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 

mortality rate, the Comprehensive Periatal Care Progr (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. 

Approximately 25 percent of CPCP funds 
 ave been awarded to community and 

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. 
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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 among industralized countres in its rate of infant monaity 10. 1 deaths per 1 000 live 

birhs.2 Although infant mortality rates in the United States have decreased durng the past 

decade, the rate of decline has slowed in recent years.3 This is largely because the incidence 

of low binhweight birs-a 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 of 8. 6 deaths per 1 000 live birhs for whites.S In 1986, the infant mortalty rate was 21.1 

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 

financial support to C/MCs, which provide comprehensive priar 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


assuring healthy pregnancy outcomes and in reducing infant deaths. 13 Equally important are


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 reucedf 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 existing perinata 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. 15

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 

were separate from the process followed for the centers' regular 329/330 funding. 16 The 

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 

CPCP as the "leading edge of DHHS' total efforts to reduce infant monaity. ,,17 Moreover 

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 

announcements of available funds published in the Federal Register, 
 and the application 

guidance developed and administered by PHS. Our review of these documents confIrmed that 

PHS has approved CPCP grt proposals consistent with the intent of Congress, the criteria in 

the Federal Register and the application guidance for the CPCP. 

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 fist year of life in order to meet effectiveiy 

the health care needs of mothers and infants. 18 The Congrss hoped that an infusion ofthese 

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 

those criteria summarzed in the Federal Register 
 and described in the application guidance 

for each year. 19 The PHS required applicants to submit proposals which addressed these 

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 

purposes outlined by Congress and described in the application guidace.20 Case 

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 

or basic level of 329p30 funding in FY 1990. This approach appears to be consistent with the 

intent of Congress,2 and Wil 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 monaityproblem. 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 greater than 12 deaths per 1 000 live 

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 

community and migrt 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 

CPCP initiative remains to be seen. As noted earlier, the progr is stil relatively new and 

these efforts ar 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 

1987 was 10. 1 deaths per 1 00 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 

population were also not eligible.30 In fact, of the ten cities in the 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 

Rates for Cities of 100,000 or More, 1987 

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 health centers are located in urban aras.31 Yet urban aras nationally have had 

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 rual areas, but so too has the incidence of infant death. Indeed, 

at least 3.5 times as many infant deaths occured in metropolitan areas as in non-metropolitan 

areas during the 3-year period 1985- 1987.32 Thus, because CPCP funds have been limited to 

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 

funds wil best serve the intent of this initiative. Resources ar 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 

evaluate CPCP's impact. The recommendations of the drt 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. 

We are now reviewing strategies to improve progr 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 

We concur. PHS is reviewing alternative strategies which optimize progr 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. 

Cuntly, CPCP and C/MC 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. 

Many aras without C/MCs have high infant monaity rates, and on this basis the drt 

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 beginning in FY 1991 PHS wil require grantees to budget

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 

future these revised budgets, which were required in FYs 
 1988 an 1989, clearly

itemize those expenditures proposed exclusively for the CPCP services. 

Further, we wish to clarif that the draft report did noi specifcally call for 

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, Medicine Health,

43(47), Faulker & Gray s Health Care Informtion Center, Washington, D.C., December 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. 

Medicare Medicaid Guide, op. cit. 

National Center for Health Statistics, Centers for Disease Control, Public Health Service, 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 Objectives for the Nation " Draft Report September, 1989, p. 11­

Death Before Life, " op. cit. 
, 

10.	 The set-aside provision requires that two-thirds of 12.75 percent of MCH block grant appropriations be set aside for infant mortality initiatives. 

S. Congress, House, 
 Omnibus Reconcilation Act of 1989, 101st Cong., 1st sess., HR 

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, Marland, 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 Amendments 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 headquarers. 

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 Comprehensive Periatal Care Program in Community and Migrant Health Centers: Application Guidance," 1988. 

S. Public Health Service, "Comprehensive Perinatal Care Program-Regional Guidance 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 funding. 

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 

mortality rates greater than or equal to 12 deaths per 1 00 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. 

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