The Assistant Secretary for Health and Surgeon General chaired the third and final review of progress in achieving Healthy People 2000 objectives for Maternal and Infant Health, designated as priority area No. 14. The review was organized by the Health Resources and Services Administration (HRSA), which serves as lead agency for the priority area, and included input from the Centers for Disease Control and Prevention (CDC), which will serve as co-lead agency with HRSA for the Healthy People 2010 focus area on Maternal, Infant and Child Health. The presentations and discussion addressed three themes -1) reducing disparities in key maternal and infant health indicators; 2) understanding issues surrounding preconception, prenatal and obstet-ric care; and 3) preventing birth defects and developmental disabilities. Through a satellite broadcast, participants were linked with viewers at remote sites, who were able to submit questions by telephone and fax. Of the 17 objectives in this priority area,the target for reducing the rate of hospitalizations for severe complications of pregnancy has been met and there is movement towardthe targets for 8 other objectives. During the overview, attention focused on the following Healthy People 2000 objectives:

14.1 Infant mortality declined from 9.2 per 1,000 live births in 1990 to 7.1 in 1997 (preliminary data), nearly meeting the year 2000 target of 7.0. For Blacks, the infant mortality rate declined from 18.0 in 1990 to 13.7 in 1997 (preliminary data). The target is 11 per 1,000 live births. The rate among American Indians/Alaska Natives declined from 13.1 in 1990 to 10.0 in 1996 (target, 8.5).

14.3 The rate of maternal mortality for all women decreased from 8.2 per 100,000 live births in 1990 to 7.5 in 1997 (preliminary data). The year 2000 target is 3.3. For black women, the rate decreased from 22.4 deaths per 100,000 to 18.3 in 1997 (preliminary data). The target is 5.

14.4 The incidence of fetal alcohol syndrome increased from 0.22 per 1,000 live births in 1987 to 0.40 in 1990, and then to 0.67 in 1993 (the last year for which data are available). The year 2000 target is 0.12 per 1,000 live births. For Blacks, the increase was from 0.8 in 1987 to 1.4 in 1990 and 5.4 in 1993 (target, 0.4 per 1,000).

14.5 The incidence of low birth weight (<2,500 grams) for the total population increased from 7.0 percent in 1990 to 7.5 percent in 1997. The year 2000 target is 5 percent. The incidence of very low birth weight (<1,500 grams) for the total population increased from 1.3 percent in 1990 to 1.4 percent in 1997 (target, 1.0 percent). For Blacks, the incidence of low birth weight decreased over the same time span from 13.3 percent to 13.0 percent (target, 9 percent) and the incidence of very low birth weight increased from 2.9 percent to 3.0 percent (target, 2.0 percent). From 1990 to 1997, the incidence of very low birth weight for Puerto Ricans resident in the U.S. increased from 1.6 percent to 1.9 percent (target, 1.0 percent). Over the same time period, the incidence of low birth weight in that population increased from 9.0 percent to 9.4 percent. The target is 6 percent.

14.7 The rate of hospitalization for severe complications from pregnancy for the total population decreased from 18 per 100 deliveries in 1990 to 14 in 1996, surpassing the year 2000 target of 15 per 100 deliveries. For black women, the rate decreased from 28 per 100 deliveries in 1991 to 23 in 1996 (target, 16).

14.8 The Caesarean delivery rate decreased from 23.5 per 100 deliveries in 1990 to 21.8 in 1996. The year 2000 target is 15 per 100 deliveries. Over the same period, the rate of first-time Caesarean deliveries decreased from 16.8 to 15.7 (target, 12 per 100 deliveries), and the rate of repeat Caesarean deliveries decreased from 79.6 to 66.4, close to the target of 65 per 100 deliveries.

14.9 The proportion of all mothers who breastfeed their infants in the early postpartum period increased from 52 percent in 1990 to 62 percent in 1997. For select populations, the rate of early breastfeeding increased over the same period as follows—for Black mothers, from 23 to 41 percent; for Hispanic mothers, from 48 to 64 percent; for American Indian/Alaska Native mothers, from 47 to 56 percent. The early breastfeeding rate for low income-mothers increased from 35 percent in 1990 to 42 percent in 1996. The year 2000 target is 75 percent.

The proportion of all mothers whose infants are still breastfed at age 6 months increased from 18 percent in 1990 to 26 percent in 1997. Among some select populations, the breastfeeding rate at 6 months increased from 1990 to 1997 as follows—for Black mothers, from 6 to 15 percent; for Hispanic mothers, from 13 to 25 percent. The breastfeeding rate at 6 months increased as well for mothers with low income, from 8 percent in 1990 to 12 percent in 1996. For American Indian/Alaska Native mothers, the rate decreased from 27 percent in 1990 to 25 percent in 1997. The target for breastfeeding at age 6 months is 50 percent.

14.10 The proportion of pregnant women who abstain from tobacco use increased from 79 percent in 1990 to 87 percent in 1997. The year 2000 target is 90 percent.

14.11 The proportion of all pregnant women who received prenatal care in the first trimester of pregnancy increased from 75.8 percent in 1990 to 82.5 percent in 1997. Among select populations, the proportion increased over that period as follows—for black women, from 60.6 to 72.3 percent; for American Indian/Alaska Native women, from 57.9 to 68.1 percent; for Hispanic women in States reporting Hispanic origin, from 60.2 to 73.7 percent. The year 2000 target is 90 percent.

14.17 The incidence of spina bifida and other neural tube defects was in the range of 6-7 cases per 10,000 live births in the early years of the decade and indications are that the incidence has not changed significantly. The year 2000 target is to have no more than 3 cases per 10,000.

• The U.S. achieved a record low infant mortality rate in 1997, yet ranks 25th lowest among developed nations in infant mortality.
• Sudden Infant Death Syndrome (SIDS), the leading cause of postneonatal mortality in the U.S., declined 38 percent between 1992 and 1996, reflecting the success of the public/private sector "Back to Sleep" education campaign. This encourages parents to place healthy infants on their back to sleep.
• Low birthweight infants, i.e., those weighing less than 5½ pounds (largely due to pre-term birth), make up 7 percent of all births and account for about two-thirds of all infant deaths. Very low birthweight infants, i.e., those weighing less than 3¼ pounds, make up only one percent of total births each year but account for one-half of all infant deaths.
• The risk of low birthweight is generational, in that mothers who were themselves born at low birthweight are more likely to bear low birthweight infants. Black women born in the U.S. give birth to low birthweight infants at almost twice the rate of Whites.
• Between 1991 and 1995, there was a four-fold increase among pregnant women who engaged in binge drinking. High blood alcohol levels during pregnancy are associated with fetal alcohol syndrome in offspring.
• Only one-fourth of women of child-bearing age are consuming adequate amounts of folic acid (400 µg daily). Achieving adequate intake levels could prevent nearly half of all neural tube disorders.
• Only 37 States have birth defects surveillance systems.

FOLLOW-UP

• Ensure the capacity for tracking the effects of welfare reform policy on availability and utilization of prenatal care, particularly for immigrant populations.
• Seek to streamline eligibility requirements for maternal and infant health care programs so as to increase levels of participation.
• Increase attention to psychosocial and socioeconomic factors influencing access to preconceptual, prenatal and postnatal counseling and health care programs.
• Ensure that maternal and infant health care programs are culturally sensitive .
• Develop new interventions to target and reduce alcohol consumption during pregnancy, especially binge drinking.
• Explore new ways to ensure continuity of care for mothers and children after child- birth. Encourage pediatricians to inquire about the mother’s health, in addition to the infant’s, and to make appropriate referrals.
• Increase dissemination of information to health care providers about the benefits of daily folic acid intake before, during, and after pregnancy.
• Strengthen efforts to establish a nationwide birth defects surveillance system encompassing all States.
• Help ensure that maternal and infant health care programs are tailored to the communities they serve by strengthening the non-medical aspects of these programs, such as transportation, child care, and home visitation.

David Satcher, M.D., Ph.D.
Assistant Secretary for Health and
Surgeon General

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