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| Co-Lead Agencies: | |
Centers for Disease Control and
Prevention Health Resources and Services Administration |
The health of mothers, infants, and children is of critical importance, both as a reflection of the current health status of a large segment of the U.S. population and as a predictor of the health of the next generation. This focus area addresses a range of indicators of maternal, infant, and child health—those primarily affecting pregnant and postpartum women (including indicators of maternal illness and death) and those that affect infants’ health and survival (including infant mortality rates; birth outcomes; prevention of birth defects; access to preventive care; and fetal, perinatal, and other infant deaths).
Infant mortality is an important measure of a nation’s health and a worldwide indicator of health status and social well-being. As of 1995, the U.S. infant mortality rates ranked 25th among industrialized nations.[1] In the past decade, critical measures of increased risk of infant death, such as new cases of low birth weight (LBW) and very low birth weight (VLBW), actually have increased in the United States. In addition, the disparity in infant mortality rates between whites and specific racial and ethnic groups (especially African Americans, American Indians or Alaska Natives, Native Hawaiians, and Puerto Ricans) persists. Although the overall infant mortality rate has reached record low levels, the rate for African Americans remains twice that of whites.[2]
In 1997, 28,045 infants died before their first birthday, for an overall rate of 7.2 deaths per 1,000 live births. This rate has declined steadily over the past 20 years; in 1975, the infant mortality rate was over 15 per 1,000 live births.2 In 1997, two-thirds of all infant deaths took place during the first 28 days of life (the neonatal period). The overall neonatal mortality rate in 1997 was 4.8 per 1,000 live births.2 The remaining one-third of infant deaths took place during the postneonatal period from an infant’s 29th day of life until the first birthday. The U.S. postneonatal mortality rate in 1997 was 2.4 deaths per 1,000 live births.2
Four causes account for more than half of all infant deaths: birth defects, disorders relating to short gestation and unspecified LBW, sudden infant death syndrome (SIDS), and respiratory distress syndrome. The leading causes of neonatal death in 1997 were birth defects, disorders related to short gestation and LBW, respiratory distress syndrome, and maternal complications of pregnancy. After the first month of life, SIDS is the leading cause of infant death, accounting for about one-third of all deaths during this period. Maternal age also is a risk factor for infant death. Mortality rates are highest among infants born to young teenagers (aged 16 years and under) and to mothers aged 44 years and older.
The death of fetuses before birth is another important indicator of perinatal health. In 1996, nearly 7 fetal deaths were reported for every 1,000 live births and fetal deaths combined, representing a slight decline from the fetal mortality rate of 7.6 per 1,000 in 1987.2 Fetal death sometimes is associated with pregnancies complicated by such risk factors as problems with amniotic fluid levels and maternal blood disorders.[3] Early, comprehensive, and risk-appropriate care to manage such conditions has contributed to reductions in fetal mortality rates.
Short gestation and LBW are among the leading causes of neonatal death, accounting for 20 percent of neonatal deaths. In 1998, a total of 11.6 percent of births were preterm, and 7.6 percent were LBW.[4] Included in these statistics were VLBW infants weighing less than 1,500 grams (3.3 pounds). The rate of VLBW births was 1.4 percent in 1998. The VLBW rate has increased slightly since 1990 among whites and other population groups including African Americans, Puerto Ricans, and American Indians.1
LBW is associated with long-term disabilities, such as cerebral palsy, autism, mental retardation, vision and hearing impairments, and other developmental disabilities. (See Focus Area 6. Disability and Secondary Conditions and Focus Area 28. Vision and Hearing.) Despite the low proportion of pregnancies resulting in LBW babies, expenditures for the care of LBW infants total more than half of the costs incurred for all newborns. In 1988, the cost of a normal, healthy delivery averaged $1,900, whereas hospital costs for LBW infants averaged $6,200.[5]
The general category of LBW infants includes both those born too early (preterm infants) and those who are born at full term but who are too small, a condition known as intrauterine growth retardation (IUGR). Maternal characteristics that are risk factors associated with IUGR include maternal LBW, prior LBW birth history, low prepregnancy weight, cigarette smoking, multiple births, and low pregnancy weight gain. Cigarette smoking is the greatest known risk factor.[6]
VLBW usually is associated with preterm birth. Relatively little is known about risk factors for preterm birth, but the primary risk factors are prior preterm birth and spontaneous abortion, low prepregnancy weight, and cigarette smoking.6 These risk factors account for only one-third of all preterm births.
The use of alcohol, tobacco, and illegal substances during pregnancy is a major risk factor for LBW and other poor infant outcomes. Alcohol use is linked to fetal death, LBW, growth abnormalities, mental retardation, and fetal alcohol syndrome (FAS).[7] Overall rates of alcohol use during pregnancy have increased during the 1990s, and the proportion of pregnant women using alcohol at higher and more hazardous levels has increased substantially. Smoking during pregnancy is linked to LBW, preterm delivery, SIDS, and respiratory problems in newborns. In addition to the human cost of these conditions, the economic cost of services to substance-exposed infants is great: health expenditures related to FAS are estimated to be from $75 million to $9.7 billion each year.7 Over $500 million a year is spent on medical expenses for infants exposed to cocaine in utero.[8] Smoking-attributable costs of complicated births in 1995 were estimated at $1.4 billion (11 percent of costs for all complicated births, based on smoking prevalence during pregnancy of 19 percent) and $2.0 billion (15 percent for all complicated births, based on smoking prevalence during pregnancy of 27 percent).[9]
Finally, breastfeeding is an important contributor to overall infant health because human breast milk presents the most complete form of nutrition for infants; therefore, the American Academy of Pediatrics recommends that infants be breastfed for approximately the first 6 months of life.[10] (The American Academy of Pediatrics recommends that women who test positive for human immunodeficiency virus (HIV) not breastfeed to help prevent transmission of the virus to their infants.)[11] Breastfeeding rates have increased over the years, particularly in early infancy. However, breastfeeding rates among women of all races decrease substantially by 5 to 6 months postpartum. The 1998 rates at 5 to 6 months were only 31 percent among white women, 19 percent among African American women, and 28 percent among Hispanic women.[12]
Also important to child health are the prevention and treatment of disabilities in children. Twelve percent of all children under age 18 years have a disability (defined as a limitation in one or more functional areas). In 1994, 10.6 percent of all children aged 5 to 17 years had limitations in learning ability, 6 percent had limitations in communication, 1.3 percent had limitations in mobility, and 0.9 percent had limitations in personal care.[13] The burden of childhood disability is compounded because affected children live with their disabling conditions many more years than do persons acquiring disability later in life. In 1992, asthma and mental retardation were the most common disabling conditions, accounting for 40 percent of all activity limitations.[14] Other major disabling conditions in childhood include speech impairment, hearing impairment, cerebral palsy, epilepsy, and leg impairment. (See Focus Area 6. Disability and Secondary Conditions and Focus Area 28. Vision and Hearing.)
The objectives in this focus area cover the broad array of childhood conditions and genetic disorders. Examples of preventable birth defects are spina bifida and other neural tube defects (NTDs). The occurrence of these disorders could be reduced by more than half if women consumed adequate folic acid before and during pregnancy.[15]
All States require newborns to be screened for genetic conditions, such as phenylketonuria (PKU) and hypothyroidism; the majority of States also require screening for sickle cell disease. Although not necessarily preventable, these conditions are susceptible to intervention after delivery. For example, nutritional interventions in infancy can prevent mental retardation in children with PKU, penicillin can prevent infection in children with sickle cell disease, and hormone replacement can prevent mental retardation in children with hypothyroidism. Thus, adequate screening of newborns is the first step toward prevention of illness, disability, and death.
In addition to infant deaths and health conditions, the effect of pregnancy and childbirth on women is an important indicator of women’s health. In 1997, a total of 327 maternal deaths were reported by vital statistics.[16] While this number is small, maternal death remains significant because a high proportion of these deaths are preventable and because of the impact of women’s premature death on families. The maternal mortality ratio among African American women consistently has been three to four times that of white women. Ectopic pregnancy is an important cause of pregnancy-related illness and disability in the United States and the leading cause of maternal death in the first trimester. The risk of ectopic pregnancy increases with age; women of all races aged 35 to 44 years are at more than three times the risk of ectopic pregnancy than are women aged 15 to 24 years.[17] Preeclampsia and eclampsia also are important causes of maternal death. Other causes of maternal death are hemorrhage, embolism, infection, and anesthesia-related complications.
The rates of many of these indicators have shown improvement over the past decade. The rate of infant mortality declined more than 27 percent between 1987 and 1997. The rate of fetal mortality declined 8 percent between 1987 and 1995.1 Other indicators show less progress. The LBW rate increased 10 percent between 1987 and 1998.1The rate of FAS has risen steeply, especially among African Americans.[18] In addition, the maternal mortality rate has not declined since 1982, nor has the disparity between African American and white women.2, [19]
Despite these unfavorable trends, evidence is encouraging about increases in women’s use of health practices that can help their own health and that of their infants. The percentage of pregnant women who start prenatal care early increased 9.2 percent between 1987 and 1998. The percentage of mothers who breastfeed their newborns also went up 18.5 percent between 1988 and 1998, with greater gains among African American and Hispanic women. Other maternal health practices have shown less improvement: in 1992–94, the proportion of women of childbearing age reporting consumption of the recommended level of folic acid (400 micrograms) was 21 percent.
Many of these conditions and risk factors disproportionately affect certain racial and ethnic groups.The disparities between white and nonwhite groups in infant death, maternal death, and LBW are wide and, in many cases, are growing. Specifically:
| n | The 1997 infant mortality rate among African American infants was 2.3 times that of white infants. Although infant mortality rates have declined within both racial groups, the proportional discrepancy between African Americans and whites remains largely unchanged.16 |
| n | The rate of maternal mortality among African Americans is 20.3 per 100,000 live births, nearly four times the white rate of 5.1 per 100,000. African American women continue to be three to four times more likely than white women to die of pregnancy and its complications. The maternal death differential between African Americans and whites is highest for pregnancies that did not end in live birth (ectopic pregnancy, spontaneous and induced abortions, and gestational trophoblastic disease).19 |
| n | Rates of LBW for white women have risen from 5.7 percent of births in 1990 to 6.5 percent in 1998. Among African Americans, the LBW rate has declined slightly in the 1990s but remains twice as high as that of whites—13 percent in 1998. African Americans also are more likely to have other risk factors, such as young maternal age, high birth order (that is, having many live births), less education, and inadequate prenatal care. Puerto Ricans also are especially likely to have LBW infants.4 |
| n | American Indians or Alaska Natives and African Americans account for a disproportionate share of FAS deaths. In 1990, the rates of FAS among American Indians or Alaska Natives and African Americans were 5.2 and 1.4 per 1,000 live births, respectively, compared with 0.4 per 1,000 among the population as a whole.18 |
African American and Hispanic women also are less likely than whites to enter prenatal care early. For both African American and white women, the proportion entering prenatal care in the first trimester rises with maternal age until the late thirties, then begins to decline. For example, in 1998, 57 percent of African American women under age 18 years began care early, compared with 66 percent of white women of the same age. Among women aged 18 to 24 years, 68 percent of African Americans received care in their first trimester, compared to 76 percent of white women. Among women aged 25 to 39 years, 79 percent of African American women entered care early, compared with 89 percent of white women.4
Women in certain racial and ethnic groups also are less likely than white women to breastfeed their infants. In the early postpartum period, 45 percent of African American mothers and 66 percent of Hispanic mothers breastfed in 1998, compared with 68 percent of white women. These differences persist at 5 to 6 months postpartum, when 19 percent of African American women, 28 percent of Hispanic women, and 31 percent of white women breastfed.12
Many of the risk factors mentioned can be mitigated or prevented with good preconception and prenatal care. First, preconception screening and counseling offer an opportunity to identify and mitigate maternal risk factors before pregnancy begins. Examples include daily folic acid consumption (a protective factor) and alcohol use (a risk factor). During preconceptional counseling, healthcare providers also can refer women for medical and psychosocial or support services for any risk factors identified. Counseling needs to be culturally appropriate and linguistically competent. Prenatal visits offer an opportunity to provide information about the adverse effects of substance use, including alcohol and tobacco during pregnancy, and serve as a vehicle for referrals to treatment services. The use of timely, high-quality prenatal care can help to prevent poor birth outcomes and improve maternal health by identifying women who are at particularly high risk and taking steps to mitigate risks, such as the risk of high blood pressure or other maternal complications. Interventions targeted at prevention and cessation of substance use during pregnancy may be helpful in further reducing the rate of preterm delivery and low birth weight.[20], [21], [22] Further promotion of folic acid intake can help to reduce the rate of NTDs.[23], [24]
Other actions taken after birth can significantly improve infants’ health and chances of survival. Breastfeeding has been shown to reduce rates of infection in infants and to improve long-term maternal health.[25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] SIDS may be preventable as well; studies show that putting infants to sleep on their backs can help to prevent SIDS.[39]
(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)
Anencephalus: Congenital absence of all or a major part of the brain.
Birth defect: An abnormality in structure, function, or body metabolism that is present at birth, such as cleft lip or palate, phenylketonuria, or sickle cell disease.
Breastfeeding: Exclusive use of human milk or use of human milk with a supplemental bottle of formula. “Exclusive breastfeeding” refers to the use of only human milk, supplemented by solid food when appropriate but not supplemented by formula.
Children with special health care needs: Children who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health care and related services of a type or amount beyond that required by children generally.
Congenital anomaly: See birth defect.
Developmental disabilities: A broad spectrum of impairments characterized by developmental delay or limitation or both in personal activity, such as mental retardation, cerebral palsy, epilepsy, hearing and other communication disorders, and vision impairment. The more severe developmental disabilities require special interdisciplinary care.
Eclampsia/Preeclampsia: A condition that occurs in the second half of pregnancy, characterized by hypertension, edema, and proteinuria. When convulsions and coma are associated, it is called eclampsia.
Ectopic pregnancy: A gestation elsewhere than in the uterus, often occurring in the fallopian tube. An ectopic pregnancy cannot develop normally and causes fainting, abdominal pain, and vaginal bleeding.
Fetal alcohol syndrome (FAS): A cluster of structural and functional abnormalities found in infants and children as a result of alcohol consumption by the mother during pregnancy and characterized by growth retardation, facial malformations, and central nervous system dysfunction.
Fetal death: The death of a fetus in utero after 20 weeks or more of gestation. The fetal death rate is the number of fetal deaths in a population divided by the total number of live births and fetal deaths in the same population during the same time period.
Genetic disorders: The group of health conditions that result primarily from alterations in a gene or combination of genes.
Gestational trophoblastic disease: A type of cancer associated with pregnancy in which a grape-like mole develops in the womb.
Hydrocephalus: A condition marked by dilation of the cerebral ventricles accompanied by cerebrospinal fluid within the skull.
Hypotonia: A condition of diminished tone of the skeletal muscles, with diminished resistance of muscles to passive stretching.
Infant death: Death of an infant less than 1 year old. Neonatal death is the death of an infant less than 28 days after birth; postneonatal death is the death of an infant between 28 days and 1 year after birth.
Infant mortality rate: The number of deaths of infants less than 1 year old (obtained from death certificates) per 1,000 live births in a population (obtained from birth certificates).
Intrapartum period: Period extending from the onset of labor through the completion of delivery.
Intrauterine growth retardation (IUGR): The failure of a fetus to maintain its expected growth potential at any stage of gestation. Infants with IUGR may be born at full term but are smaller than expected.
Level III hospital: A facility for high-risk deliveries and neonates that can provide care to very small infants, including mechanical ventilation and neonatal surgery and special care for transferred patients and for which a full-time neonatologist serves as the director.
Live birth: The complete expulsion or extraction from its mother of an infant, irrespective of the duration of pregnancy, which after such separation, breathes or shows any other evidence of life, such as the beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. Each infant from such a birth is considered live born.
Low birth weight (LBW): Weight at birth of less than 2,500 grams (about 5.5 pounds).
Maternal death: Death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
Maternal mortality rate: (also referred to as the maternal mortality ratio) Represents the number of maternal deaths for every 100,000 live births.
Medical home: Medical care for infants and children that is accessible, continuous, comprehensive, family-centered, coordinated, and compassionate.
Neonatal period: The first 28 days of life.
Neural tube defects (NTDs): A set of birth defects that result from failure of the neural tube to close in utero. Two of the most common NTDs are anencephaly (absence of the majority of the brain) and spina bifida (incomplete development of the back and spine).
Occurrence: As the term is used in this chapter, occurrence is the incidence of new cases among live births per year that are caused primarily by prenatal factors. In the spina bifida and other neural tube defects objective, identification is in the first year of life, and occurrence is reported as the number of cases per 10,000 live births per year. In the fetal alcohol syndrome objective, some children who have the condition at birth are not identified until age 4 or 5 years; occurrence is reported as a number per 10,000 live births. In the developmental disabilities objective, children with specified conditions such as mental retardation are not always identified until about age 7 or 8 years even though the conditions are usually caused by prenatal events; occurrence in these objectives is reported as a number per 10,000 children aged 8 years.
Perinatal death: Includes fetal deaths after 28 weeks of gestation and infant deaths within the first 7 days of birth.
Postneonatal period: The period from an infant’s 29th day of life until the first birthday.
Postpartum period: The 6-week period immediately following birth.
Preeclampsia: (see eclampsia).
Prenatal care: Pregnancy-related health care services provided to a woman between conception and delivery. The American College of Obstetricians and Gynecologists recommends at least 13 prenatal visits in a normal 9-month pregnancy: one each month for the first 28 weeks of pregnancy, one every 2 weeks until 36 weeks, and then weekly until birth.
Preterm birth: Birth occurring before 37 weeks of pregnancy.
Renal agenesis: Associated with duplicated vagina and uterus.
Sudden infant death syndrome (SIDS): Sudden, unexplained death of an infant from an unknown cause.
Surfactant: A surface-active agent that prevents the lungs from filling with water by capillary action.
Synthetic surfactant: An artificial substance that prevents a newborn’s lungs from filling with water.
Teratogenic: Causing malformations of an embryo or fetus.
Very low birth weight (VLBW): Weight at birth of less than 1,500 grams (about 3.3 pounds).
[1] National Center for Health Statistics (NCHS). Health, United States, 1999. Hyattsville, MD: U.S. Department of Health and Human Services, 1999.
[2] Ventura, S.J.; Anderson, R.N.; Martin, J.A.; et al. Births and deaths: Preliminary data for 1997. National Vital Statistics Report 47(4):1-42, 1999.
[3] Hoyert, D.L. Medical and life-style risk factors affecting fetal mortality, 1989–90. Vital and Health Statistics 20 Data National Vital Statistics System 31:1-32, 1996.
[4] Ventura, S.J.; Martin, J.A.; Curtin, S.C.; et al. Births: Final data for 1997. National Vital Statistics Report 48(3), 2000.
[5] Lewit, E.M.; Baker, L.S.; Hope, C.; et al. The direct cost of low birth weight. Future Child 5(1):35-56, 1995.
[6] Camas, O.R.; Cheung, L.W.Y.; and Lieberman, E. The role of lifestyle in preventing low birth weight. Future Child 5(1):121-138, 1995.
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[18] NCHS. Healthy People 2000 Review, 1997. Hyattsville, MD: Public Health Service, 1997, 131-132.
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[57] Main, E.K. Reducing cesarean birth rates with data-driven quality improvement activities. Pediatrics 103:374-383, 1999.
[58] ACOG, Task Force on Cesarean Delivery. Considerations in Evaluating the Incidence of Cesarean Delivery. Washington DC: ACOG, in press
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