May 5,
1999
2-4 p.m.
A live broadcast from Washington, DC
Dr. David
Satcher, Assistant Secretary for Health and Surgeon General, will be
joined by a panel of experts representing the public and private health
sectors. Dr. Edward Sondik, Director of the National Center for
Health Statistics, Centers for Disease Control and Prevention (CDC); Peter
C. van Dyke, M.D., M.P.H., Acting Associate Administrator for Maternal and
Child Health, Health Resources and Services Administration; and David
Erickson, D.D.S., Ph.D., Acting Director of the Division of Birth Defects
and Pediatric Genetics, National Center for Environmental Health, CDC will
review the progress towards the targets for the objectives in the Maternal
and Infant Health priority area of Healthy People 2000. The
participants will then engage in a discussion that focuses on three main
topics.
Reducing
disparities in key Maternal, Infant, and Child Health indicators; Understanding
issues surrounding preconception, prenatal, and obstetric care; Preventing
birth defects and developmental disabilities: NTD and FAS.
Presentation made by:
Edward J. Sondik, Ph.D.
Director
National Center for Health Statistics
May 5, 1999
Washington, DC
Thank you Dr. Satcher.
Chart
1. (Pie chart) I’m pleased to report significant progress in improving
the health of mothers and infants. To summarize: Out of 17 objectives,
we've met the target to reduce severe complications of pregnancy and we're
moving toward the targets in 8 other objectives. For example, we’ve seen
significant reductions in infant and fetal deaths and healthier practices
during pregnancy. In fact, timely prenatal care is at the highest rate
ever, fewer expectant mothers are smoking, and more gain the appropriate
weight during their pregnancies.
But not all the trends
are positive: Maternal mortality has not improved; low birthweight is at
the highest level since 1973; and we may be seeing more infants born with
Fetal Alcohol Syndrome.
And throughout these
objectives, wide disparities are very evident, disparities by race,
ethnicity, or by income and health care coverage.
Chart
2. (web addresses) By the way all the charts I’ll show this afternoon and
several additional charts are on the NCHS Web site. The address is posted
on the screen.
Let’s focus first on
infant mortality--a figure used worldwide as one of the principal
indicators of the health of a population.
Chart
3. (IMR trends). There has been remarkable progress in reducing infant
mortality. In the early 1900's one out of every 10 infants died in the
first year of life; today fewer than 1 in 100 will fail to reach a first
birthday. In 1997 the infant mortality rate reached a record low of 7.1
deaths per 1,000 live births, just barely missing the goal of 7, sure to
be achieved before the decade ends. But in the face of this significant
progress, we should note that the U.S. ranks 25th in the world in infant
mortality. Twenty-four other nations--large and small--have had greater
success in preventing infant deaths.
Chart
4. (IMR map). That is the overall picture of infant mortality. However,
infant mortality rates vary greatly across the country. Note that many of
the States in the west as well as a few others--shown in dark blue--have
achieved the lowest rates. The almost solid block of southeastern States,
in red, have the highest rates. The variation by race and ethnicity, which
we’ll examine in the next chart, is the source of some--but by no means
all--of the variation in this map.
Chart
5. (IM detailed race/ethnicity) The infant mortality rates for African
Americans, American Indian/Alaska Natives, and Puerto Ricans are the
highest. While I’m pleased to say that the rates are declining, they are
still considerably short of the targets set in Healthy People 2000. In
1997 the rate for black infants was the highest at almost 14 deaths per
1,000 births, compared to the lowest rate of under 4 for Chinese infants.
Let’s look at some of the factors we know are affecting infant survival.
Chart
6. (LBW and mortality) Low birthweight is perhaps the most important
factor associated with infant mortality. These infants weighing less than
5 1/2 lbs. make up 7 percent of all births--as shown in red on this
chart--but account for about two-thirds of all infant deaths. Not shown on
this chart but even more striking, is the fact that very low birthweight
babies (weighing less than 3 and 1/4 lbs.) are only one percent of the
infants born in the United States each year but they account for one-half
of all infant deaths. And it is important to realize that even when
infants survive, low birthweight may result in significant health problems
into childhood and beyond. As a nation, we’re losing ground in reducing
low birthweight. The percent of infants born at low birthweight in 1997 is
at the highest level since 1973
Chart
7. (LBW by race/ethnicity) Now let’s look again at disparities by race
and ethnicity. The data show a threefold difference in low birthweight,
ranging from 4 percent of Korean infants born at low birthweight to 13
percent of black infants.
Chart
8. (Smoking and pregnancy) Smoking is another risk factor, of course for
mothers, but also for their infants. Women who smoke cigarettes during
pregnancy are almost twice as likely to have a low birthweight infant than
women who don’t smoke. The chart shows that more women now abstain from
smoking during pregnancy, nearing the goal of 90 percent. However there is
a critical and growing problem. Smoking during pregnancy is up among
teenagers, with large increases among black and Puerto Rican teens.
Chart
9. (FAS) Still another risk is alcohol use, with Fetal Alcohol Syndrome
the most serious consequence. Earlier estimates from CDC's Birth Defects
Monitoring Program indicate a rate of 67 cases per 100,000 births. A word
of caution in interpreting the data--a portion of the increases, shown on
this slide, may be due to improved reporting, however, there are some
indications that FAS may be actually underestimated. A new CDC
surveillance system--the FAS Network--coming soon will be able to more
accurately report trends. Better monitoring is important because recent
surveys report an increase in frequent and binge drinking among pregnant
women.
Let me mention another
birth defect--neural tube disorders such as spina bifida. Each year about
4,000 infants are born with some form of neural tube disorders and about
half of these developmental defects could have been prevented with
adequate folic acid intake by women before and during their pregnancy.
Recognition of the benefits of folic acid has increased among women of
childbearing age but the use of folic acid has not improved and rates of
neural tube disorders are unchanged. Healthy People 2010 recognizes the
importance of this topic with several proposed objectives to directly
monitor folate intake and its levels in the population.
Chart
10. (SIDS trends) Turning to another important issue, Sudden Infant Death
Syndrome or (SIDS). SIDS has been associated with preterm or low
birthweight infants, late or no prenatal care, smoking, and substance
abuse during pregnancy.
Research in the early
part of the decade showed that infants who sleep on their back had a lower
risk of SIDS. Back to Sleep, a national public education campaign, was
launched to get that word out. Between 1992 and 1996, the percent of
infants placed on their stomachs to sleep declined by 66 percent; that’s
the left side of this chart. SIDS death rates had been declining, but
between 1992 and 1996 the drop accelerated, down by an impressive 38
percent during this time period.
Chart
11. (SIDS by race/ethnicity) SIDS rates do vary for different groups,
however. They are down among all population groups but the 1996 rate for
American Indian/Alaskan Natives is almost five times that for Asian or
Pacific Islanders. The rate is relatively low for Hispanics and whites and
considerably higher for black infants.
Chart
12. (Early Prenatal Care) Turning to an important intervention--early
prenatal care--defined as care within the first trimester. Early prenatal
care is the best opportunity for counseling and screening. Overall, the
percent of women receiving first trimester care improved for the 8th
consecutive year, rising to 83 percent in 1997. While there are still
significant differences--as you can see on this chart, the groups at
highest risk--as identified in Healthy People 2000--have shown remarkable
strides in improving prenatal care.
Chart
13. (Cesareans) Another important aspect of maternal health is the method
of delivery. Healthy People 2000 established a target of 15 cesareans for
every 100 deliveries to balance the sometimes medical necessity of
cesarean delivery with the greater risk of surgical complications, longer
postoperative recovery and increased medical costs. After rising
throughout the 1970's and 1980's to a high of 25 percent, cesarean rates
have steadily declined in the 1990's to about 21 percent in 1997, when the
decline appears to have stalled.
Chart
14. (Breast-feeding, race/ethnicity) Like cesarean deliveries,
breast-feeding has also been the focus of public information and education
efforts. The rate of breast-feeding by mothers in the hospital just after
delivery is up by about 20 percent. The percent of infants being
breast-fed at 6 months has nearly doubled since 1990. At both points in
the infants’ first year, there are differences among population groups,
with low income and black women the least likely to breast-feed their
infants.
Chart
15. (Maternal Mortality) Our final chart illustrates a remaining challenge
to improving maternal and infant health. In the early part of this
century, the maternal mortality rate was 100 times what it is today, with
20,000 mothers dying in childbirth or of pregnancy related conditions each
year. While we’ve seen enormous progress, still at least 300 women died
of maternal causes in 1997. And we’ve seen no improvement over the past
decade despite the fact that most of these deaths are preventable and
despite the fact that we have made such excellent progress in other
critical areas of maternal and infant health.
Slides Off. To
summarize, most of these objectives show real progress. However, even as
we have achieved this progress, significant disparities remain.
Documenting the differences across the many indicators is an essential
step in identifying the causes of disparities, pointing to effective
interventions, setting priorities and finally closing the gaps. This is
the process at the core of Healthy People and it is the foundation for
Healthy People 2010, which calls for eliminating health disparities.
Healthy People rests on turning the results of research into public health
policy and public health action. The progress we’ve reported today has
been possible only because it builds on a firm knowledge base on which the
public and the health community can unite.