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Preventing Low Birthweight
Committee to Study the
Prevention of Low Birthweight
Division of Health Promotion and
Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1985
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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of En~eenng, and the Institute
of Mediane. The members of the committee responsible for the report were chosen for
their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to the
procedures approved by a Report Review Committee consisting of members of the Nation-
al Academy of Sciences, the National Academy of Engineenng, and the Institute of
Mediane.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to
enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy 1863 congressional charter responsibility to be an adviser to the federal govem-
ment and its own initiative in identifying issues of medical care, research, and education.
A digest of this volume is availablefrom the National Academy Press at the address above Please inquire
for once and quantity discounts.
Library of Congress Catalog Card Number 84~2849
International Standard Book Number 0-309-03530-9
Cover photo by Susie F~tzhugh for Children's Hospital
National Medical Center, Washington, D.C.
Printed in the United States of America
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Committee to Study
the Prevention of Low Birthweight
RICHARD E. BEHRMAN, Chairman, Committee to Study the Prevention of
Low Bir~weight, Instih~te of Medicine, and Dean, School of Medicine,
Case Western Reserve University, Cleveland, Ohio
JEFFREY E. IS, Associate Professor, Depa~ent of Economics,
Massachusetts Institute of Technology, Cambridge, Massachusetts, and
Clinical Associate, Massachusetts General Hospital, Boston,
Massachusetts
CALM ]. HOBEL, Professor of Obstetrics, G~ecolo~ and Peas,
School of Medicine, University of California at Los Angeles, and
Director, Matemal-Fetal Medicine, Cedars Sinai Medical Center, Los
Angeles, California
JEROME O. KLEIN, Professor of Pediatrics, Boston University School of
Medicine, and Director, Division of Pediatric Infectious Diseases, Boston
City Hospital, Boston, Massachusetts
LUELLA KLEW, President, American College of Obste~aans and
Gynecologists, and Professor of Gynecology and Obstetrics, Emory
University School of Medicine, Atlanta, Georgia
MARIE C. MCCORMICK, Assistant Professor of Pecliatrics, University of
Pennsylvania School of Medicine, Philadelphia, Pennsylvania
JAMES METCALFE, Professor of Medicine, Oregon Health Sciences
University, Portland, Oregon
C. ARDEN MILLER, Professor and Chairman, Depa' lenient of Maternal and
Child Health, School of Public Health, University of North Carolina at
Chapel Hip, Chapel Hip, North Carolina
JO~ T. QUEENS, Professor and Chapman, Department of Obstetrics and
Gynecology, Georgetown University Hospital, Washington, D.C.
JIJ[IUS B. RICHMOND, Director, Division of Health Policy Research and
Education, and John D. MacArthur Professor of Health Policy and
Management, Harvard University, Boston, Massachusetts
I~ P. ROOM, President, American College of Nurse-~ves,
Portlancl, Oregon
SAM SHAP~Ro, Professor of Health Policy and Management, and Past
Director, Health Services Research and Development Center, School of
Hygiene and Public Health, Johns Hopkins University, Baltimore,
Maryland
. . .
111
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Study Staff
SARAH S. BROWN, Study Director, Committee to Study the Prevention of
Low Birthweight
ENRIQUETA C. BOND, Director, Division of Health Promotion and Disease
Prevention
STEPHANIE C. BRUGLER, Research Assistant, Division of Health Promotion
and Disease Prevention
EVE K. NICHOLS, Editor, Division of Health Promotion ant! Disease
Prevention
WALLACE K. WATERFALL, Editor, Institute of Medicine
LINDA DEPUGH, Administrative Secretary, Division of Health Promotion and
Disease Prevention
NAOMI HUDSON, Administrative Secretary, Division of Health Sciences Policy
Consultant
LORRAINE KLERMAN, Professor of Public Health and Head, Division of
Health Services Administration, Department of Epidemiology and
Public Health, School of Medicine, Yale University, New Haven,
Connecticut
Commissioned Papers
ROBERT GOLDENBERG, Professor of Obstetrics and Gynecology, Department
of Obstetrics and Gynecology, The University of Alabama, Birmingham,
Alabama
VILMA HUNT, Professor of Public Health, Pennsylvania State University,
University Park, Pennsylvania
LORRAINE KLERMAN, Professor of Public Health and Head, Division of
Health Services Administration, Department of Epidemiology and
Public Health, School of Medicine, Yale University, New Haven,
Connecticut
CAROL C. KORENBROT, Research Specialist, Center for Population and
Reproductive Health Policy, Institute of Health Policy Studies,
University of California, San Francisco, California
JOAN MAXWELL, Senior Associate, Greater Washington Research Center,
Washington, D.C.
MARGARET A. MCMANUS, Health Policy Consultant, Washington, D.C.
MARIE MEGLEN, Director, Bureau of Maternal and Child Health, South
Carolina Depatl~ent of Health and Environmental Control, Columbia,
South Carolina
MARY PEOPLES, Assistant Professor, Department of Maternal and Child
Health, School of Public Health, University of North Carolina at Chapel
Hill, Chapel Hip, North Carolina
BEATRICE l. SELWYN, Research Assistant Professor in Epidemiology, School
of Public Health, University of Texas, Houston, Texas
1V
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JOE LEIGH SIMPSON, Professor of Obstetrics and Gynecology and Head,
Section of Suntan Genetics, Prentice Women's Hospital and Maternity
Center, Northwestern University Medical Center, Chicago, Illinois
STEVEN SMOOKLER, Assistant Dean for Special Programs, School of
Medicine, Case Western Reserve University, Cleveland, Ohio
SUSAN WILNER, Pew Fellow, Institute of Health Policy Series, University
of California at San Franasco, San Francisco, California
Contributed Papers
HEINZ W. BE~NDES, Director, Epidemiology and Biometry Research
Program, National Institute of Ch]d Health and Human Development,
Bethesda, Maryland
NAOMI BRESLAU, Associate Professor of Epidemiology and Community
Health, School of Medicine, Case Western Reserve University,
Cleveland, Ohio
AMY FINE, Project Director, Child Health Outcomes Project of the
University of North Carolina, Washington, D.C.
STEPHEN G. GABBE, Professor of Obstetrics, Gynecology and Pediatrics, and
Director, lerrold R. Golding Division of Fetal Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
KENNETH G. JOHNSON, Director, Health Services Research Center, The
Kingston Hospital, Kingston, New York
SAMUEL S. KESSEL, Chief, Research and Training Branch, Division of
Maternal and Child Health, Department of Health and Human Services,
Washington, D.C.
MARK KLEB~OFF, Medical Staff Fellow, Epidemiology and Biometry
Research Program, National Institute of Child Health and Human
Development, Bethesda, Maryland
MILTON KOTELCHUCK, Assistant Professor of Health Policy, Department of
Social Medicine and Health Policy, Harvard MecTical School, Boston,
Massachusetts
MORTON LEBOW, Administrator for Public Affairs, Amencan College of
Obstetricians and Gynecologists, Washington, D. C.
DAVID SAL~VER, Professor of Health Policy and Management, School of
Hygiene and Public Health, Johns Hopkins University, Baltimore,
Maryland
JOHN SINCLA~, Professor of Pediatrics, Department of Pediatrics,
McMasters University, Hamilton, Ontario
LEON SPEROFF, Professor and Chairman, Department of Obstetrics and
Gynecology, Case Western Reserve University, and Director, McDonald
Hospital for Women, Cleveland, Ohio
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Preface
· .
V11
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TABLE 1. Percentage of Nlery Low Birthweight (VLBW) and Low
Birthweight (LBW) Live Births in Selected Developed Countries, 1980
Country VLBWa LBWb
Austria 0.80 5.68
CanadaC 0.84 6.10
Denmark O.72 6.00
Federal Republic of Germany 0.71 5.51
German Democratic Republic 0.55& 6.19
Israel 0.99 7.16
Italy 0.83 6.71
Japan 0.39 5.18
New Zealand 0.65 5.27
Norway 0.59 3.25
Swedene 0.49 4 03
Switzerland 0.49 5.14
United Kingdom
England and Walesf 0.77 6.79
Scotland 0.96 6.73
United States 1.15 6.84
al,SOO grams or less. May represent underestimates if infants weighing less than 500 grams are
excluded.
b2,500 grams or less.
CData for 1979.
Probably an underestimate due to a nonstandard definition of live births and late fetal deaths.
eData for 1978.
fMacfarlane A and Mugford M: Birth Counts, Statistics of Pregnancy and Childbirth, p. 14. London:
Her Majesty Stationary Office, 1984.
gMcIlwaine GM, Dunn F. Howat RCL, Smalls M, Wyllie MM, and MacNaughton MC: Perinatal
Mortality Survey, Scotland, 1977-1981. Glasgow: University of Glasgow, 1983.
SOURCE: United Nations: Demographic Yearbook 1981. New York, 1983.
United States and other countries often limit the applicability of data collected abroad to
the United States.
Acknowledgments
Funding was provided principally by the Commonwealth Fund, with additional sup-
port from the Ford Foundation, the March of Dimes Birth Defects Foundation, the Na-
tional Institute of Child Health and Human Development, and the National Research
Council Fund. The support of these funding sources is gratefully acknowledged.
In my role as chairman of the committee that developed this report, ~ also wish to
express my gratitude to the many individuals who contributed so much to our debbera-
tions. In particular, it was a privilege to be associated with such a hardworking and dedi-
cated committee, whose members gave so generously and unreservedly of their time and
energies. Similarly, the committee joins me in acknowledging our great appreciation and
indebtedness to the staff of this study, especially the study's director, Sarah Brown.
Without her support and exceptional efforts in our behalf, the work could not have been
. . .
V111
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so successfully completed. The many contributions of Lorraine Klerman, a consultant to
the study and the author of several papers for the project, are also gratefully acknowI-
edged. And particular thanks go to Eve Nichols, the report editor, for her tireless atten-
tion to countless details of both form and substance.
We were also fortunate in benefitting from the substantial help and stimulation pro-
vided by a number of thoughtful commissioned and contributed papers, the authors of
which are listed at the beginning of the report. These authors also provided useful per-
sonal insights for which we are thankful. Several components of the Department of
Health and Human Services provided valuable assistance in data analysis, in locating
various materials needed by the committee, and in providing helpful commentary. We
extend particular thanks to Vince Hutchins and Samuel Kessel within the Division of
Maternal and Child Health; Joel Kleinman, Jacob Feldman, Paul Placek, Selma Taffel,
Robert Hartford, and Mary Grace Kovar of the National Center for Health Statistics; and
Heinz Berendes, Mark Klebanoff, Sumner Yaffe, Wendy Baldwin, and Charles Lowe of
the National Institute of Child Health and Human Development.
Many other individuals played an important role in the committee's deliberations by
providing information, critical analysis, advice, and reviews of draft material. In particu-
lar, we gratefully recognize the help provided by Robert Bragonier, Alexander Burnett,
John Carl, Frederick Frigoletto, Phyllis Freeman, Steven GorUnaker, Asta Kenney, Mary
Lou Moore, Merry-K Moos, Elena Nightingale, Anthony Robbins, Sara Rosenbaum,
Anne Rosewater, Lisbeth Schorr, Steven Warsof, and Ronald Williams.
RICHARD E. BEHRMAN, M.r).
Chairn^.an
K
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Contents
Summary and Recommendations . . . . . . . . . . . . . . . . . .
PART I: Definitions, Risk Factors, and Trends
I. The Significance of Low B~rthweight.
2. Etiology and Risk Factors.
3. Trends in Low Birthweight .
PART Il.: Reducing the Incidence of Low Birthweight
An Overview of Pro~sing Interventions
Planning for Pregnancy
The Effectiveness of Prenatal Care.
Ensuring Access to Prenatal Care
Improving the Content of Prenatal Care
4.
5.
6.
7.
8.
9. A Public Information Program
10. Prenatal Care and Low Birthweight:
Effects on Health Care Expenditures.
APPENDIXES
A. Risk Factors Associated with Tow Birthweight .
B. Data on Selected Low Birthweight Trends
(Supplement to Chapter 3) .
C. A Summary of Three Prematurity Prever~hon Programs.
D. Notes on National Data Available to Study Low B~rthweight
Trends and to Monitor Related Programs
Index
ma
21
46
94
115
119
132
150
175
202
212
241
252
266
275
279
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