Service Area Statistics

1. Need
   1. Introduction and Project Plan:  Low Country Healthy Start (LCHS) will provide the required core services of outreach and client recruitment, health education, interconceptional continuity of care, perinatal depression screening, counseling, follow up, and case management to all program participants. The only perinatal specific, targeted core services available currently in the Service Area are those through Healthy Start funding. The county health departments provide Family Support Services (FSS) for Medicaid clients; which could be a quasi-perinatal service intervention, however, the service plan is very limited, must be ordered by a clinician and must meet a medical need. Services are very episodic and short term.

      The only other case management services available to clients in the perinatal period are Early Intervention resources for infants and very young children with disabilities through the SC Department of Disabilities and Special Needs (SCDDSN). Early intervention workers provide coordination and family training to children ages 0-3. LCHS case management staff work closely with SCDDSN by referring clients who score below average for developmental milestones on the Ages and Stages questionnaire.

      The purpose of the LCHS project is to work with African American women to help them improve their own perinatal outcomes; improve their own lives and the lives of their children and families. LCHS is also building a solid infrastructure in the communities by creating partnerships with other perinatal providers such as Federally Qualified Health Centers (FQHC), state and local Title V agencies, birthing hospitals, private obstetric providers, family practices, faith based and community based organizations.

      The quality of life for the African American population is poor with many families experiencing chronic health problems and facing significant barriers to accessing care and meeting basic human needs. The section that follows describes the daunting education, poverty and health status of many African American women. LCHS efforts and interventions, therefore, will focus on the African American population’s poor birth outcomes, poor life skills , obesity related illnesses, and overall mental health status. Other pregnant women, however, referred by perinatal partners will be offered and provided services if the risk criteria are met. The Hispanic population is small, but growing. According to the 2000 Census, data for the Service Area reveal that 0.9% of female population between the ages of 10 and 44 are Hispanic.

      Without Healthy Start resources, the core services needed to improve perinatal health will not be provided or coordinated and women will not be encouraged to take advantage of services that could possibly help. As state budget cuts cause resources to be withdrawn and staff terminated, essential resources that remain available are more difficult to access. LCHS staff help women learn what they need to do to secure services and resources needed by themselves and their families. Area providers are willing to work with LCHS and are willing to make some changes in their work but they are not willing to lead. Change will only occur with LCHS leadership, perseverance and focus.

      African Americans, living in these four counties - Allendale, Bamberg, Hampton, Orangeburg - have extremely high rates of poverty and are geographically isolated from services. Many have to travel outside of the Service Area to receive obstetric care and other specialty services. Provider retention in rural communities is fragile and some perinatal services not available. Many of LCHS partners have difficulty in retaining perinatal medical providers and the consistent turn over, and frequent losses of coverage, are difficult to manage. LCHS will continue to focus, and encourage partners to focus, on women receiving adequate and risk appropriate prenatal care, first trimester admission to prenatal care and, on improving the postpartum and family planning system for African American women at risk for unintended pregnancy. LCHS will focus on African American women receiving adequate and risk appropriate prenatal care and entering prenatal care in the first trimester. The challenges with the prenatal system are enormous and the content of prenatal care provided is concerning. The Local Health System Action Plan addresses how LCHS, and partners, will improve prenatal care utilization and pregnancy intent and describes the level of involvement from the staff, Consortium, Title V, program participants and community participants.

      Proposed contracts have been strategically considered and proposed with essential partners. The chart below provides an overview of the staffing and partners proposed for each Core Service.

      Core Service	Proposed Number of Staff	Proposed Caseload per staff	Proposed Contractors and Partners
      Outreach and Client Recruitment	4 outreach workers who also assist with clinic based retention services	4 outreach workers with caseload of 55 clients to contact and follow per year. Total caseload of 220.	Will work with FQHCs, physicians, CNM and other perinatal providers in the Service Area
      Case Management	7 Perinatal Resource Coordinators	7 with 50 clients per year; mother and infant making up one case for two years. Total caseload of 350 clients.	FQHCs, physicians, CNM and other perinatal providers in the Service Area
      	3.5 Perinatal Social Workers	3 with 50 clients per year, with the mother and infant considered as one case for two years; .5 with 25 clients per year. Total caseload of 175 clients.
      Health Education and Training		Childbirth & Breastfeeding classes, 20 and 12 classes per year, respectively; Community Group Education, 6 per year	Contracted Perinatal Health Educators
      Interconceptional Care Services	Staffed by the same group in Case Management	250 women followed to assure pregnancy spacing and improved life and career skills; 250 infants followed to ensure medical home, well baby care and immunizations.	FQHCs, physicians, CNM, health departments and other perinatal providers in the Service Area
      Perinatal Depression	3.5 Perinatal Social Workers	Screen 425 pregnant and postpartum women per year.	FQHCs, physicians, CNM and mental health centers in the Service Area

       

   2. Community Assessment:  The LCHS geographic Service Area is four rural counties - Allendale, Bamberg, Hampton and Orangeburg - in the Low Country region of South Carolina. The African American population is the focus of this proposal’s interventions, as perinatal indicators are substantially unequal to the white population, and to the African American population in much of South Carolina and the nation. Most health outcomes and many social and economic indicators reveal the disparity in health and in prosperity experienced by the African American population living in this area.

      There are some perinatal provider assets available by county, as shown below. The health service assets shown are highly vulnerable to changes in Medicaid and Medicare policies as the population is substantially uninsured through work and private health insurance. Federal investments from the Bureau of Maternal and Child Health, as well as investments and assistance from other HRSA programs – Office of Rural Health Policy, Bureau of Primary Care and the Bureau of Health Professions – make a critical difference in the health care infrastructure of this very poor area. At the time of this proposal, all providers noted below accept Medicaid as a payment source and none have a waiting list for new patients.

      Perinatal Service	Allendale	Bamberg	Hampton	Orangeburg
      Obstetricians	No	No	No	Yes
      Pediatricians	No	No	No	Yes
      Family Physicians – delivery and newborn care	Yes	Yes	No - OB; Yes-Newborn	No
      Certified Nurse Midwives – delivery and newborn care	Yes	Yes	No	No
      Birthing Hospital	Yes, Level 1	Yes, Level 1	No	Yes, Level 2
      Health Department	Yes	Yes	Yes	Yes
      Federally Qualified Health Center	Yes	No	Yes	Yes

      Obstetric and newborn capacity is acceptable now; however, the FQHCs in Allendale and Orangeburg have serious, long-term problems in perinatal provider retention. At times, the medical perinatal capacity is not sufficient. Frequent provider turnover is a problem for clients, as well as for the providers and hospital staff working in perinatal care. The Allendale FQHC is essential as that center provides the bulk of perinatal services for the clients and families in Allendale and Hampton Counties.

      Psychiatric capacity in the Service Area is minimal, with no psychiatrist available to provide care to Medicaid clients except in the direst, life threatening situations. The LCHS Program Director and the SC Office of Rural Health director are working with medical school leaders at the University of South Carolina to resolve this serious deficit through using psychiatric residents and telemedicine. They will continue working until a remedy is developed and implemented.

      The following charts depict perinatal events and outcomes for the African American and white population, by county, compared with the Service Area and state. In all data charts, black is synonymous with African American. In some cases, the numbers of events are included as well as rates. This is necessary with few events. African American infant mortality and percent of low weight and very low weight births are unacceptably high; however, progress is being made. This proposal outlines work that will be done to decrease the rates and improve birth outcomes.

      Required data for 1999 - 2001 follow, and when available data for 2000 - 2002 for the Service Area and SC are provided. The actual number of live births for the black population decreased from 1999 – 2001 to 2000 to 2002, as did the total number of births. LCHS and other partners have worked to assist women with spacing and planning pregnancies. The decrease in the number of births is welcomed as too many births are unplanned and unintended.

      Live Births
      	Total	White		Black		Other or Unknown
      	Number	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	524	80	15.3	443	84.5	1	0.2
      Bamberg	666	217	32.6	447	67.1	2	0.3
      Hampton	912	355	38.9	551	60.4	6	0.7
      Orangeburg	3,939	1,229	31.2	2,675	67.9	35	0.9
      Service Area	6,041	1,881	31.1	4,116	68.1	44	0.7
      South Carolina	166,418	105,560	63.4	57,605	34.6	3,253	2.0
      2000 - 2002
      Service Area	5,847	1,814	31.0	3,996	68.3	37	0.6
      South Carolina	166,165	106,029	63.8	56,744	34.1	3,392	2.0
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      Infant and neonatal mortality in the African American population have dropped significantly since LCHS began its work in the region. Many other providers, and state and federal policy, contributed to this success. According to the SC Office of Research and Statistics, there is a statistically significant decreasing trend from 1999 to 2002 for the African American (Black) infant mortality rate and African American neonatal mortality rate in the Service Area. The neonatal mortality in the African American infant population contributed most to the infant mortality decline in 2000-2002. The African American postneonatal mortality dropped enough to match the state rate. While LCHS is gratified by these important reductions in deaths and improvement in health indicated, much remains to be done and LCHS will continue the work begun and with some changes in strategy expect to make an even bigger impact in the lives of African American families.

      The number and rate of infant deaths attributable to SIDS is low. From 1999^through 2001, in the Service Area, one white infant died whose death were diagnosed as a SIDS death and four Black infants died whose deaths were diagnosed as SIDS. The African American rate per 100,000 live births for 1999-2001 is 97.2 and the black rate for South Carolina in the same period is 114.6, per 100,000 live births.

      Infant Mortality
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	2	25	6	13.5	0	0	8	15.3
      Bamberg	0	0	9	20.1	0	0	9	13.5
      Hampton	2	5.6	6	10.9	0	0	8	8.8
      Orangeburg	4	3.3	48	17.9	0	0	52	13.2
      Service Area	8	4.3	69	16.8	0	0	77	12.7
      South Carolina	634	6	897	15.6	17	5.3	1548	9.3
      2000 - 2002
      Service Area	6	3.3	57	14.3	0	0	63	10.8
      South Carolina	606	5.7	863	15.2	21	6.2	1491	9
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      
      

      Neonatal Mortality
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	2	25	2	4.5	0	0	4	7.6
      Bamberg	0	0	5	11.2	0	0	5	7.5
      Hampton	0	0	4	7.3	0	0	4	4.4
      Orangeburg	3	2.4	38	14.2	0	0	41	10.4
      Service Area	5	2.7	49	11.9	0	0	54	8.9
      South Carolina	424	4.0	637	11.1	10	3.1	1071	6.4
      2000 - 2002
      Service Area	5	2.8	39	9.8	0	0	44	7.5
      South Carolina	404	3.8	605	10.7	13	3.9	1023	6.2
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      
      

      Postneonatal Mortality
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	0	0	4	9	0	0	4	7.6
      Bamberg	0	0	4	8.9	0	0	4	6
      Hampton	2	5.6	2	3.6	0	0	4	4.4
      Orangeburg	1	0.8	10	3.7	0	0	11	2.8
      Service Area	3	1.6	20	4.9	0	0	23	3.8
      South Carolina	210	2.0	260	4.5	7	2.2	477	2.9
      2000 - 2002
      Service Area	1	0.6	18	4.5	0	0	19	3.2
      South Carolina	202	1.9	258	4.5	8	2.4	468	2.8
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      The percent of births that are low birth weight and very low birth weight in the African American population in the Service Area exceed the state rate, however, the Service Area African American LBW and VLBW rate declined from the 1999 - 2001 to the 2000 - 2002 data average as shown below. This is a big step forward as fewer low birth weight births is a significant improvement in health for African American children and savings in terms of health costs.

      Number and Percent of Low Birth Weight Infants (<2500 grams)
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	4	5.0	67	15.1	0	0.0	71	13.5
      Bamberg	13	6.0	63	14.1	0	0.0	76	11.4
      Hampton	19	5.4	64	11.6	1	16.4	84	9.2
      Orangeburg	86	7.0	441	16.5	5	14.3	532	13.5
      Service Area	122	6.5	635	15.4	6	13.6	763	12.6
      South Carolina	7,651	7.2	8,252	14.3	251	7.7	16,154	9.7
      2000 - 2002
      Service Area	112	6.2	601	15.0	5	13.5	718	12.3
      South Carolina	7,796	7.4	8,135	14.3	283	8.3	16,214	9.8
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      
      

      Number and Percent of Very Low Birth Weight Infants (<1500 grams)
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	2	2.5	9	2.0	0	0.0	11	2.1
      Bamberg	1	0.5	19	4.3	0	0.0	20	3.0
      Hampton	3	0.8	14	2.5	0	0.0	17	1.9
      Orangeburg	11	0.9	99	3.7	0	0.0	110	2.8
      Service Area	17	0.9	141	3.4	0	0.0	158	2.6
      South Carolina	1,323	1.3	1,931	3.4	30	0.9	3,284	2.0
      2000 - 2002
      Service Area	15	0.8	126	3.2	0	0.0	141	2.4
      South Carolina	1,327	1.3	1,850	3.3	41	1.2	3,218	1.9
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      Adolescents having babies is an ever present concern of LCHS staff as well as of parents, civic leaders, faith leaders and community leaders. LCHS has worked to make it a relevant and understood concern of girls, as well. LCHS has worked to drive home the message that giving birth as an adolescent is a ticket to a life of poverty. This message is echoed by other health, faith and education leaders in the Service Area and, finally the message appears to be getting through, however, the service percent of live births to girls less than 17 exceeds the unacceptably high state percent for both the white and black rates. The percent of live births to teens less than 18 is shown below for 1999 - 2001 and 2000 - 2002. The decreases in the black percentage of live births to girls less than 18 in the Service Area in the 2000 - 2002 timeframe is positive and likely reflects improved understanding about pregnancy, risks, family planning and abstinence.

      According to the SC Office of Research and Statistics, the Service Area experienced a statistically significant decreasing trend from 1999 to 2002 for African American (Black) births to teens 17 and under, as compared with all African American births, in the Service Area, as well as for African American births to teens 17 and under in the entire state.

      Percent and Number of Live Births to Teens Age 10 – 17
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	3	3.8	49	11.1	0	0.0	52	9.9
      Bamberg	10	4.6	38	8.5	0	0.0	48	7.2
      Hampton	27	7.6	49	8.9	0	0.0	76	8.3
      Orangeburg	54	4.4	242	9.0	1	2.9	297	7.5
      Service Area	94	5.0	378	9.2	1	2.3	473	7.8
      South Carolina	3958	3.7	5132	8.9	95	2.9	9185	5.5
      2000 - 2002
      Service Area	73	4.0	309	7.7	2	5.4	384	6.6
      South Carolina	3712	3.5	4646	8.2	97	2.9	8455	5.1
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      Adolescent pregnancy rates for girls 15 to 17 years of age have also declined in the Service Area, according to Kids Count and SC DHEC since 1999. In Bamberg the rate fell from 42.3 in 1999 to 25.0 per 1,000 in 2002. The other counties have also reduced their rates with Allendale reducing their rate from 100.0 in 1999 to 85.7 in 2002; Orangeburg reduced their rate from 59.9 in 1999 to 40.1 in 2002; and Hampton County's rate was reduced from 65.2 in 1999 to 46.5 in 2002. In SC the rate was 38.2 in 2002. The Hampton rate is creeping up again and Allendale continues to lead South Carolina as the county with the highest teen pregnancy rate.

      Providing and receiving timely, adequate and risk appropriate prenatal care is a significant challenge in the Low Country. There are systemic problems, which LCHS has addressed in the past and proposes to address in the future. Some improvements have been made but the system issues, outlined in other sections, must be continuously addressed. System issues have been identified addressed and then become broken again especially the system issues around financial barriers. Medicaid (as shown below) covers the majority of African American births. However, before women are given a prenatal appointment in Orangeburg County, Medicaid coverage has to be confirmed. This is a serious and frustrating problem that was basically solved for a few years and then worsened as Medicaid budgets got tighter and officials made the application process more cumbersome. In Allendale and Hampton counties, client education and recognition that prenatal care in the first trimester is important, has been a barrier to overcome. In the years reflected below in Hampton County, there were no prenatal providers. In Allendale the only prenatal care provider is the FQHC. LCHS will remain focused on early entry into prenatal care as a major priority and will continuously investigate system corrections required and attempted. Messages about the importance of first trimester prenatal care will be targeted for clients and obstetric providers.

      Percent of Total Births Covered By Medicaid
      	White	Black	Total	White	Black	Total	White	Black	Total
      	Year: 1999			Year: 2000			Year: 2001
      Allendale	53%	93%	88%	52%	76%	73%	39%	72%	69%
      Bamberg	44%	80%	69%	38%	80%	66%	40%	79%	67%
      Hampton	46%	82%	68%	51%	81%	69%	47%	79%	66%
      Orangeburg	45%	72%	63%	42%	70%	61%	43%	68%	61%
      Service Area	45%	76%	66%	43%	73%	63%	44%	71%	63%
      South Carolina	36%	71%	49%	34%	69%	47%	35%	69%	47%
      	Year:2002			Year: 2003			2004 data not yet available
      Allendale	42%	69%	66%	35%	88%	77%
      Bamberg	41%	76%	65%	51%	75%	69%
      Hampton	51%	82%	69%	53%	83%	72%
      Orangeburg	41%	71%	61%	50%	72%	65%
      Service Area	43%	73%	63%	50%	75%	67%
      South Carolina	34%	68%	47%	36%	69%	48%
      Data Source: Uniform Billing data, Office of Research and Statistics

      Trimester of admission to prenatal care is a fundamental measure used to evaluate not only the effectiveness of the prenatal system but also access to care. As depicted below, the disparity regarding when care begins for the black population is a serious problem for the Service Area and for each county. A little progress was achieved in the Service Area in terms of the percent of first and second trimester of admission to prenatal care for black women comparing 1999 - 2001 with 2000 - 2002. There is improvement in first trimester admissions in Allendale, Bamberg and Hampton. The lack of improvement in Orangeburg held the Service Area improvement down, as the number of black births in Orangeburg is higher than in the other counties. The state percent remained constant in these two, three year rates in first trimester admissions. This measure is one that is being addressed by the Local Health System Action Plan.

      Percent Live Births Entering Prenatal Care by Trimester
      	White	Black	Other	Total	White	Black	Other	Total
      	1999-2001				2000-2002
      First Trimester
      Allendale	81.7	55.1	100.0	59.3	75.3	56.6	100.0	59.3
      Bamberg	83.0	69.0	100.0	73.6	85.8	70.9	66.7	75.7
      Hampton	79.3	58.6	100.0	66.7	80.8	63.2	100.0	70.4
      Orangeburg	86.8	69.0	76.5	74.7	84.6	68.0	66.7	73.0
      Service Area	84.8	66.1	81.0	72.0	83.6	66.4	71.8	71.7
      South Carolina	83.9	69.1	75.3	78.5	82.8	69.1	74.5	77.9
      Second Trimester
      Allendale	9.6	30.0	0.0	26.8	13.7	29.8	0.0	27.5
      Bamberg	11.3	21.4	0.0	18.1	8.3	21.3	33.3	17.2
      Hampton	11.7	27.9	0.0	21.6	10.5	23.4	0.0	18.2
      Orangeburg	9.5	22.3	20.6	18.3	11.5	23.8	30.0	20.1
      Service Area	10.1	23.8	16.7	19.5	11.0	24.2	25.6	20.2
      South Carolina	11.8	22.0	18.2	15.5	12.9	22.6	19.5	16.4
      Third Trimester
      Allendale	3.7	11.3	0.0	10.1	8.2	9.8	0.0	9.6
      Bamberg	2.8	3.8	0.0	3.4	3.4	3.6	0.0	3.5
      Hampton	5.4	6.6	0.0	6.1	4.4	6.8	0.0	5.8
      Orangeburg	2.1	5.6	2.9	4.5	2.3	6.1	3.3	4.9
      Service Area	2.9	6.2	2.4	5.1	3.1	6.3	2.6	5.3
      South Carolina	2.8	5.6	4.6	3.9	3.0	5.7	4.7	3.9
      Data Source: SC DHEC Vital Records, SC Office of Research and Statistics

      The adequacy of prenatal care, as measured by the Kessner Index, is a serious Service Area problem. The following table clearly reveals the disparity in terms of adequacy of prenatal care. Too many African American women still are not receiving adequate care; however, LCHS is heartened by the slight Service Area improvement for Black women in the 2000 to 2002 period. LCHS will continue to work directly with providers and African American women, and the people who influence them, to clarify why and how adequate care is life changing for a newborn and thus the entire family and community.

      Women with Less Than Adequate Prenatal Care (Kessner)
      	White		Black		Other / Unknown		Total
      	Number	Percent	Number	Percent	Number	Percent	Number	Percent
      1999 - 2001
      Allendale	18	22.5	239	54.0	0	0	257	49.0
      Bamberg	51	23.5	163	36.5	0	0	214	32.1
      Hampton	97	27.3	277	50.3	2	33.3	376	41.2
      Orangeburg	249	20.36	1,022	38.2	9	26.5	1,280	32.5
      Service Area	415	22.1	1,701	41.3	11	25.6	2,127	35.2
      South Carolina	22,057	20.9	21,057	36.6	389	30.6	44,103	26.5
      2000 - 2002
      Service Area	416	22.9	1,604	40.1	14	37.8	2,034	34.8
      South Carolina	23,001	21.7	20,667	36.4	1,086	32.0	44,754	26.9
      Data Source: Community Assessment Network, SC Department of Health and Environmental Control

      Data regarding HIV/AIDS and other sexually transmitted diseases are presented below. The county and state data are presented for Black (or African American) and the white rates are included for SC only for comparison. The HIV/AIDS rates are unacceptably high, as are the Chlamydia and Gonorrhea rates. These data will be the subject of the first Multidisciplinary Team meeting in 2005 and will be a central target of the corrective action needed by perinatal partners in the region. These rates will also be discussed and included in the Local Health System Action Plan as a part of the family planning indicator.

      HIV/AIDS Three-Year Cases Rates and Prevalence
      	1998-2000		2001-2003		Prevalence*
      	Cases	Rate	Cases	Rate	Cases	Rate
      Allendale	20	58.8	7	21.2	47	429.3
      Black	18	75.9	7	29.3	43	541.1
      Bamberg	20	40.4	21	42.8	107	655.9
      Black	19	61.6	19	61.6	104	1,016.0
      Hampton	32	53.6	23	35.9	96	450.4
      Black	32	96.9	19	52.2	86	710.2
      Orangeburg	112	42.0	93	34.0	484	530.8
      Black	106	65.8	81	47.0	438	760.6
      South Carolina	3,122	26.6	2,707	22.0	13,087	318.6
      White	609	7.5	515	6.1	3,225	115.0
      Black	2,436	66.6	2,081	53.6	9,569	734.2
      * Prevalence counts consist of cumulative cases still living at the end of 2003. AIDS cases are cumulative from 1981. HIV/AIDS cases are commutative from 1986. AIDS cases are included in counts of HIV/AIDS cases. Cells with < 4 cases are censored due to confidentiality restrictions. Case rates per 100,000 population based on census estimates. Data Source: STD/HIV Division, SC Department of Health and Environmental Control

      
      

      	Chlamydia Cases and Annual Rates*						Gonorrhea Cases and Annual Rates*
      	2001		2002		2003		2001		2002		2003
      	Cases	Rate	Cases	Rate	Cases	Rate	Cases	Rate	Cases	Rate	Cases	Rate
      Allendale	128	1,158.9	131	1,196.5	90	823.1	80	724.3	72	657.6	58	530.5
      Black	80	1,005.8	63	797.6	49	614.7	52	653.8	40	506.4	34	426.5
      Bamberg	110	671.0	99	606.8	135	841.6	87	530.7	54	331.0	58	361.6
      Black	71	688.3	60	589.1	66	654.8	58	562.2	43	422.2	38	377.0
      Hampton	102	476.4	88	412.8	300	1,402.5	51	238.2	34	159.5	253	1,182.7
      Black	76	630.0	49	408.4	198	1,623.7	44	364.7	23	191.7	175	1,435.1
      Orangeburg	542	593.4	543	595.5	606	665.7	403	441.2	341	373.9	295	324.1
      Black	293	521.3	306	540.2	292	511.0	286	508.8	232	409.6	172	301.0
      South Carolina	12,755	313.9	12,435	302.8	14,879	358.8	8,716	214.5	7,960	193.8	8,646	208.5
      White	1,570	56.3	1,783	63.6	1,943	68.8	734	26.3	665	23.7	908	32.2
      Black	6,739	551.9	6,754	545.1	7,132	567.2	5,784	473.7	5,015	404.8	5,217	414.9
      Data Source: SC DHEC and SC Office of Research and Statistics. * Case rates per 100,000 population are based on Census estimates.

      Following are data regarding the health of infants and children less than two. The data from the SC Department of Social Services, as reported by Kids Count, regarding infant and child abuse and neglect are stunning. Clearly case workers are finding that a higher proportion of reported African American infants and children less than two are actually being victimized. Progress is being made in two of the four counties, however, in the other two - it appears that the situation is worsening and that a higher percent of African American infants and children are being victimized. LCHS will continue to work with other providers, as well as families and community and faith leaders to bring to light the causes of this abuse and neglect, and work to help families deal better with stress, move out of poverty and help them control their lives through family planning and through improving health and thus quality of life.

      Infant/Child Abuse and Neglect
      	Number of Investigations into Reported Cases	Number of Indicated Cases	Number of Children Victimized	Percent White (of Children Victimized)	Percent Black and Other (of Children Victimized)
      1999-2000
      Allendale	45	20	29	6.9	93.1
      Bamberg	67	21	33	3	97
      Hampton	118	50	93	34.4	65.6
      Orangeburg	346	88	112	20.5	79.5
      2000-2001
      Allendale	48	25	60	0.0	100.0
      Bamberg	49	22	39	30.8	69.2
      Hampton	108	41	83	15.7	84.3
      Orangeburg	289	79	132	25.8	74.2
      Data Source: Kids Count 2001, SC Budget and Control Board, Office of Research and Statistics Number of indicated cases refers to the number of investigations the Department of Social Services indicated for abuse or neglect.

      Other health behaviors and health indicators must be addressed because of their impact on perinatal health. Too many African American women are unhealthy when they conceive. Too many African American women of child bearing age, female children and adolescents are plagued by obesity. The level of obesity experienced by adolescent girls and women exacerbates many other women's health conditions, including perinatal complications such as long labors, unstable menses, diabetes, heart disease, hypertension, as well as the associated risks for breast cancer. Too many women, female children and adolescents are not physically active and do not exercise. Too seldom do females choose, purchase, prepare and eat healthy, nutritious food.

      In rural communities, the cost of food is higher than in urban communities and this is especially true of fresh fruits and vegetables as grocers are charged more for transportation and rural stores have too much spoilage. In the LCHS area, there are too few walking paths, bike paths, fitness centers that are attractive, affordable and acceptable to African American women and families. LCHS has worked to influence schools, hospitals and county governments to consider how to make increased physical activity a part of community life.

      Maintaining healthy weight, through better nutrition and increasing physical activity, are perinatal health issues LCHS will address. The contribution of obesity to high risk pregnancies is significant, as hypertension, diabetes, heart disease; birth weight and cesarean sections are all impacted negatively and exacerbated by obesity of the pregnant woman.

   3. Identification of the Targeted Population(s):  The Service Area is rural in geography, with all counties designated as non-metropolitan areas. The population is beleaguered by lack of education, lack of job opportunities and poverty. There are very few pockets of affluence. Below information is charted related to women of childbearing age and poverty, average education level, employment stat us, and major industries that employ women in the target population.

      Women of Childbearing Age, By Race, Low Country Service Area and South Carolina
      	Total population White	Total population Non-White	Total population Percent of Non-White	Total population	Total population Female; 10 to 44	Number of Non-White Female; 10 to 44	Percent of Non-White Female; 10 to 44
      Allendale	3,068	8,143	72.6%	11,211	2,494	1,998	80.1%
      Bamberg	6,075	10,583	63.5%	16,658	4,306	3,047	70.8%
      Hampton	9,173	12,213	57.1%	21,386	5,055	3,149	62.3%
      Orangeburg	34,045	57,537	62.8%	91,582	24,348	17,138	70.4%
      Service Area	52,361	88,476	62.8%	140,837	36,203	25,332	70.0%
      South Carolina	2,695,560	1,316,452	32.8%	4,012,012	1,026,682	377,429	36.8%
      Source: U.S. Census Bureau - SF1 - Table P7 and SF 3- Table P12, Census 2000

      Living in poverty is the variable that leads to poor health, low educational attainment, depression, stress and a cascade of negative life experiences. African American women living in the Service Area are beset by poverty as the following table shows. The percentages of white females with incomes below poverty are included for the staggering comparison.

      Black or African American Female Population for Whom Poverty Status is Determined, by Age and Poverty Status – 2000 Census
      	Total Black Females 15 years to 44 years	Total Black Females Below poverty level – 15 to 44 years	Percent of Black Females Below Poverty Level	Percent of White Females Below Poverty Level
      Allendale	1,591	685	43.1%	9.6%
      Bamberg	2,290	907	39.6%	18.2%
      Hampton	2,497	798	32.0%	8.9%
      Orangeburg	12,792	3,862	30.2%	9.8%
      South Carolina	277,717	75,687	27.3%	10.4%

      The 2000 Census data below provide the percent of black females of child bearing age that are not employed. More recent published data are not available.

      Percent of Black Females Not Employed by Age Group
      	SC	Allendale	Bamberg	Hampton	Orangeburg
      16 to 19 years:	42,177	261	534	420	2,536
      Unemployed	5,175	7	103	44	224
      Not in labor force	22,737	177	346	283	1,716
      Percent Not Employed	67.5%	70.5%	84.1%	77.9%	76.5%
      20 to 24 years:	46,917	263	564	380	3,049
      Unemployed	6,503	36	52	47	538
      Not in labor force	13,619	126	316	169	920
      Percent Not Employed	42.9%	61.6%	65.2%	56.8%	47.8%
      25 to 29 years:	42,675	231	319	342	1,881
      Unemployed	3,462	28	15	17	154
      Not in labor force	9,515	94	115	106	469
      Percent Not Employed	30.4%	52.8%	40.8%	36.0%	33.1%
      30 to 34 years:	44,172	221	341	367	1,733
      Unemployed	3,00	24	31	16	87
      Not in labor force	10,788	75	92	101	561
      Percent Not Employed	31.2%	44.8%	36.1%	31.9%	37.4%
      35 to 44 years:	101,692	549	735	896	4,688
      Unemployed	5,765	47	30	52	240
      Not in labor force	26,820	176	197	273	1,329
      Percent Not Employed	32.0%	40.6%	30.9%	36.3%	33.5%
      Source: Census 2000 Summary File 4 (SF 4) - Sample Data. Sex by Age, by Employment Status for the POPULATION 16 YEARS AND OVER [185] - Universe: Population 16 years and over

      Employment opportunities for the target population in the Service Area are primarily in the service sector or in the manufacturing sector. Service sector jobs are primarily for Hampton and Allendale residents and those jobs are not located within the county. Economies in these counties are not diverse. Women often work in service and retail industries. Service industry jobs usually translate to low wages, long hours and scant benefits. In Allendale and Hampton Counties, there are very few jobs for unskilled workers causing many women to leave the county to work in the hotel/motel industry and other service work on Hilton Head Island and other coastal vacation and retirement communities for the wealthy. The travel time is grueling and the wages low. From Hampton to Hilton Head is 65 miles, from Allendale, 83 miles. The trip begins at a central pick-up point in Allendale County at 4:30 to 5:00 AM. The bus proceeds on to Hampton County to pick up workers. The bus returns around 7:30 PM. Workers have an approximate round trip commute of three to four unpaid hours.

      Manufacturing remains a top employer; however, many plants have closed and jobs have been lost over the past five years. In the rural south and in the Service Area in particular, people working in manufacturing are generally not union members. Benefit packages are scant. Manufacturing plants do not operate full time all year long and many are on the verge of closing.

      The South Carolina Employment Security Commission maintains a web site with the top 20 employers, by county, listed. According to those lists the top twenty employers can be aggregated as follows.

      • Education system, including local school districts, universities and technical schools
      • Manufacturing
      • Retail, including grocery
      • City, county, state governments
      • Hospitals and Federally Qualified Health Centers

      Women of childbearing age who are not educated will likely only be employed in the retail and manufacturing sector. Poverty rates are included in the following section. Young women who seriously lack education, work skills and job contacts are more likely to need financial assistance from friends, family, government or charitable sources. In the Low Country Service Area, charitable services are limited, with little organized capacity to help young women or families in times of need. Families try to help, but as the poverty rates and educational levels indicate, too many people have too little.

      The SC Employment Security Commission provides information on their web site regarding occupations in the area and the growth outlook. For the Lower Savannah workforce area (which includes three of the four counties), according to a December 2004 report, the top 6 positions follow, with the number of projected annual openings, average wage and education level needed.

      Occupation	Annual Openings	Average Wage	Education Level Required
      Retail sales	145	$ 6.10 – $ 8.82 per hour	Some on the job training
      Teachers, secondary schools	84	$38,138 annual	Bachelor’s degree
      Top executives	78	$21.32 – $48.19	Experience, plus degree
      Registered nurses	72	$16.09 – $23.43	Associate’s degree
      Child Care Workers	67	$ 5.67 – $ 6.65	Some on the job training
      Marketing or Sales Supervisors	65	$10.75 – $15.64	Experience in related job

      The data on educational attainment is below. The positions listed above associated with the educational attainment below paints a depressing picture of too few women able to compete for the higher paying positions. The positions some women in the target population might qualify for pay very little. A 40 hour a week job, with 52 hours of work per year, in the child care field would be an annual income of $11,794 for the lower hourly rate and $ 13,832 for the higher end of the range. In 2004, the poverty level for a family of two is $ 12,490. A woman working full time as a child care worker, earning in the lower range, with one infant would be living in poverty even if she works 40 hours a week for 52 weeks a year.

      Too many schools in the Low Country Service Area are marginal, depriving children of the education and skills needed for success. Five years ago, the State Board of Education declared Allendale County schools to be in an emergency state and assumed State control of the School District. This unprecedented action was due to sustained poor performance of the Allendale County system, the teachers and students. The State still controls the Allendale School District.

      Educational Attainment (shown as a percent of Age, Race, Sex Group)
      	Educational Attainment	% Black Females 18-24	% Black Females 25-34	% Black Females 35-44
      Allendale	Less than 9th Grade	6.6	1.8	7.3
      	High School Diploma or GED	25.3	41.6	32.8
      	Graduate or Professional Degree	0.0	0.0	0.0
      Bamberg	Less than 9th Grade	2.8	3.3	4.2
      	High School Diploma or GED	30.4	28.2	26.8
      	Graduate or Professional Degree	1.3	4.5	.8
      Hampton	Less than 9th Grade	.9	2.7	3.3
      	High School Diploma or GED	33.6	37.4	37.3
      	Graduate or Professional Degree	.2	1.3	1.7
      Orangeburg	Less than 9th Grade	1.2	.6	2.3
      	High School Diploma or GED	27.1	32.6	37.6
      	Graduate or Professional Degree	.7	7.6	7.4
      South Carolina	Less than 9th Grade	2.0	1.7	2.1
      	High School Diploma or GED	33.5	35.0	36.3
      	Graduate or Professional Degree	.3	3.2	3.3
      Data Source: SC Office of Research and Statistics, US Bureau of Census, 2000 – SF4 – Table PCT65. Professional degrees include law, medical, etc.

      As shown in the following section, health behaviors of the target population too often include high risk sexual behavior. African American women in the target population are too often over weight or obese, choose foods that are not healthy and do not engage in physical activity. LCHS has learned, and reaffirmed, that target population women are interested in changing their health behaviors and outcomes, even though it is very difficult given social and cultural norms, poverty and short term needs for gratification. This proposal outlines activities that will promote healthy sexual behavior, including abstinence, as well as choosing, preparing and consuming healthy foods, such as fresh fruits and vegetables and increasing physical activity.