PROBLEM: Despite Pittsburgh's international reputation as the site of a prestigious medical center, the city has struggled since the beginning of the century to improve the survival odds for its African American and low-income white babies. With an infant mortality rate that has for years exceeded that of other major U.S. cities and many third-world countries, Pittsburgh and Allegheny county see Healthy Start as the catalyst for positive change.
The 36-square mile Project Area's six Service Areas, including 45 Pittsburgh neighborhoods and four municipalities in Allegheny county, has a population of 228,049--one-sixth of the County's population and half of the city's, two-thirds of the African-Americans residing in the county and 89% of those in the city. Women of childbearing age (10-44) constitute more than one-fourth (61,500, 27%) of the area's total population, which is 43 percent nonwhite (principally African-American). The Project Area accounts for more than one-third (37%) of the county's infant deaths and almost two-thirds (65%) of those in the City. A 50% reduction in infant mortality in the Project Area, therefore, will clearly have significant impact on the total city and county rates.
For 1995, there were 3,205 births to residents of the Project Area and 51 infant deaths. The 15.9 infant mortality rate for 1995 reflects an 20% decline from the 1988-90 baseline, of 19.8. The IMR for African Americans remains 2-4 times higher than for whites in the Project area.
Three quarters (76%) of all infants who died were born at low birthweights (less than 2500 grams); almost three quarters (71%) weighed less than 1500 grams. Eighteen infant deaths (35%) weighed less than 500 grams. The 1995 percentage of low and very low birth weights (13.5 and 3.2%) has remained constant being nearly twice the county-wide percentage of 8.1% and 1.7% and somewhat higher than the city which is 11.3% and 2.4%. The percentage of births accounted for by teenage mothers (ages 17 or younger) has dropped from 9.4% to 8.7%. Compared to Allegheny county, Project Area women who give birth are more than twice as likely to be single, to have less than a high school education, to be under age 18, and to seek prenatal care in the last trimester or not at all.
GOALS AND OBJECTIVES: To achieve the Healthy start Project goal of reducing infant mortality by 50 percent by September 30, 1996, six objectives were identified in the comprehensive Plan. They call for the reduction in the percentage of low birthweight and preterm infants, neonatal deaths that result from preventable conditions, and unplanned or ill-timed pregnancies; reduction in the use of tobacco, alcohol, and other drugs during pregnancy; and increasing the percentage of young women who complete high school and/or enter post-secondary education or training programs. On the basis of current data and experience, additional objectives were added. These initiatives pertain to male involvement, expanded community-based services, creative outreach methods, transitional care for women who have substance abuse problems and need parenting support, and assure sustainability for critical components.
METHODOLOGY: In keeping with the community-based, "bottom-up" model described in the Comprehensive Plan, Healthy Start maintains its focus on addressing, in a realistic and holistic way, the needs of participants. The project seeks to effect change not only in individuals through an enhanced understanding of the importance of prenatal care, healthy behaviors, and family planning but also in the provider system of health and human services on which she depends. Central to this service model are the multidisciplinary core Teams, located in each Service Area which serve as the interface between Healthy Start and participating hospitals, clinics, and community health centers.
Home visits are conducted with women whose pregnancies are at high risk, and community health nurses visit the homes of low and very low birth-weight infants and those whose mothers received no prenatal care. Neighborhood outreach workers recruit clients to the Healthy Start system and serve as support persons to the participants, facilitating their entry to the array of existing and enhanced services that can reduce risk and improve the potential for a positive pregnancy outcome. Nutrition education is provided through the WIC program and the birth spacing health education, mental health services, and substance abuse referrals and treatment are available.
For women of childbearing age and their infants, Healthy Start offers a comprehensive continuum of family planning, prenatal, obstetrical, pediatric and postpartum health care services, provided through the coordination and/or expansion of existing services and the addition of needed new services. Working in tandem with the Core Teams is a network of family planning centers located in each of the service areas and community based primary care services. Specialists in birth spacing offer education, guidance and support to access services and improve decision making.
An intensive outreach and public information campaign, utilizing the local media, a telephone information Help Line, community events (health fairs and "baby showers"), and community mobilization through grassroots participation in local consortia in each service area, has made 98% of the women residing in the Project Area aware of Healthy Start. Point of entry for most participants is the telephone Helpline. In addition, an array of social supports-transportation, child care, job skills training, adult education, youth development, parent training, drug and alcohol prevention and treatment, and support groups for both the women and their male partners is provided.
Recognizing the critical need for additional supports for women with special needs, Healthy Start is working with subcontractors to develop drug-free transitional care for recovering women, infants, adolescent mothers and others who are at risk because of disabilities or homelessness. Because early
hospital discharge practices and first time parent needs, our Healthy Start House will provide education and support services for our families.
The project's design and implementation are the product of extensive collaboration among Healthy Start, the Allegheny county Health Department, federal, state and local public officials, hospital and health care providers, health and human service agencies, foundations, the public schools, and the community. Healthy Start funds are used to expand, enhance, and coordinate the elements of a continuum of care as well as to add innovative initiatives to fill gaps in service as they are identified.