FALLING THROUGH THE CRACKS: Introduction
The need for focused attention on births to low-income mothers in Hennepin and Ramsey counties is compelling. Within the state of Minnesota, slightly more than one third (35.7%) of births occur in the metropolitan area represented by the counties of Hennepin and Ramsey . Yet, Hennepin and Ramsey account for over 43.5% of the states infant deaths annually, a disproportionate share compared to number of births. Slightly less than one-third (30%) of all Minnesota births occur in the low-income population insured under the states Medicaid program which includes fee-for-service Medical Assistance (MA), the Prepaid Medical Assistance Program (PMAP) and MinnesotaCare . In Hennepin and Ramsey counties the percentage of newborns eligible to receive Medicaid during 1999 was 40%. This increased number of low-income births is likely due to the combination of higher concentrations of poverty and higher birth rates among residents of Minneapolis and St. Paul .
Two infant mortality review projects conducted in the Twin Cities area in the 1990s concluded that a highly-fragmented perinatal service delivery system is a factor in many urban infant deaths. Reviewers from the two projects repeatedly identified the lack of comprehensive, coordinated support servicesabove and beyond the provision of basic medical careas a systems issue contributing to infant mortality. Comprehensive medical, social, and behavioral risk assessments, coupled with indicated support services, have long been recognized as essential components of high quality perinatal care. To provide such comprehensive services requires a coordinated approach and a barrier free system with sufficient capacity (Brown, 1988).
Based on estimates of poverty and birth rates described above, it is projected that between 8,000 and 9,000 births annually to women in poverty in the Twin Cities metropolitan area may be impacted by a system of perinatal care that lacks adequate coordination. During the three-year period 1997-99, the overall infant mortality rate for the state of Minnesota was 6 infant deaths per 1000 live births. In Hennepin and Ramsey counties the rate was 7. 9 for those years. Within the city limits of Minneapolis and St. Paul, the rate was 8. 6 for the same time period . These data raise the following question: Does fragmented care for low-income women contribute to the excess infant deaths experienced by families in Hennepin and Ramsey counties?
In addition to concerns about the urban disparity, the racial and ethnic infant mortality disparity between populations of color and American Indians as compared to the white population is well-documented and long-standing in Minneapolis and St. Paul as well as in Hennepin and Ramsey counties.
In spite of improvements in health care for all infants, the difference between African American and white infant mortality rates continues to be two- to three-fold. American Indian infant mortality differences have actually increased in the last time period measured to rates three to four times greater than the white rate. As may be expected, similar disparities are demonstrated at the county level.
Concern about these data prompted maternal and child health leaders in the health departments of Minneapolis and St. Paul to conduct the first infant mortality review project on deaths occurring in 1993. The second project reviewed randomly selected deaths occurring in Hennepin and Ramsey counties in 1996-97.
While the two infant mortality reviews identified weaknesses and gaps in perinatal
care coordination, they were not intended to document system-wide capacity.
Therefore, in 1999, the Perinatal Survey Team was formed to examine perinatal
care coordination and identify capacity issues in the metropolitan area. The
vehicle chosen for this study was a qualitative survey, developed specifically
for use in this research and administered to
health care agencies and organizations serving Hennepin and Ramsey counties. This research report contains the findings of those surveys, a discussion of key issues, conclusions and recommendations, and an update of community changes that have occurred since the surveys were completed.
1. There are 23,542 resident births in Hennepin and Ramsey counties
combined, with 65,953 total births statewide. Minnesota Center for Health Statistics,
2. Minnesota Department of Human Services, personal communication.
3. Minnesota Center for Health Statistics, MDH
4. Minnesota Center for Health Statistics, MDH
Page 4 of 21