricians, pediatric sub-specialists, etc.), nurses (including pediatric and family nurse practitioners), developmental specialists, mental health specialists, and other team members located in health care delivery sites and systems (physicians' offices, multi-specialty ambulatory clinics, health maintenance organizations, children's hospitals, and other service sites).

Notes

Ala. Admin. Code r. 410-2-2-.02

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 03, December 31, 2014, eff. 1/6/2015. Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 06, March 31, 2020, eff. 5/15/2020.

Author: Statewide Health Coordinating Council (SHCC)

Statutory Authority: Code of Ala. 1975, § 22-21-260(4).