Local health department perspectives on linkages among birthing hospitals.

OBJECTIVES: To describe perinatal linkages among hospitals, changes in their numbers and their impact on relationships among high-risk providers in local communities. STUDY DESIGN: Data were obtained about the organization of perinatal services in 1996-1999 from a cross-sectional study evaluating fetal and infant mortality review (FIMR) programs nationwide. Geographic areas were sampled based on region, population density, and the presence of a FIMR. A local health department representative was interviewed in 76% (N=193) of eligible communities; 188 provided data about hospitals. RESULTS: Linkages among all hospitals were reported in 143 communities and with a subspecialty hospital in 122. All but 12 communities had a maternity hospital, and changes in the number of hospitals occurred in 49 communities. Decreases in the number of Level II hospitals were related to changes in relationships among providers of high-risk care for mothers and newborns; they were associated with changing relationships only for mothers in Level I hospitals. These relations were noted only where established provider relationships existed. CONCLUSIONS: Decreases in the number of maternity hospitals affect provider relationships in communities, but only where there are established linkages among hospitals.

The nationwide evaluation of fetal and infant mortality review (FIMR) programs: development and implementation of recommendations and conduct of essential maternal and child health services by FIMR programs.

OBJECTIVE: An evaluation of fetal and infant mortality review (FIMR) programs nationwide was conducted to characterize their unique role in improving the system of perinatal health care. The aim of this paper is to examine intermediate outcomes of the FIMR, in particular the development and implementation of recommendations produced by the FIMRs and the conduct of essential MCH services by the FIMRs. METHODS: We report on 74 FIMRs whose communities were selected for the nationwide evaluation and for whom we had data from the FIMR director or comparable respondent. We focus on the recommendations of the FIMRs and the essential maternal and child health (MCH) services conducted by the FIMRs as intermediate outcomes (or outputs) and then examine how selected characteristics of the FIMR may influence these. RESULTS: FIMRs developed recommendations on a broad range of topics but there were some areas for which nearly all programs had developed recommendations. The FIMRs relied primarily on strategies related to programs and practices, with few FIMRs reporting attention to policy-oriented approaches. Implementation of recommendations was high. Factors that influenced likelihood of implementing recommendations and conduct of essential MCH services included structure of the FIMR and training received by FIMR directors and staff. CONCLUSIONS: The focus of FIMR recommendations and the likelihood of implementation vary across FIMRs as does the conduct of essential MCH services. FIMR team structure and training of the director and staff are important areas to consider in efforts to maximize the impact of FIMR.

The relation of FIMR programs and other perinatal systems initiatives with maternal and child health activities in the community.

OBJECTIVES: To evaluate the association of the presence of a fetal and infant mortality review (FIMR) program, other perinatal systems initiative (PSI), or both in a community with the performance of essential maternal and child health (MCH) services by local health departments (LHDs). METHODS: Data were obtained from telephone interviews with professionals from LHDs across the United States. Logistic regression was used to estimate the odds of a LHD conducting each essential MCH service in communities with and without FIMR programs or with and without PSIs, adjusted for geographic area. RESULTS: Of the 193 communities in the sample, 41 had only a FIMR program, 36 had only a PSI, 47 had both programs, and 69 had neither. The presence of a FIMR was related to greater performance of essential MCH services in LHDs in six areas: data assessment and analysis; client services and access; quality assurance and improvement; community partnerships and mobilization; policy development; and enhancement of capacity of the health care work force. Similar findings were noted for the same broad essential services for PSIs. The comparisons of LHDs in FIMR and non-FIMR communities, however, showed greater involvement of communities with a FIMR program in essential MCH services related to data collection and quality assurance than were found for comparisons of LHDs in communities with and without a PSI. The presence of a PSI was uniquely associated with conducting needs assessments for pregnant women and infants, participation in coalitions for infants, promoting access for uninsured women to private providers and involving local officials and agencies in health plans for both populations. When both programs were present, LHDs had a greater odds of engaging in essential MCH services related to assessment and monitoring of the health of the population, reporting on progress in meeting the health needs of pregnant women and infants, and presenting data to local political officials than when either program alone was in the community. CONCLUSIONS: Local health departments in communities with FIMR programs or PSIs appear to be more likely to conduct essential MCH services in the community. Some of these relations are unique to FIMR, particularly for data collection and quality assurance services, and some are unique to PSIs, for example those that involve interaction with other community agencies or groups. Performance of the essential MCH services also appears to be enhanced when both a FIMR program and a PSI are present in the community.