In the 13th session in the second series of assessments of
Healthy People 2010, Anand Parekh, Acting Deputy Assistant Secretary
for Health (Science and Medicine), chaired a focus area Progress Review on
Maternal, Infant, and Child Health. He was assisted by staff of the co-lead
agencies for this Healthy People 2010 focus area, the Centers for
Disease Control and Prevention (CDC) and the Health Resources and Services
Administration (HRSA). Also participating in the review were representatives
from other U.S. Department of Health and Human Services (HHS) offices and
agencies. While acknowledging that substantial progress had been made in many
fields covered by the focus area, Dr. Parekh noted that disparities among
racial and ethnic groups persist as a significant and sometimes growing problem
that calls for redoubled efforts on the part of all concerned.
The complete November 2000 text for the Maternal, Infant,
and Child Health focus area of Healthy People 2010 is available online at
www.healthypeople.gov/document/html/volume2/16mich.htm.
Revisions to the focus area chapter that were made after the January 2005
Midcourse Review are at www.healthypeople.gov/data/midcourse/html/focusareas/fa16toc.htm.
Some more recent data used in the Progress Review for this focus areas
objectives and their detailed definitions can be accessed at wonder.cdc.gov/data2010. For
comparison with the current state of the focus area, the report on the
first-round Progress Review (held on October 22, 2003) is archived at
www.healthypeople.gov/data/2010prog/focus16/2003fa16.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the CDC National Center for Health Statistics (NCHS): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa16-mich2.htm.
Data Trends
In his overview of data for the focus area, NCHS Director
Edward Sondik summarized the current health status of children and mothers in
the United States. About 6 million pregnancies occur annually in the country.
In 2005, the U.S. rate of births assisted by cesarean section reached the
highest level ever recorded. Birth defects affect 1 in 33 U.S. births and, with
reference to the rate of infant mortality, the United States is ranked 29th
internationally, having fallen from 12th place in 1960. Of the measurable
objectives and subobjectives for Maternal, Infant, and Child Health, 21 are
improving (i.e., have made significant advances toward their targets), 3 have
met or exceeded their targets, 10 are getting worse, 8 show little or no
change, and 4 have no trend data to update the baseline estimate. Four
subobjectives were dropped at the January 2005 Midcourse Review due to the lack
of a data source. Dr. Sondik examined in greater detail the objectives selected
for highlighting during the Progress Review.
(Obj. 16-1c): The death rate for infants up
to 1 year of age decreased from 7.2 per 1,000 live births in 1998 to 6.8 per
1,000 in 2004. In 2004, the infant death rates per 1,000 live births among the
five racial or ethnic groups for which data were available were as follows:
Asian/Pacific Islander, 4.7; Hispanic, 5.5; non-Hispanic white, 5.7; American
Indian/Alaska Native, 8.4; and non-Hispanic black, 13.6. Although the infant
death rate among the non-Hispanic black population has improved markedly since
the early 1940s, when it was more than 70 per 1,000, the decrease in the rate
has flattened over the past decade. The target for all groups is 4.5 per 1,000
live births. The five leading causes of infant death were congenital
abnormalities (20 percent), short gestation or low birth weight (LBW) not
elsewhere classified (17 percent), sudden infant death syndrome (SIDS) (8
percent), maternal pregnancy complications (6 percent), and unintentional
injuries (4 percent). However, Dr. Sondik stated that a re-analysis of the
causes of infant mortality in 2004 revealed that 37 percent of the deaths were
due to preterm-related causes.
(Objs. 16-16a and 16-15): Consumption of
the recommended daily amount of folic acid (at least 400 µg daily) by
nonpregnant women ages 15 to 44 years increased from 21 percent in the period
199194 to 27 percent in the period 200304. The target is 80
percent. This increase in consumption corresponds to a decrease in the
incidence of spina bifida and other neural tube defectsfrom six new cases
per 10,000 live births in 1996 to five new cases per 10,000 in 2003. The target
is three new cases per 10,000 live births.
(Obj. 16-11a, -11c): In 2004, the
proportion of preterm births (<37 weeks of gestation) was 12.5 percent, an
increase from 11.6 percent in 1998. The target is 7.6 percent. Among the five
racial or ethnic populations for which data were available, the proportions of
preterm births in 2004 were as follows: Asian/Pacific Islander, 10.5 percent;
non-Hispanic white, 11.5 percent; Hispanic, 12.0 percent; American
Indian/Alaska Native, 13.7 percent; and non-Hispanic black, 17.9 percent. Among
the non-Hispanic black population, 4.1 percent of the preterm births in 2004
were at less than 32 weeks of gestation, compared with 1.6 percent of births
among the non-Hispanic white population. The target is 1.1 percent for all
groups.
(Obj. 16-10a, -10b): In 2004, LBW
(<2,500 grams) affected 8.1 percent of live births, an increase from 7.6
percent in 1998. The target is 5 percent for all groups. Among the five racial
or ethnic populations for which data were available, the proportions of LBW
infants in 2004 were as follows: Hispanic, 6.8 percent; non-Hispanic white, 7.2
percent; American Indian/Alaska Native, 7.5 percent; Asian/Pacific Islander,
7.9 percent; and non-Hispanic black, 13.7 percent. In 2004, very low birth
weight (VLBW) (<1,500 grams) affected 1.5 percent of live births, an
increase from 1.4 percent in 1998. The target is 0.9 percent for all groups.
Among the five racial or ethnic populations for which data were available, the
proportions of VLBW infants in 2004 were as follows: Asian/Pacific Islander,
1.1 percent; Hispanic, 1.2 percent; non-Hispanic white, 1.2 percent; American
Indian/Alaska Native, 1.3 percent; and non-Hispanic black, 3.1 percent.
(Obj. 16-1h and 16-13): The rate of SIDS
deaths among infants aged less than 1 year decreased from 79 per 100,000 live
births in 1996 to 55 per 100,000 in 2004 (54 per 100,000 among non-Hispanic
white infants, compared with 111 per 100,000 among non-Hispanic black infants).
The target is 23 per 100,000. Over the same period of time, the proportion of
infants aged less than 8 months who were put to sleep on their backs increased
from 36 percent in 1996 to 70 percent in 2004, meeting the 2010 target. In
2006, the proportion put to sleep on their backs increased to 76 percent.
(Obj. 16-4): Maternal deaths increased from
a rate of 9.9 per 100,000 live births in 1999 to 13.1 per 100,000 in 2004. The
target is 4.3 per 100,000 for all groups. The rate increase seen in 2003 and
2004 is in large part attributed to changes in the reporting system that have
led to improved classification of maternal deaths and more accurate estimates
of maternal mortality. Among mothers aged 35 years and older, the rate in 2004
was 28.2 per 100,000; among mothers aged less than 20 years, it was 6.6 per
100,000. Among the four racial or ethnic populations for which reliable data
were available, the maternal death rates in 2004 were as follows: Hispanic, 8.5
per 100,000; Asian/Pacific Islander, 9.6 per 100,000; non-Hispanic white, 9.8
per 100,000; and non-Hispanic black, 36.1 per 100,000.
(Obj. 16-9a, -9b): The proportion of
cesarean births from low-risk pregnancies among women with no prior cesarean
birth increased from 18 percent in 1998 to 25 percent in 2004. The target is 15
percent. The proportion of cesarean births from low-risk pregnancies among
women who had a prior cesarean birth increased from 72 percent to 90 percent
over the same time period. The target is 63 percent.
(Obj. 16-6a): The proportion of pregnant
women who received prenatal care beginning in the first trimester was 84
percent in 2004 (77 percent among the non-Hispanic black population, compared
with 89 percent among the non-Hispanic white population). The target is 90
percent for all groups. Among pregnant women aged less than 15 years, the
proportion who received such care in 2004 was 49 percent, compared with 90
percent of pregnant women aged 30 to 34 years. Estimates of prenatal care in
the first trimester varied by level of education: 73 percent of pregnant women
with less than high school education received care in 2004, compared with 82
percent among high school graduates and 92 percent among those with at least
some college education.
(Obj. 16-19a, -19b, -19c, -19e): The
proportion of mothers who had ever breastfed their infants increased from 70
percent among those with infants born in 2000 to 74 percent among those with
infants born in 2004. The target is 75 percent. The proportion who breastfed
their infants at 6 months of age was 42 percent among those with infants born
in 2004, an increase from 34 percent among those with infants born in 2000. The
target is 50 percent. The proportion who breastfed their infants at one year of
age also increased: from 16 percent among those with infants born in 2000 to 21
percent among those with infants born in 2004. The target is 25 percent. The
proportion who breastfed exclusively through their infants first 6 months
of life increased from 10 percent among those with infants born in 2003 to 11
percent among those with infants born in 2004. This new subobjective has a
target of 17 percent. Breastfeeding has been shown to lower total healthcare
costs by reducing sick care visits, prescriptions, and hospitalizations.
(Obj. 16-14c): In metropolitan Atlanta, GA,
the median age at which autism spectrum disorder (ASD) was identified among
8-year-old children decreased from 69 months in 1996 to 62 months in 2002,
surpassing the target of 66 months. Among the three racial or ethnic groups for
which data were available, the median age of ASD identification in 2002 was as
follows: non-Hispanic white, 58 months; non-Hispanic black, 61 months; and
Hispanic, 68 months. By gender, the median age of ASD identification in 2002
was 65 months for female 8-year-olds and 61 months for male 8-year-olds.
(Obj. 16-23): In 2001, the only year for
which data are currently available, 35 percent of children aged 18 years or
younger received their care in family-centered, comprehensive, and coordinated
systems. The target is 100 percent. In that year, the proportions by race and
ethnicity were as follows: two or more races, 21 percent; American
Indian/Alaska Native, 23 percent; Hispanic, 24 percent; non-Hispanic black, 29
percent; Asian, 31 percent; non-Hispanic white, 38 percent; and Native Hawaiian
and Other Pacific Islander, 38 percent. By education level, the proportions in
2001 were as follows: less than high school completion, 23 percent; high school
graduates, 35 percent; and at least some college, 38 percent.
Key Challenges and Current Strategies
In presentations that followed the data overview, the
principal themes were introduced by Peter van Dyck, HRSAs Associate
Administrator for Maternal and Child Health; Edwin Trevathan, Director of
CDCs National Center on Birth Defects and Developmental Disabilities
(NCBDDD); and Eve Lackritz, Chief of the Maternal and Infant Health Branch
within CDCs National Center for Chronic Disease Prevention and Health
Promotion (NCCDPHP). Their statements and briefing materials provided to
Progress Review participants for later discussion identified a number of
barriers to achieving the objectives, as well as activities under way to meet
these challenges, including the following:
Barriers
-
The underlying causes of racial and ethnic disparities
in maternal mortality are manifold and complex, involving social, behavioral,
and medical factors that remain poorly understood. Women older than 35,
regardless of race or ethnicity, have a higher risk of death from all major
causes of pregnancy-related mortality.
-
Reduction of maternal deaths requires a detailed
knowledge of clinical and behavioral events leading up to death and a framework
for identifying opportunities for prevention. Much of this information cannot
reliably be obtained from vital records. State-based reviews have strengthened
the data in this field, but many States do not have a formal mechanism for
reviewing maternal deaths.
-
A national CDC study found that the prevalence of
complications during pregnancy was often similar for black women and white
women, but that black women were more likely to die when they had these
complications; that is, they had increased case fatality rates.
-
Pre-pregnancy overweight or obesity poses increased
risk to both the mother and the infant, including increased risk for
gestational diabetes, cesarean section, and subsequent juvenile obesity and
diabetes. Because weight loss during pregnancy is not medically recommended,
early intervention prior to pregnancy is critical.
-
Rates for both primary and repeat cesarean deliveries
among low-risk pregnancies have been rising in the United States since 1996, a
trend that has been attributed in part to changes in physician practices,
demographics, and maternal choice.
-
The recently observed decline in SIDS deaths has been
offset by an increase in the rate of deaths classified as cause
unknown/unspecified, accidental suffocation in bed, and other causes of Sudden
Unexpected Infant Deaths (SUID). Thus, most of the decline in SIDS rates since
1999 is likely due to a shift in the diagnosis and reporting of the
syndrome.
-
In addition to its major impact on the infant mortality
rate, preterm birth can also lead to an increased incidence of long-term
disability, including congenital neurological problems, such as cerebral palsy.
The rate of preterm birth has increased 18 percent since 1990, and recent
estimates by the Institute of Medicine (IOM) suggest that at least $26.2
billion is spent each year for the hospitalization of preterm infants, not
including rehospitalizations and long-term care. Approximately one-half of
preterm births occur in women with no known risk factors, and no screening
tests exist to accurately identify women who will deliver preterm.
-
Lack of support from healthcare professionals and
employers is a major barrier to breastfeeding initiation and maintenance.
Working full-time outside the home has been strongly associated with lower
rates of breastfeeding initiation and shorter duration. Low-income women are
more likely than their higher income counterparts to return to work sooner
after delivery and to be engaged in jobs that make it challenging for them to
continue breastfeeding.
-
Recent data from CDCs Autism and Developmental
Disabilities Monitoring Network show that the majority of affected children
studied in the greater metropolitan Atlanta area had documented developmental
concerns before the age of 3. However, the average age of diagnosis was much
laterin some cases, after 5 yearsby which age, many children would
have missed the opportunity for critical early intervention.
Activities and Outcomes
-
HRSAs Title V Block Grant to States has operated
as a Federal-State partnership for more than 65 years. States and other
jurisdictions use Title V funds to design and implement a wide range of
programs to improve the health of women, children, and families. Specific
initiatives may vary among the 59 States and jurisdictions utilizing the funds,
but all programs are aimed at reducing infant mortality. The outcomes of these
efforts provide an index of accountability to the States and the Nation as a
whole.
-
Through an education program for all coroners and
medical examiners, CDC headed a national initiative that developed an accurate
and standardized method for investigating and reporting of infant death
scenes.
-
Since 1990, HRSAs Maternal and Child Health Bureau
(MCHB) has funded the National Fetal and Infant Mortality (FIMR) Resource
Center to support States and communities in examining the causes of fetal and
infant death and improving services and resources for women, infants, and their
families. The FIMR Resource Center is a joint partnership between MCHB and the
American College of Obstetricians and Gynecologists.
-
With support from HRSA and other HHS agencies, the IOM
is updating its 1990 recommendations on weight gain during pregnancy, as well
as suggestions for encouraging use of the recommendations by consumers,
practitioners, and the public health community.
-
Breastfeeding is one of the six core strategies of the
CDC State-based cooperative agreements to address obesity and related chronic
diseases using a socio-ecological model. The CDC Guide to Breastfeeding
Interventions provides States with an ongoing resource for improving
breastfeeding protection, promotion, and support in communities.
-
HRSA is completing an employer-based resource kit and
companion train-the-trainer curricula to increase employers awareness of
the economic benefits of breastfeeding and to increase the number of employers
that have a worksite breastfeeding support program in place. These materials
outline manageable, flexible models for implementing or enhancing such
programs.
-
CDC and its partners have undertaken the largest
population-based study of birth defects ever conducted in the United States:
the National Birth Defects Prevention Study. Initiated in 1999, the study has
collected data from more than 25,000 participants, which has enabled scientists
to explore key avenues of research, including the relationship between smoking
and risk of orofacial clefts, the use of antidepressants and birth defects, and
the relationship between obesity and birth defects.
-
To advance toward the nationwide provision of the
essential infrastructure for monitoring prevalence and conducting etiologic
studies, CDC has assisted in the establishment of surveillance systems for
developmental disability and autism in 11 States, which are now components of
the Autism and Development Disabilities Network. Four of these States are now
monitoring also for cerebral palsy.
-
HRSAs Healthy Start program provides services
tailored to the needs of high-risk pregnant women, infants, and mothers in
geographically, racially, ethnically, and linguistically diverse high-risk
communities (defined as communities in which the infant mortality rate is 1.5
times the national average). Comprising nearly 100 federally funded projects,
the program targets women who have or have had an adverse pregnancy outcome or
are at high risk for one. Focusing on the 2-year interconceptional period after
delivery, the program works to ensure that the mother, the infant, and their
family have a medical home and the health and social services needed for
healthy lives. Healthy Start projects have strong collaborative linkages with
State programs, including Title V Maternal and Child Block Grants, Medicaid,
and State Child Health Insurance Programs, as well as with local perinatal
systems, such as community health centers.
-
Through targeted, culturally sensitive health
communication interventions, CDC is working with local, State, and national
agency partners to increase folic acid consumption by Hispanic women (by
encouraging the addition of folic acid to corn flour, for example) and to
increase the number of women who consume at least 400 micrograms of folic acid
every day. Currently, the proportion of Hispanic women who follow this
recommended regimen of daily uptake is less than half that of non-Hispanic
white women.
-
Through its Leadership Education in Neurodevelopmental
Disabilities grant program, HRSA trains individuals from a wide variety of
professional disciplines to assume leadership roles and to ensure levels of
clinical competence to improve the health of children who have, or are at risk
of developing, neurodevelopmental or other related disabilities, such as autism
and mental retardation.
-
In 2007, CDC published findings from Project Choices
which showed that women who received brief motivational counseling sessions
were twice as likely to reduce their risk for an alcohol-exposed pregnancy as
women who did not receive the counseling. CDC is working with partners to
increase the proportion of healthcare professionals who offer screening and
brief intervention to high-risk women at the individual and community level.
This includes collaboration with the American College of Obstetricians and
Gynecologists in development of a tool kit to guide healthcare providers in the
screening.
Approaches for Consideration
Participants in the Progress Review made the following
suggestions for public health professionals and policymakers to consider as
steps to enable further progress toward achievement of the objectives for
Maternal, Infant, and Child Health:
-
Make greater use of data collected for other purposes,
for example, by third-party payers, to monitor pregnancy complications and
maternal illness. Creative use of such data offers the opportunity to better
define severity and provide better surveillance of those complications of
pregnancy that threaten the lives of women.
-
Increase the proportion of healthcare providers who are
knowledgeable about the benefits of, and are advocates for, folic acid
consumption by women of childbearing age and breastfeeding by new mothers.
-
Seek to expand access to prenatal care services
nationwide.
-
Ensure that the same methodologies used for control of
all other epidemics are brought to bear on the prevention of preterm birth, the
leading cause of hospitalization among pregnant women.
-
Expand research to determine the factors contributing to
the disparate rates of maternal mortality between black and white women.
-
In health promotion outreach activities directed toward
mothers, expectant mothers, and women of childbearing age in general, encourage
greater use of home visits by culturally sensitive healthcare workers. Explore
ways to assist communities with the cost of such visits.
Contacts for information about Healthy
People 2010 focus area 16Maternal, Infant, and Child
Health:
|
[Signed December 26, 2007] Donald Wright, M.D.,
M.P.H. Acting Assistant Secretary for Health
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