COMPREHENSIVE PERINATAL

CARE PROGRAM

Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-D1-90-00460  NOVEMBER 1990  EXECUTIVE SUMMARY 
PURPOSE 
The purose of ths inspection was to asses.s the initial implementation of the Comprehensive 
Perinatal' Care Program (CPCP), an initiative of the Public Health Service (PHS) to reduce 
infant mortalty. The specific issues examed in this inspection concerned: (1) the extent to 
which CPCP grantees' goals and objectives have met stated program criteria; (2) the extent to 
which PHS has conducted oversight of the CPCP grantees; and, (3) the extent to which the 
CPCP funds have been distrbuted to aras experiencing high infant mortality rates for the 
general and minority populations.

BACKGROUND 
This report examines one Deparent initiative diected at reducing the nation s high infant 
Progr 
mortality rate, the Comprehensive Periatal Care  (CPCP). The CPCP provides 
supplemental funds for enhancing perinatal care systems in community and migrant health 
centers (C/MC). The purpose of the CPCP has been to improve the pregnancy outcomes 
and health status of women and infants served by these centers. The DIG' s interest in the 
CPCP initiative is based on the Deparment s continuing concern over the nation s high infant 
mortality rates and the growing investment being made in this initiative. The inquir was 
based on: (1) discussions with PHS staff in headquarrs and regional offces who were 
involved in the CPCP grant application review process and ongoing grtee oversight; (2) 
discussions with Congressional staf famliar with the legislative history of the CPCP; (3) 
review of relevant documents for the C/MHC program and CPCP initiative including program 
guidance and application guidance memoranda, CPCP grant applications and application 
review protocols, and approved budgets and data on perinatal users for all FY 1988 CPCP 
grantees; (4) a review of recent relevant studies and evaluations of infant monaity and 
perinatal care servces; and (5) census and infant monaity data from the National Center for 
Health Statistics. 
FINDINGS 
The goals and objectives set forth in CPCP grant proposals approved by PHS have been in 
accord with the intended purposes of the program. 
In some cases, PHS had limited information on how grantees planned to spend the CPCP 
funds awarded during the first year. 
The PHS has established a basic framework for gathering information useful for assessing 
the impact of CPCP services, although it is too soon to have been tested.  Many areas of the country with high rates of infant mortality have not been receiving CPCP 
funds. 
ave been awarded to community and 
Approximately 25 percent of CPCP funds 

migrant health centers serving areas with inant mortality rates below the threshold 
established by PHS for high infant monaity-12 deaths per 1,00 live birhs. 
Almost half of all community and migrant health centers have not appliedfor 
CPCP funds while others-including those serving areas with high infant monaity
rates-
have applied and have been disapproved. 
Nearly half of the nation s largest cities with high infant mortality rates-greater 
than 12 deaths per 1 00 live birs-have not been eligible for CPCP funds 
because they have no centers funded through sections 329/330 of the Public Health 
Service Act.

RECOMMENDATIONS 
The PHS should strengthen its procedures 
for approving CPCP grants to assure adequate
accountability for CPCP funds. 
The PHS should strengthen its efforts to provide technical assistance to community and mi
grant health centers preparing CPCP grant proposals. 
The PHS should reexamine the approach for allocating CPCP funds to assure that these 
funds are directed to areas of high infant mortality. 
COMMENTS 
We received comments from the Assistant Secretar for Planning and Evaluation and the 
Public Health Service. Both agencies concured with our 
recommendations. Their detaled 
comments on the draft report and our responses to them appear in the final section of this 
report.  . . . . . ..  ..  ..  ..  ..  ..  ..  ..  ...   ...   ...   ...   .;..   ...   ... -  . . .  ...  . .. .  . .. .  . ...    ....    ....    ....    ....    ....    ....    ......      ......      .......       .......       .......       .......       .......       ........        ........        ....... .      . ..... ...    .   .... ....    .    .. ...... .        ..........          ..........          ..........          ..........          ..........          ..........          ..........          ..........          .........     ....
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION.  8 . . . . . . . . . . . . 1 
FINDINGS 
The goals and objectives set forth in CPCP grant

proposals approved by PHS have been in accord with

the intended purposes of the program. . . 

In some cases, PHS had limited information on how 
grantees planned to spend the CPCP funds awarded 
during the first year 
PHS has established a basic framework for gathering

information useful for assessing the impact of CPCP

services, although it is too soon to have been tested

Many areas of the country with high rates of infant 
mortality have not been receiving CPCP funds. . . 
RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
The PHS should strengthen its procedures for

approving CPCP grants to assure adequate

accountabilty for CPCP funds

The PHS should strengthen its efforts to provide 
technical assistance to community and migrant health 
centers preparing CPCP grant proposals 
The PHS should reexamine the approach for 
allocating CPCP funds to assure that these funds are 
directed to areas of high infant mortality. . . 
COMMENTS ON THE DRAFT REPORT AND OIG RESPONSE 
APPENDIX A: ENDNOTES 
....................................... A
 INTRODUCTION

PURPOSE 
The purose of this inspection was to assess the initial implementation of the Comprehensive 
Perinatal Care Program (CPCP), an initiative of the Public Health Service (PHS) to reduce 
infant mortalty. The specific issues examined in this inspection concerned: 
The extent to which CPCP grantees' goals and objectives have met stated program 
crteria; 
The extent to which PHS has conducted oversight of the CPCP grantees; and, 
The extent to which the CPCP funds have been distrbuted to areas experiencing high 
infant mortality rates for the general and minority populations. 
BACKGROUND 
Infant Mortality in the United States

Infant monaity is a serious problem in the United States. In 1987, the United States raned 
21 st a2m oAnlgth ionudguhs tirnaflaiznet dm coortuanlittrye sra itne sit sin r tahtee  Uofn iintefda nStt amteosn haaitvye  dec1r0e. a1s ededa ths per 1 000 live 
birhs. durng the past 
3 This is largely because the incidence 
decade, the rate of decline has slowed in recent years.
birs-a 
of low binhweight  major factor influencing infant mortalty-has declined only 
slightly during this period. 
Infant mortlity rates among certai ethnic 
groups and in certain urban and rual geographic 
areas remai high, and in some instances, have been increasing. In 1987, for example, the 
national infant mortlity rate for blacks was 17.9 deaths per 1 00 live birhs-twice the rate 
S In 1986, the infant mortalty rate was 21.1 
of 8.6 deaths per 1 000 live birhs for whites.
deaths per 1,000 live birs in Washington, D.C., 20.3 in Detroit, and 16.3 in Cleveland.6 For 
the fIrst 6 months of 1989, Washin  , D.C. reported an unprecedented infant mortlity rate 
of 32.2 deaths per 1 000 live birhs. 
The nation s high infant mortality rates have, over the years, attacted widespread attention 
from the public, health professionals, and the government. Ten years ago, the Deparent of 
Health and Human Services (HHS) set national goals for improving the health of Americans 
by 1990. Several goals focussed specifically on infant mortality. One of these stipulated that, 
by 1990, the national infant mortality rate not exceed 9 deaths per 1 00 live birs and 
another that no county and no racial or ethnic group have infant mortality rates greater than 12 
deaths per 1,000 live birhs.  HHS Efforts to Reduce Infant Mortality 
The Deparent of Health and Human Services (HS) has long supported programs aied 
reducing infant monaity though improved health care for mothers and infants. Beginning in 
1935, Title V of the Social Security Act authorize grants- to the States for services to promote 
maternal 
and child health. Over the years, Title V has been amended a number of times, 
although the goal of promotig the health of mothers and childrn, especially those at risk for 
. poor health, has remaied the same. 
In 1981, Title V was amended to establish the Maternal and Child Health Services Block 
Grants which provided consolidated fundig to the States for the varous categorical programs 
which had been supported under Title V. The States have used the block grant funds to 
support a varety of health service programs, including those aimed at reucing infant 
mortality. These infant mortlity initiatives may be strengthened in the years ahead because of 
a new Federal set-aside provision contained in Omnibus Reconciliation Act of 1989. This 
provision prescribes a certn percentage of funds from the MCH block grant appropriations 
be set aside specifically for infant mortality initiatives with preference being given to projects 
in areas with higher than average infant mortality rates. 
Furher, the Medicaid program (Title XIX of the Social Security Act) has, since the 
mid-1960s, provided an importt source for financing health services, including prenatal and 
postnatal care, for low income women and infants. Since the mid-1980s, Congress has sought 
to expand Medicaid coverage for pregnant women and childrn though varous options and 
mandates to the States. 
Community and Migrant Health Centers and the Comprehensive Perinatal Care Program 
Community and migrant health centers (C/MCs) have been another major cornerstone of
Deparental efforts to reduce infant mortality. Since the early 1970s, PHS has provided 
priar 
financial support to C/MCs, which provide comprehensive 
health services in 
medically underserved areas. CUlTently, PHS supports approximately 600 C/MCs through 
grants funded under sections 329 and 330 of the Public Health Service Act and through the

National Health Service COIpS (NHSC) which provides health personnel such as nurse

practitioners, obstetrcians, and pediatrcians to many centers. The C/MCs serve nearly six

millon people, most of whom ar poor, uninsured or insured by Medicaid, and members of 
mmonty groups. 
The PHS requires C/MCs to provide perinatal care services among other tyes of primar 
health services. Periatal care includes medical, educational, and social support services 
provided to pregnant women and infants from conception through 
postparum and newborn
12 Experts have long recognized that comprehensive perinatal services
care.  ar critical in

13 Equally important are

assuring healthy pregnancy outcomes and in reducing infant deaths. 
access to early and continuous prenatal care services; case management, whereby one person

the case manager, coordinates clients ' services; and, one-stop-shopping, meaning the
 integration of comprehensive perinatal care with other speciald services. These approaches 
to care are emphasized by C/MCs. 
Recently, the Congress and the Deparment became increasingly concerned over the slowing 
decline in the nation s infant mortality rates and the possibilty that the Surgeon General' 
goals for reducing these rates by 1990 would not be attained. They agree on the need to 
bolster Deparental efforts to reduce infant mortality given that also durng this period, 
Federal appropriations for the C/MCs were being reuced
f Federal support for the NHSC
was declining, and medcal malpractice costs were soarng. 4 Thus Congrss appropriated 
additional funds for a special infant mortality initiative in FY 1988. The PHS used these 
funds to develop and implement the Comprehensive Perinatal Cae Program (CPCP) ih 
C/MCs. 
The purpose of the CPCP initiative has been to improve the pregnancy outcomes and health 
status of women and infants served by the C/MCs and thereby reduce infant mortality in 
these communities. The PHS has used the CPCP funds to supplement-or, in some cases, to 
maintan-the existing1 perinat5a services offered by the centers, rather than to demonstrate 
innovative approaches for reducing infant mortality. This strategy has been consistent with 
the intent of Congress which has, through varous appropriations and authorization 
documents, made clear that these funds should support expanded capacity and enhanced
servIces In e centers. 
The PHS awarded 207 CPCP grants in FY 1988 and 263 grants in FY 1989. In both FY 1988 
and FY 1989, PHS established application and review processes for the CPCP funds which 
16 The 
were separate from the process followed for the centers' regular 329/330 funding. 
CPCP initiative is administered in PHS by the Division of Special Populations Program 
Development, Bureau of Health Car Delivery 
and Assistace, Health Resources and Services 
Administration. 
The short history of the CPCP initiative ilustrates the growing investment being made by the 
Congress and the Deparment in this program. As the fIrst CPCP grants became operational in 
1989, former Secretar of Health and Human Services, Dr. Otis R. Bowen, referred to the 
17 Moreover 
CPCP as the "leading edge of DHHS' total efforts to reduce infant monaity. ,,
fundig for the initiative, which is a separate line item in the budget, has increased steadily. 
Congress appropriated $20. 1 millon in FY 1988, $20.5 milion in FY 1989, and $32 millon 
in FY 1990. The FY 1991 President s Budget includes a request for $36 milion for the 
CPCP-which, if appropriated, would represent an 80 percent increase in CPCP funding since 
FY 1988. 
In view of the continuing concern over the countr s high infant mortality rates and the 
enhanced investment being made in the CPCP, we examined this initiative to assist the 
Deparent in strengthening its efforts to reduce infant mortality. Accordingly, this report 
presents our findings related to the implementation of the CPCP and concludes with 
recommendations to PHS regarding the management of this initiative.  Sources of information for this study included: (1) discussions with PHS staf in headquarers 
and regional offces who were involved in the CPCP grant application review process and 
ongoing grantee oversight; (2) discussions with Congressional 
staf familiar with the 
legislative history of the CPCP; (3) review of relevant documents for the C/MC 
program and 
CPCP initiative including program guidance and application guidance memoranda, CPCP 
grant applications and application review protocols, and approved budgets and data on
periatal' users for all FY 1988 CPCP grantees; (4) a review of reent relevant studies and 
evaluations of infant mortalty and perinatal care services; and (5) census and inant mortality 
data from the National Center for Health Statistics, PHS.  FINDINGS

The goals and objectives set forth in CPCP grant proposals approved by PHS have been in 
accord with the intended purposes of the program. 
The puroses of the CPCP have been described in varous Congressional documents, the 
and the application 
announcements of available funds published in the  Federal Register, 

guidance developed and administered by PHS. Our review of these documents confIrmed that 
grt 
PHS has approved CPCP  proposals consistent with the intent of Congress, the criteria in 
Federal Register and the application guidance for the CPCP. 
the 
The PHS has reviewed and approved CPCP grant proposals consistent with the intent of 
Congress that CPCP funds be awarded to C/MCs "to help them integrate and coordinate 
appropriate services throughout the pregnancy and  in order to meet effectiveiy 
fist year of life 
18 The Congrss hoped that an infusion ofthese 
the health care needs of mothers and infants. 
funds would help reduce infant monaity consistent with the Surgeon Genera' s goals for 1990. 
The criteria PHS developed to evaluate the CPCP grant proposals were also consistent with 
and described in the application guidance 
those criteria summarz1ed9 i nT thhe e PHS requireFedde raalp Rpegliisctear n
 ts to submit proposals which addressed these 
for each year. 
criteria: the demonstrated effectiveness of existing perinatal care programs; a documented 
assessment of needs; an adequate and feasible plan to meet the needs; the extent to which the 
center is par of a coordinated system of care in its community; an adequate plan to evaluate 
the results of the services; and the appropriateness of the proposed budget. 
Our analysis of the budgets for FY 1988 CPCP grtees indicates that, for those grantees for 
which information was available, the grantees ' projected expenditures were in accord with the 
20 Case 
purposes outlined by Congress and described in the application guidace.
management, outreach services, health education, nutrtion counseling, patient follow-up and 
transportation to prenatal appointments were among the services to be supported with CPCP 
funds. These grantees projected spending nearly three-fourths of their CPCP funds on 
personnel such as nurses, case managers, obstetrcians and gynecologists, and social workers 
(see figure 1) to provide these services.  The present distrbution pattern of CPCP funds is likely to be perpetuated though the 
consolidation of the CPCP and the C/MC review and funding processes this year. The PHS 
wil incorporate the level of CPCP support provided to the FY 1989 grantees into their "base 
funding in FY 1990. This approach appears to be consistent with the 
or basic level of  329p30 
2 and Wil 
intent of Congress, provide reasonable assurance to grantees of more stable, 
long-term support for perinata services. At the same time, however, PHS wil have less 
flexibilty in targeting these special funds to areas of highest need. 
We acknowledge that the CPCP funds allocated to areas with infant monaity rates less than 
12 deaths per 1 000 live birhs ar nevertheless helping to address the nation s infant monaity
problem. These areas may have pockets of higher infant mortalty rates, which would not be 
reflected in the rates for the larger ara. In some areas, the infant mortality rates may be 
increasing, even if they ar stil below 12 deaths per 1 00 live birs. Also, the CPCPfunds 
may help some areas to maintain their low rates. However, this distrbution pattern raises a 
major policy question regarding how these scarce resources can best be 
diected in accord 
with the national concern about high infant mortality rates. 
Almost half of all community and migrant health centers have not applied for CPCP 
funds while others-including those serving areas with high infant mortality 
rates-
have applied and have been disapproved. 
Many centers funded through sections 329/330 of the Public Health Service Act-which by 
definition provide services in medically underserved areas-dd not apply for CPCP funds in 
either FY 1988 or FY 1989. In fact, only slightly more than half of 
al centers applied for 
CPCP funding during either year, and not all applications were approved. In FY 1988, PHS 
was unable to approve approximately one-third of the CPCP applications. Among those 
disapproved were applications from at least 47 centers-alost hal of all those 
disapproved-serving areas with infant monaity rates  000 live 
greater than 12 deaths per 1 
birhs. In FY 1989, PHS was unable to approve only about 15 percent of the CPCP 
applications. Twenty-six, or more than half, of the disapproved 
centers serving areas with infant mortality rates greater than 12.Nplications were from 
Nearly half of the nation s largest cities with high infant mortlity rates-greater than 
12 deaths per 1,000 live birhs-have not been eligible for CPCP funds because they 
have no centers funded though sections 329/330 of the Public Health Service Act. 
A significant number of the nation s largest cities-those with populations of 100,000 or 
more-
have not parcipated in the CPCP initiative because they have lacked 329/330 
migrt 
community and  health centers-the required conduit for the CPCP funds. These 
major cities are among the areas of the countr experiencing the highest rates of infant 
mortality. 29

Nearly 40 percent of all infant deaths and slightly more than 60 percent of black infant deaths 
occurred in these cities in 1987. According to the National Center for Health Statistics, there  . The extent to which these tyes of infonnation wil enable PHS to assess the impact of the 
progr 
CPCP initiative remains to be seen. As noted earlier, the  is stil relatively new and 
ar 
these efforts  largely untested. The data from the perinatal user profies, for example, do 
not specify the extent, types, or timig of perinatal services. Moreover, the progress reports 
we reviewed from FY 1988 grantees vared greatly in scope and quality. Finally, it is not clear 
at this time how PHS wil account for the CPCP funds and assess their impact when the 
application review and funding processes are consolidated this year. Even now PHS has not 
required grantees to report on expenditures incured specifcaly for CPCP support services. 
. Thus, the information specific to the CPCP funded services may not prove 
suffcient for 
adequately assessing the impact of the CPCP and assuring adequate accountabilty for this 
increasing investment of Federal funds. 
Many areas of the country with high rates of infant mortality have not been receiving CPCP 
funds. 
Approximately 25 percent of CPCP funds have been awarded to community and 
migrant health centers serving aras with infant mortality rates below the thrshold 
established by PHS for high infant mortality-12 deaths per 1;00 live birhs. 
Approximately one in four CPCP dollars each year has been awarded to centers with service 
areas that have infant mortlity rates less than 12 deaths per 1 00 live birhs for both the 
general and minority populations25 -awards which involved sixty different centers. These 
rates are the levels above which PHS has considered the incidence of infant mortality to be 
high. In its 1990 Health Objectives for the Nation, fonnulated in 1980, PHS set as a goal that 
by 1990 no county and no racial or ethnic group of the po  ulation should have an infant 
mortality rate in excess of 12 deaths per 1 00 live birhs. More recently, PHS used this 
same rate in its review of CPCP applications to define C/MCs with service areas 
experiencing high infant mortlity. Areas with rates higher than 12 were viewed as being 
greater need of CPCP funds than areas with lower rates. However, nearly $10 milion of the 
CPCP funds over the past 2 years have been diected to centers serving areas with infant

mortality rates not considered by PHS to be paricularly high.

The PHS did consider the infant mortality rates of the areas served by centers when funding

CPCP grantees. However, those rates considered high-above 12 deaths per 1 000 live

births-were not heavily weighted in the funding process which included many other

considerations.

Moreover, a sizeable number of centers serving areas with infant mortality rates below the 
national rate have received CPCP funds. As noted earlier, the national infant monaty 
rate in 
00 
1987 was 10. 1 deaths per 1  live birhs. The PHS awarded CPCP funds to 27 centers each 
year with service areas where the infant mortality rates were less than 10 for both the general 
and minority populations.  . . 
FIGURE 1 
Personnel Expenditures Projected by CPCP Grantees, 
Fiscal Year 1988

Admin/Clerical 
Midwives 
Nutritionists 
Case Managers 
18% 
Other 
16% 
Social Workers 
11% 
Note: N=152 of 207 CPCP Grantee Budgets

Source: OIG/OEI analysis of FY 1966

data provided by U.S. PHS

In some cases, PHS had limited information on how grantees planned to spend the CPCP 
funds awarded during the first year. 
Our analysis of the approved budgets for fIrst year grantees indicated that for slightly more 
than 25 percent of the grantees, PHS did not have budgets which clearly depicted the 
expenditures projected specifcally for the CPCP funds. In most cases
, PHS had to rely on 
revised budgets rather than the original grant applications for an accurate picture of the 
services to be provided and the tyes of expenditures planned. Although the original 
applications were the bases upon which PHS made approval and funding decisions, they 
usually did not accurately portay the CPCP services to be implemented. This was the case 
because, in most instances, the CPCP grants which were actually awarded by the PHS were 
significantly lower than the amounts requested and described by the applicants in their 
ongm 
app lcatIons. 
In some cases, CPCP funds were not distinguished from other types of funds in these revised 
budgets. In other instances, no itemized expenditures were projected for the CPCP funds, or 
the CPCP funds which were itemized did not total to the amount of the grant award as 
reported to us by PHS. Without this documentation, PHS could not know the specifc 
periatal services to be supported with CPCP funds.  i'f' 
were 177 cities with populations of 100;00 or more in 1987. There were 38,408 infant 
deaths nationally in 1987; 15,140 (39 percent) of these deaths occured in these 177 cities. 
There were 11,461 infant deaths among blacks nationally in 1987; 7,080 (62 percent) of these 
deaths occured in these 177 cities. 
Among the cities of 100,00 or more population, 43 percent of those having high rates of 
infant mortalty for blacks in 1987 were not eligible for CPCP funds the fIrst year because 
they had no 329/330 community or migrant health centers (see figur 2). Likewise, among 
these large cities, 40 percent of those having high rates of infant mortality for the general 
30 In fact, of the ten cities in the 
population were also not eligible. countr with the highest 
infant mortalty rates, two of them-Richmond and Portsmouth, Virginia-were among those 
without 329/330 community and migrant health centers and thus not eligible to receive CPCP 
funds. 
. FIGURE 2 
CPCP Eligibilty and Black Infant Mortaliy 
100,000 or More, 1987 
Rates for Cities  of 
CPCP Ineligible 
43% 
Black IMR )-= 12
Black IMR -( 12  70% 
30% 
CPCP Eligible

57%

Note: Pie N=177 Cities 
Column N=136 Cities 
Source: U.S. Public Health Service

It is important to note that less than half-approximately 40 percent--f the community and 
migrt  31 Yet urban aras nationally have had 
health centers are located in urban aras.
higher rates of infant monaity than rual aras, although, to be sure, some rual areas have 
indeed had high rates of infant mortalty. Not only have the rates of infant mortality been 
higher in urban areas than in  so too has the incidence of infant death. Indeed, 
rual areas, but 
at least 3.5 times as many infant deaths occured in metropolitan areas as in non-metropolitan 
32 Thus, because CPCP funds have been limited to 
areas during the 3-year period 1985-1987.
329/330 community and migrant health centers, many large cities with high need but without 
such centers have not received CPCP funded services.  RECOMMENDATIONS 
In light of the situation described in the previous pages, we offer the following 
recommendations to the PHS with respect to its management of the CPCP initiative. 
The PHS should strengthen its procedures for approving CPCP grants to assure adequate 
accountability for CPCP funds. 
It is essential that the approval process for CPCP grants assurs that PHS has specific, 
comprehensive, and up-to-date information on how CPCP grantees plan to spend their grant 
funds. This information is essential for assuring the financial integrty of the CPCP and for 
assessing the impact of the program. 
The PHS should strengthen its efforts to provide technical assistance to community and 
migrant health centers preparing CPCP grant proposals. 
As we have seen, many centers have not applied for CPCP funds; others serving areas with 
high infant mortality rates have had their proposals disapproved. We encourage PHS to 
strengthen its technical assistance to these centers so that more of them apply for CPCP funds 
with high quality grant proposals. 
The PHS should reexamine the approach for allocating CPCP funds to assure that these 
funds are directed to areas of high infant mortality. 
The CPCP has been a significant new initiative in the Deparment 
s continuing effort to 
reduce the countr s high rates of infant mortality. With considerable support from Congress, 
the CPCP has offered PHS an opportunity to direct specially appropriated funds into services 
aimed at reducing infant mortality in the low income, medically underserved areas served by 
the centers. 
We urge the PHS to reexamne the approach to allocating the CPCP funds. Our analysis 
raises important policy issues regarding whether these CPCP monies ar being diected in the 
most strategic manner and whether continuation of the present pattern of allocating these 
ar 
funds wil best serve the intent of this initiative. Resources  scarce, and the need for 
improved perinatal services is great in many areas of the countr. Yet, as we have seen, a 
substatial porton of CPCP funds-about 25 percent in both FY 1988 and FY 1989-has not 
been directed to areas experiencing high rates of infant mortality. Moreover, many aras of 
high need, including many large cities of the countr, have been deprived of CPCP supported 
services-ither because they have lacked a 329/330 community or migrant health center or 
because the center s application for CPCP funds has been disapproved. 
Among the importnt policy questions to consider are the following. Should infant monaity 
rates figure more prominently in the application and funding process for CPCP funds? Should 
any increases in the CPCP appropriations be more selectively targeted to centers serving areas  COMMENTS ON THE DRAFT REPORT AND OIG RESPONSE 
We received comments on the draft report from the Assistant Secreta for Planning and 
Evaluation (ASPE) and the Public Health Service (PHS). The comments ar contained below 
in their entirety and are followed by the DIG response. 
COMMENTS FROM ASPE 
As you know, reducing infant monaity has been a Deparental priority for a number of 
years. We have seen numerous maternal and child health demonstrations and program 
expansions arve with great promise, only to observe no change in infant mortality and 
morbidity rates. 
The report on the CPCP was parcularly useful in terms of evaluating our policy direction 
since it appears that the funding may not have gone to the highest priority areas, not all the 
potential funding candidates applied for assistace, and we lack the information necessar to 
drt 
evaluate CPCP's impact. The recommendations of the  report point out that an innovative 
idea may not meet its full potential because of serious admnistrative failures. 
OIG RESPONSE 
We are pleased with ASPE's concurrence with our recommendations. 
COMMENTS FROM PHS 
Attached are the PHS comments on the subject DIG draft report. 
We concur with the report s recommendations to (i) improve PHS technical assistance to 
comprehensive perinatal care program (CPCP) grantees and approval process for grant 
proposals, and (ii) reexame the approach for allocating funds to aras of high infant 
mortality rates. 
progr 
We are now reviewing strategies to improve  accountabilty, and target technical 
assistace to grantees in areas of high infant monaity rates. We wil consider alternative 
strategies (other than CPCP) to fund perinatal activities at current CPCP sites at which infant 
mortality rates and other indicators reflect lesser need. This wil assure that contiued 
eligibilty for CPCP funding is based on highest need. 
OIG RECOMMENDATION 
The PHS should strengthen its procedures for approving Comprehensive 
Perinatal Care Program (CPCP) grants to assure 
adequate accountabilty for 
CPCP fund.
 with the highest rates of infant mortality? How might perinatal services be supported more 
intensively in those very needy areas without community or migrant health centers? Is it a 
more effective use of limited resources to fund many centers in modest amounts or to taget 
fewer centers in the neediest areas for more substantial support? As the Federa investment in 
the CPCP continues to increase each year and as evaluation fmdings become available, we 
urge PHS to consider questions such as these in order that the limited dollars available for the 
CPCP achieve the maximum impact on this most pressing problem of infant mortality.  COMMENT FROM PHS 
progr 
We concur. PHS is reviewing alternative strategies which optimize  accountabilty 
and which also are sensitive to the grantee s admistrative burden of submitting applications 
for the Community and Migrant Health Center (C/MC)-Programs as well as the CPCP. 
C/MC 
Cuntly, CPCP and  grantees use a single budget which combines dollars for both 
programs. By the end of Fiscal Year 1991, PHS wil requir separte budgeting of CPCP 
. costs. In cases where that CPCP award differs from the original request, PHS 
wil require a 
revision of the CPCP budget. 
OIG RECOMMENDATION 
The PHS should strengthen its efforts to provide technical assistance to 
Community and Migrant Health Centers preparing CPCP grant proposals. 
COMMENT FROM PHS 
We concur. PHS plans to strengthen its efforts by targeting technical assistance to C/MCs in 
areas of highest infant mortality which have not yet been able to develop an approved and 
funded application. By October 1990 PHS wil identify and prioritize key cities that have 
high infant mortality rates and do not have any CPCP grts. By November 1990 PHS wil 
define priority areas to develop successful CPCP proposals. The plan wil drw on regional 
clinical expertse. In addition, PHS wil taget a portion of Fiscal Year 1991 CPCP 
appropriations, which ar in excess of the amount required for continuation grantees, to fund 
new CPCP grants at C/MCs in areas with the highest infant monaity rates. 
OIG RECOMMENDATION

The PHS should reexamine the approach for allocating CPCP funds to assure

that these funds are directed to areas of high infant mortality.

COMMENT FROM PHS 
We concur. We have targeted and wil continue to target CPCP resources to areas of greatest 
need by considerig county infant mortality rates and other indicators of local area need. By 
December 1990, PHS wil consider alternative strategies (other than CPCP) to fund periatal 
activities at curent CPCP sites at which infant mortlity rates and other indicators reflect 
lesser need. This wil assure that continued eligibilty for CPCP fundig is based on highest 
need. 
drt 
Many aras without C/MCs have high infant monaity rates, and on this basis the 
report suggests broadening eligibilty for CPCP funding. Curent appropriation language 
prohibits this. However
, PHS wil identify areas with exceptional need, including periatal 
human immunodeficiency virus, and other excessive health risks, to receive priority 
consideration should funds become available for new C/MHC and CPCP awards. In addition 
PHS wil explore the possibilty of coordinating infant monaity reduction efforts with those 
of other relevant programs.  We believe that limited CPCP funds can be most effectively utilized by targeting 
community-based prima care systems. These systems are well estab ished in C/MCs. To 
do otherwise deletes the cumulative impact of the C/MC and CPCP initiatives. 
OIG RESPONSE TO PHS COMMENTS 
We appreciate PHS' positive response to our recommendtions. 
We are pleased that  PHS wil require grantees to budget
beginning in FY  1991 
separately for CPCP costs and to revise grant budgets in cases where the actul 
award difers from the amount requested. We think it is important that in the 
clearly
future these revised budgets, which were required in FYs 
 1988  an  1989, 
itemize those expenditures proposed exclusively for the CPCP services. 
that the draft report did noi specifcally call for 
Further, we wish to clarif 
broadening eligibilty for CPCP funding. Rather, we expressed concern that 
many areas of the country with high rates of infant mortality lacked CIMHCs. 
Therefore, we suggested that PHS consider, among other issues, how perinatal 
services in those areas might be supported more intensively. 
Finally, we are particularly pleased that PHS is reexamining its approach for 
allocating CPCP funds to assure that these limited funds are targeted to areas of 
highest need.
 , " 
APPENDIX A 
ENDNOTES 
Infant monaity refers to infant 
deatQs before age one. 
Kathleen McCormick  Prenatal Care: Rationing the Risks,  Health,
Medicine 
43(47), Faulker & Gray s Health Care Informtion Center, Washington, D.C., Decem
ber 4, 1989. 
Medicare and Medicaid Guide  Number 597, Commerce Clearng House, Inc., Chicago, 
Illnois, October 11, 1989, p. 8. 
Prenata Care," op. cit. 
Infants born weighing less than 2 500 grs ar low bir weight infants. These infants 
are as much as 40 times more likely to die in the first month of life than normal weight 
infants. 
The National Commission to Prevent Infant Mortalty, "Death Before Life: The 
Tragedy of Infant Mortality," August, 1988, p. 23. 
op. cit. 
Medicare  Medicaid Guide, 
National Center for Health Statistics, Centers for Disease Control, Public Health Ser
vice, Deparment of Health and Human Services. 
Prenata Care," op. cit. 
S. Public Health Service, "The 1990 Health Objectives for the Nation: A Midcourse 
Review," 1986, pp. 36-37. 
The Deparent of Health and Human Services recently released the draft objectives for 
the year 2000, including that the national infant mortalty rate not exceed 7 deaths per 
00 live birhs and that the black infant monaity rate not exceed 11 deaths per 1,000 
live birhs. 
S. Public Health Service, "Promotig Health/venting Disease: Year 2000 Objec
tives for the Nation " Draft Report September, 1989, p. 11
Death Before Life, " op. cit.  , " 
10.	 The set-aside provision requires that two- 75 percent of MCH block grant ap
thirds of 12.
propriations be set aside for infant mortality initiatives. 
Omnibus Reconcilation Act  1989, 101st Cong., 1st sess., HR 
S. Congress, House, 
 of 
3299, Congressional Record, 
 Vol. 135, no. 165, Daily ed. (November 21 , 1989), H9472
H9473. 
11.	 Death Before Life, " pp. 64-65. 
12.	 John Snow, Inc., "Periatal Care: How to Establish Periatal Services in Community 
Health Centers," August, 1985, p. 2. 
13.	 Death Before Life, " p. 7. 
14.	 Contract No. HRSA 240-87-0056, La Jolla Management Corporation  Perinatal Care in 
Communities Served by Community and Migrant Health Centers," Columbia, Mar-
land, 1989, p. ii. 
15.	 S. Senate, Report No. 100-189, "Deparments of Labor, Health and Human Services, 
and Education and Related Agencies Appropriation Bil, 1988," October 1 , 1987. 
S. Senate, Report No. 100-343, "Community and Migrant Health Centers Amend
ments of 1988," Public Law 100-386, August 10, 1988. 
16.	 The PHS reviewed grant applications once each year in a process involving review 
teams in both the regions and headquarers. Final award decisions were made in head
quarers. 
17.	 Bowen, Otis R., M.  , Fiscal Year 1990 Budget Press Conference, Januar 9, 1989. 
18.  S. Senate, Report No. 100-343, op. cit. 
19.	 53 FR 11345-11347. 
54 FR 5679-5681. 
S. Public Health Service, "Supplemental Grants for the Development of a Compre
hensive Periatal Care Program in Community and Migrant Health Centers: Applica
tion Guidance," 1988. 
S. Public Health Service, "Comprehensive Perinatal Care Program-Regional Guid
ance Memorandum 89-4," March 8, 1989. 
S. Public Health Service, "Comprehensive Perinatal Care Program-Grant Application 
Review Process, Regional Guidance Memorandum 89-6," April 28, 1989.  11 
20.	 We reuested the approved budgets for all FY 1988 CPCP grtees from the ten PHS 
Regional Offces. This analysis is based on the budgets for 152 of the 207 FY 1988 
grantees. Budgets from the remaining FY 1988 grantees were not suffciently specific 
to be included. This analysis was limted to FY 1988 grantees because data for the FY 
1989 grantees was not yet available. 
21.	 Ninety-one percent ofFY 1988 grantees and 90 percent ofFY 1989 grantes were 
awarded CPCP funds in amounts lower than the sums they had requested. In both 
years, the average grant award was nearly 60 percent less than the average request. The 
average request in FY 1988 was $232 996; the average amount awarded was $96,325. .. 
In FY 1989, the average request was $182, 140; the average award was $73,508. The 
FY 1989 grantees were awarded funds for periods raging from 3 to 15 months in order 
that they termnate on the last day of the centers
' grant periods for basic 329/330 fund
ing. 
22.	 The PHS has imposed few reporting requirements on grantees regarding their CPCP 
funds-an approach favored by the Congress in order that the new services be initiated 
as quickly as possible. (U.S. Senate, Report No. 100-343, op. cit.) 
23.	 Contract No. HRSA 240-87-0056, "Perinatal Care in Communities Served by Migrant 
and Community Health Centers," op. cit. 
24.  S. Senate Report No. 100-343, op. cit. 
25.	 Our analysis is based on infant mortality rates for the centers' service areas provided to 
us by PHS. These rates were used by PHS when makg funding decisions for CPCP 
grant awards. The PHS calculated infant mortlity rates for each center based on infant 
mortality rates aggregated by county. The PHS acknowledges that these calculated rates 
are thus estimated rates for each center because the center s specific service area may be 
larger or smaller than the county(ies) included in the calculations. 
26.  The 1990 Health Objectives for the Nation " op. cit. 
27.	 S. Senate, Report No. 101-127, "Deparments of Labor, Health and Human Services, 
and Education and Related Agencies Appropriations Act of 1990," Public Law 101-166, 
November 21, 1989, pp. 53 and 55. 
28.	 This analysis is based on infant mortality rates provided by PHS. The data for FY 1988 
is incomplete because rates were not available for all centers and data on disapproved 
applications was not available for one region. 
29.  Prenata Care," op. cit. 
A - 3  ,.-:, .. 
f. 

30.	 This analysis is based on infant mortality data for 1987 from the National Center for 
Health Statistics, PHS. Data on community and migrant health centers are from the 
Bureau of Health Car Delivery and Assistance (BHCDA), PHS. 
Among the 177 cities with populations of 100,00 or more, 136 cities had black infant 
00 
mortality rates greater than or equal to 12 deaths per 1  live birhs; 58 of these 136 
cities were ineligible for CPCP funds. 
Among these 177 cities, 74 cities had genera infant mortality rates 
grater than or equal 
to 12; 30 of these 74 were ineligible for CPCP funds. 
31.  Death Before Life, " p.. 63. 
32.	 Based on infant mortality data for 1985-1987 provided by the National Center for 
Health Statistics, PHS. 
A