Mayor John Lindsay, in a recent communication to Secretary Elliot Richardson, stated that:

It appears most unlikely that local funds could be made available to support these lifesaving health programs if the Federal MIC funds are not available after June 30, 1972.

To abandon the MIC program and return the MIC patients to the overcrowded clinics of inadequately staffed and underfinanced municipal hospitals would nullify most of the advancements made in maternity care during the past 7 years. Once again, these patients, many of whom face special health hazards, would be subjected to long hours of waiting in the overcrowded clinics of most of the municipal hospitals. There would be a means test and charges which would result in many of the patients not receiving care. The quality of maternity care now available in the MIC clinics would not be available if we tried to serve this population without the MIC grants.

Gone would be the warm patient-doctor and patient-nurse relationship never before known to most of the patients before MIC. The MIC clinics convenient to the homes of the patients now serve one-fifth of all of the general service patients in the city. Thirty percent of these MIC patients are on welfare and 70 percent come from what have been designated as working poor families.

Without MIC or other Federal funding, the MIC maternity clinics in New York City we are certain will have to close. Last week, I met with Dr. Byron Hawks, the MIC director in Little Rock, Ark., who told me that if MIC funds are not continued there the low-income women in that city would have to return to "granny midwives" for maternity care.

I know your committee is giving consideration to various proposals for financing nationwide health services. I hope that whatever legislation is enacted will assure the financing of specialized high quality maternity and infant care services wherever needed. Since a new nationwide health program cannot be operative for several years, discontinuing MIC would leave an enormous void between 1972 and until a national health program is in full operation.

I can assure you that tens of thousands of women living in ghetto areas of the cities who have or will benefit from MIC services will be grateful and relieved if the Congress approves continuation of these desperately needed health services for mothers and their children. I thank you.

Mr. BURKE. We will interrupt the testimony at this point, and without objection your chart and the data you have provided appended to your statement will appear in the record.

(The charts referred to follow :)

MATERNITY & INFANT CARE FAMILY PLANNING PROJECTS

- Figure 2. NUMBER OF NEW PRENATAL & NEW FAMILY PLANNING CASES ADMITTED BY MONTH JULY 1964 TO PRESENT

NEW YORK CITY'S IN-HOSPITAL FAMILY PLANNING PROGRAM

(By Edwin F. Dailey,* M.D., Aileen R. Sirey and Lucille S. Goodlet)

In May 1970 over 2,800 medically indigent maternity or post-abortal patients in 23 New York City municipal and voluntary hospitals received family planning counseling-and in seven out of 10 cases were initiated on a contraceptive me thod-before hospital discharge. The counseling is provided on the maternity wards by 51 family planning counselors specially trained and employed by the Maternity and Infant Care-Family Planning Project (MIC-FP) of the New York City Department of Health. The counselors are themselves mothers; some had been on welfare; all live in the vicinities of the hospitals they serve.

The In-Hospital Family Planning Program was begun on an experimental basis in July 1969 with maternity patients in three hospitals. The program is expected to reach 4,000 low-income women each month by the end of 1970 and will be extended from the obstetrics and gynecology departments at least to the outpatient departments of the municipal hospitals. Two more municipal, eight voluntary and four state mental hospitals will be added to the program, with counselors assigned to medical, surgical, psychiatric and other services. It is hoped that eventually in-hospital family planning counseling and services can be offered to all of the 140,000 general service patients of child-bearing age who are discharged each year from New York City municipal and voluntary hospitals. The major objectives of the new in-hospital program are:

To offer family planning information and services to large numbers of women of childbearing age at a time when they are most receptive;

To create a community system to provide such patient education and service involving the cooperation of the Department of Health and the OB/GYN departments (and eventually other departments) of New York City's municipal and voluntary hospitals;

To develop an effective method to select and train community women so as to foster a maximum of commitment and initiative, and provide them with sufficient skill and knowledge so that they can work with a minimum of supervision; To operate this program at a per patient cost far less than the cost of traditional outreach programs; and

To augment scarce manpower resources by employing community women and preparing them as family planning counselors, thus channeling much of the program's funding back into the communities that are served.

BACKGROUND

The MIC-FP project basically provides prenatal care for 12,000 new patients each year in 14 neighborhood centers and hospitals, and family planning services for some 16,000 new patients a year in 28 neighborhood centers.

Early in 1968 the Department of Health, Education and Welfare invited the New York City Department of Health to submit a plan and budget for an expanded family planning program. The MIC-FP director met with chiefs of obstetrics and gynecology in 1 hospitals then participating in the MIC-FP program to seek their advice. These physicians emphasized the importance of getting family planning help to patients as soon as possible after delivery, since this was the period when motivation to accept contraception was highest. They pointed out that numbers of patients were becoming pregnant between their hospital discharge and post partum visit, and that at least 60 percent of patients never returned for a post partum examination. They also suggested that it would be useful to introduce birth control to post-abortal, medical, surgical and psychiatric patients of childbearing age. Despite the tremendous need for introduction of such services, these physicians said, family planning was a low priority item for busy hospital residents, nurses and social workers. A new type of health worker was needed, they said, recruited from the patients' own communities, and specially trained to educate their neighbors about family planning.

Initiation of contraceptive counseling and services immediately after parturition and services immediately after parturition had been tried with some success at Cook County Hospital in Chicago and Grady Memorial Hospital in Atlanta. In neither case, however, was the counseling performed by peer group

*Edwin Daily is a Director of MIC-FP Projects 507 and 707; Aileen Sirey is Director of Community Education and Training, MIC-FP and Lucille Goodlet is Research Associate, MIC-FP, New York City Department of Health.

women drawn from the patients' own neighborhoods. (In Chicago, volunteerspredominantly white and middle-class-counseled a patient group which was poor and mostly black; in Atlanta nurses provided the counseling.) The InHospital Family Planning Program was developed (and endorsed by the OB/GYN chiefs of the 12 hospitals and other key health and family planning leaders in the city) so that family planning counselors would be recruited from the hospital communities, trained by MIC-FP project staff and placed in hospitals which wished to initiate family planning for their patients. The plan and budget ($137,000 for the first 12 months; it is now up to $500,000 a year) was approved by the Department of Health, Education and Welfare (DHEW) Children's Bureau* in March 1969. By July:

A core staff of family planning coordinators had been hired in MIC-FP's Division of Community Education to organize recruitment, screening, training and supervision of the family planning counselors. The coordinators are college graduates, some with experience in teaching or the behavioral sciences, and all with a deep interest in the development of family planning services. Site visits were made to Grady and Cook County Hospitals to observe the in-hospital family planning programs developed there.

A seven-week training course for family planning counselors was developed, and an initial group of six women was recruited and trained.

DEVELOPING THE PROGRAM IN NEW YORK CITY

In October 1969 the program was extended to the OB/GN departments of the nine voluntary and six municipal hospitals then currently participating in MICFP projects. Subsequently, agreements to participate in the in-hospital program were signed with a total of 13 municipal and 10 voluntary hospitals with two more municipal, eight more voluntary and four state mental hospitals expected to join the program by the end of 1970.

The in-hospital agrement is a formal document signed by the OB/GN chief of the hospital and the MIC-FP director. The OB/GYN department of the hospital agrees:

To take charge of the family planning program in the hospital;

To offer all generally accepted methods of family planning (including IUD, pills, tubal ligation and rhythm);

To offer family planning services at least to all maternity and abortion patients, before discharge unless there is a medical contraindication;

To provide family planning services and materials to patients without charge; To acquaint all doctors, nurses and nurses' aides working with women of childbearing age in the hospital with the importance of family planning to the health of the mother and of future children and to the economy of the family; To inform all prenatal patients attending the hospital's OPD service of the importance of family planning and provide appropriate family planning literature;

To appoint a physician thoroughly familiar with all methods of family planning and the indications and contraindications for various methods, and give him responsibility for medical supervision of the in-hospital and out-patient family planning program;

To appoint a nurse-midwife or a nurse interested and fully informed about family planning to assume day-by-day supervision of the family planning counselors;

To instruct all nurses on daytime duty on floors covered by the family planning program about dispensing of pills when this is the method prescribed, and to instruct residents serving these floors about medical approval or disapproval of the methods selected and about insertion of IUDs;

That patients started on a family planning regimen (other than tubal ligation), will be given a written appointment for their first post discharge family planning visit in a hospital or health department clinic most convenient for the patient; a copy of the appointment slip will be sent to the clinic selected, and a copy sent to the MIC-FP director; and

That missed return appointments to the family planning clinic will be followed up by one or two telephone calls or letters requesting that another appointment be made.

*The Childrens Bureau initially directed DHEW's family planning projects grant program, now under the jurisdiction of the National Center for Family Planning Services of the Health Services and Mental Health Administration.

70-174 O 72 pt. 11 15

The MIC-FP director agrees:

To employ and train family planning counselors and assign them to participating hospitals on a full- or part-time basis (depending on the average number of discharges per day of patients);

If the OB/GYN department already has family planning counselors, to reimburse the department for the number of hours each month spent on the inhospital family planning program; and

To pay the OB/GYN department to help defray its added costs: $4.00 for each in-patient initiated on a family planning regime of pills or diaphragm before discharge; $6.00 for each patient with an iUD inserted before discharge; $25.00 for each in-hospital tubal ligation before discharge.

The per capita reimbursement to the OB/GYN departments averages about $7.25 per patient who is initiated on a medically prescribed method.

The role of the counselor is clearly defined: Her duties consist solely of providing family planning information to patients, filling out statistical forms required for reimbursement and seeing to it that a post partum and family planning appointment is arranged for every patient who is initiated on a contraceptive method.

After the agreement is signed, the MIC-FP's Director of Community Education and Training and one of the family planning coordinators begin a series of informal meetings with key hospital staff to reinforce their awareness of program objectives and their understanding of the role of the family planning counselor, as well as to assist professionals in working through complementary role activities with these new peer counselors. Experience has shown that in some hospitals the program is met hesitantly at first.

Typical questions raised are: "Who are these people?" "What kind of training do they have?" "How much supervision will they need?” And, though never articulated, some staff members' attitudes clearly showed that they felt professionally threatened.

MIC-FP's coordinator is responsible at each hospital for establishing an atmosphere of cooperation, and assuring staff involved that the family planning counselors will not add to their already heavy responsibilities.

RECRUITMENT OF FAMILY PLANNING COUNSELORS

Community women are recruited as trainees for the in-hospital program through discussions with such grass-roots agencies as community corporations, Puerto Rican Manpower Development, Planned Parenthood's Community Action Department, the Puerto Rican Guidance Center and the New York State Employment Center. In some cases advertisements are placed in community newspapers. No educational qualifications were established for the position of family planning counselor in order fully to utilize the untapped human resources in the community. At the same time some kind of criteria were needed to evaluate candidates so that the program would not be faced with continual turnover of staff into whose training a great deal of money, time and effort had been expended. A screening process was devised whereby groups of seven to 10 applicants are seen by a staff interviewer and observer. The interviewer describes the program, briefly outlines the responsibilities of the family planning counselor and stimulates group discussion on such subjects as local community problems or the applicants' feelings about family planning. Through this group screening process candidates are sought who can discuss "sensitive" topics on a mature level, show tolerance of the opinions of others and can articulate their own thoughts and feelings. Candidates are expected to show an interest in hospital work and need to be able to read and write sufficiently well to handle the statistical forms.

The interviewer and observer meet after each screening session to discuss each applicant's responses and to select candidates for training. Applicants about whom there is some question are asked back for an individual interview with a different staff member. About one out of five applicants are accepted for training. Successful candidates are started in the training program immediately. The salary during the seven weeks of training is $2.50 per hour, $3.00 an hour when assigned to a hospital and $3.50 an hour after six months. The salary is supplemented with full health insurance (a benefit available for the first time to many of these women and their families).

TRAINING

The training program was developed to provide factual knowledge about family planning, reliable techniques to impact knowledge to patients and an understanding of hospitals and hospital procedures.