In a review of progress on Healthy People 2000 objectives for maternal and infant health, the Health Resources and Services Administration, lead agency for this priority area, provided an overview on the status of 17 objectives:

14.1 The provisional infant mortality rate for 1994 dropped to 7.9 per 1,000 live births from the 1987 baseline of 10.1. The year 2000 target is 7. While the mortality rate for black infants also declined, they die at a rate of more than twice that of white infants and this disparity has increased between 1987 and 1993.

14.2 In 1993, the fetal death rate declined to 7.1 (per 1,000 live births plus fetal deaths) for the total population and to 12.8 for blacks. The year 2000 target is 5 deaths per 1,000 for the total population, and 7.5 for blacks.

14.3 In 1993, the maternal mortality rate was 7.5 per 100,000 live births for the total population and 20.5 for blacks, continuing a generally downward trend since 1990 for both groups. The year 2000 target is 3.3 deaths per 100,000 for the total population and 5 deaths per 100,000 for blacks.

14.4 Rates of fetal alcohol syndrome (FAS) have increased for all groups. In 1993, the incidence of FAS reached 0.67 per 1,000 live births for the total population and 5.4 for blacks. The most recent data for American Indians/Alaska Natives are from 1990 and show a rate (5.2) that was more than 10 times the rate for the total population in that year. To a degree, better reporting may account for these increases. The year 2000 targets are 0.12 cases per 1,000 live births for the total population, 2 per 1,000 for Native Americans, and 0.4 per 1,000 for blacks.

14.5 The rate of low birthweight increased to 7.2 percent of live births in 1993 (Year 2000 target = 5 percent) and remained at 1.3 percent for very low birthweight (Year 2000 target = 1 percent.) Cigarette smoking and use of drugs, especially cocaine, are contributing factors. There are special population targets for blacks and Puerto Ricans.

14.6 In 1988, the most recent year for which data are available, 75 percent of women achieved the recommended weight gain during pregnancy. The year 2000 target is 85 percent.

14.7 The rate of hospitalizations for severe complications of pregnancy has declined, perhaps reflecting a shift to ambulatory care. In 1994, the rate was 15 per 100 deliveries overall (attaining the year 2000 target) and 24 per 100 for blacks. The year 2000 target for blacks is 16 per 100.

14.8 The rate of Caesarean sections has declined from the 1987 baseline of 24.4 per 100 deliveries to 22 per 100 in 1994. The year 2000 target is 15 per 100. A decline has also occurred in repeat Caesarean deliveries, from 91.2 per 100 deliveries in 1987 to 70.3 per 100 in 1994. The year 2000 target is 65 per 100 deliveries.

14.9 The 60 percent overall rate of breast-feeding during the early postpartum period in 1995 equals the rate for 1984, the best year of record. The year 2000 target is 75 percent. Rates of breast-feeding for blacks and for low-income mothers, while lower than for the total population, have increased at a greater rate.

14.10 In 1993, 80 percent of pregnant women abstained from use of tobacco and 81 percent from alcohol, well short of the year 2000 targets of 90 percent and 95 percent, respectively. The abstention rates in 1993 for cocaine and marijuana were 99 percent and 97 percent, respectively. The year 2000 target for each is 100 percent.

14.11 There was a slight increase (to 78.9 per 100 live births in 1993) in the proportion of pregnant women who received prenatal care in the first trimester. Rates for blacks, American Indians/Alaska Natives, and Hispanics lagged more than 10 points behind the rate for the total population. The year 2000 target is 90 percent for all groups.

14.12 The year 2000 target is 60 percent for the proportion of primary care providers who routinely provide age-appropriate preconception care and counseling. The 1992 baselines ranged from 36 percent for pediatricians and family physicians to 65 percent for obstetricians/gynecologists.

14.13 In 1992, 51 percent of women who subsequently delivered live babies were screened for fetal abnormalities, up from the 1988 baseline of 29 percent. The year 2000 target is 90 percent.

14.15 Based on 43 States reporting in 1990, 89 percent of infants were screened for sickle cell disease. In 38 States reporting, 97 percent of infants were screened for galactosemia.

14.17 This new objective was added as a part of the midcourse review to track the incidence of spina bifida and other neural tube defects (NTDs). The incidence of these birth defects can be reduced by consumption of folic acid prior to conception and during early pregnancy. The 1990 baseline was 6 cases per 10,000 live births and the year 2000 target is 3 per 10,000. The rate in 1993 was 7 per 10,000.

Two objectives lack baseline data--14.14, 14.16

In two objectives--Breastfeeding 14.9 and Prenatal Care 14.11--rates for special populations generally increased more rapidly than for the total population, thus narrowing the gap between special populations and the total population. In most other instances in which targets for special populations have been set, the gap has not been closing. The twofold higher rate of infant mortality for blacks is attributable largely to prematurity, low birthweight, and smoking and substance abuse by mothers. The maternal mortality rate for blacks is 3 times that for whites. Contributing factors include hemorrhage, ectopic pregnancy, preeclampsia and stroke.

HIGHLIGHTS

• Based on findings from studies of sudden infant death syndrome (SIDS), recommendations were issued on the optimal sleeping position for infants. The 25 percent reduction in the SIDS rate appears to be related to the national campaign promoting placement of infants on their backs.
• Early discharge (<48 hours post delivery) of mothers and newborns from hospitals has been associated with increased incidence of jaundice and maternal infections. More than half of the States have enacted legislation to define a minimal hospital stay after childbirth to be covered by all insurance.
• In comparative rates of infant mortality and low birthweight, substantial dis-parity between blacks and whites persists for women of similar educational attainment and social status.
• Recent data have shown that diagnosis and treatment of bacterial vaginosis have been associated with a decrease in the rate of 24-26 week preterm births.
• Guidelines issued by the American College of Obstetricians and Gynecologists have influenced the increase in the rate of vaginal deliveries after Caesarean sections.
• Unintendedness of pregnancy in all age groups correlates with increased incidence of low birthweight.
• Under a new Healthy Start public educational campaign, telephone callers to an "800" number will be connected with their State's maternal and child health office for answers in English or Spanish to questions about pregnancy, childbirth and infant care.

FOLLOW-UP

• Evaluate the evidence on risk factors and interventions for low birthweight and preterm birth to develop new public health approaches for progressing toward Year 2000 targets.
• Analyze public health interventions to reduce racial/ethnic disparities in key maternal and infant health indicators.
• Monitor scientific and legislative developments in early discharge of mothers and newborns from hospitals.
• Conduct an assessment of fetal alcohol syndrome among tribes of Native Americans, focusing on comparative rates of employment, poverty, and other risk factors for alcohol abuse.
• Suggest that a performance measure on breastfeeding and breastfeeding education be incorporated within the Health Plan Employer Data and Information Set (HEDIS). Also, examine rates of breastfeeding in for-profit and non-profit health maintenance organizations.
• Support professional education in lactation so as to improve clinicians' ability to inquire and counsel about breastfeeding.
• Conduct further studies on the correlation of unintendedness of pregnancy with adverse outcomes in childbirth.
• Recommend that health insurers and other third-party payors provide women subscribers with complete information about their plans' coverage of family planning and maternal and infant health care and referral services.
• Undertake a concerted effort to ensure timeliness in the collection and distribution of data on maternal and infant health.
• Work with managed care plans and other insurers to collect and analyze data on the experience and outcomes of women receiving maternal and infant health care services in managed care settings.
• Provide public education on the preventive role of folic acid and other vitamins to ensure that their benefits are available to all prospective mothers.
  

PARTICIPANTS
American College of Obstetricians and Gynecologists
Agency for Healthcare Research and Quality (AHRQ)
Centers for Disease Control and Prevention
Health Care Financing Administration
Health Resources and Services Administration
Indian Health Service
Interfaith Medical Center (New York)
National Institutes of Health
Office of the Assistant Secretary for Planning and Evaluation
Office of Disease Prevention and Health Promotion
Office of Minority Health
Office of Public Health and Science
Office on Women's Health
San Antonio Metropolitan Health District
Secretary's Advisory Committee on Infant Mortality
Office of Population Affairs
Substance Abuse and Mental Health Services Administration
The University of Alabama at Birmingham

Philip R. Lee, M.D.
Assistant Secretary for Health

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