Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 170
22. Maternal and Infant Health
A nation's infant mortality rate is often regarded as
an indicator of a country's effectiveness in addressing
health needs. By that measure, the United States is
ailing. Primarily because of relatively high rates
among the poor, minorities, and adolescents, the
United States falls toward the bottom of the list when
the infant mortality rates of industrialized nations are
ranked.
Yet behind that grim fact lies a tremendous
opportunity. The 133 witnesses who concentrated on
maternal and infant health emphasized that biological
breakthroughs or technological miracles are not
required to improve those statistics-the knowledge
necessary to make progress is already at hand.
Preventive measures, primarily adequate prenatal care,
can improve pregnancy outcome. Cessation of tobac-
co, alcohol, or drug use during pregnancy is also an
important means of reducing the infant mortality rate
and morbidity in newborns.
These preventive strategies have not changed much
since the 1990 Objectives were formulated. If objec-
tives for the year 2000 are to be met, the national
commitment to making those strategies available must
change, according to many witnesses.
Although there has been some overall decline in
the infant mortality rate in the past decade, many of
the 1990 Objectives pertaining to infant mortality will
not be met, especially those relating to minorities. In
addition, there is now concern that progress is slowing
and infant mortality rates for some subpopulations
may actually be increasing. A witness for the March
of Dimes Birth Defects Foundation sets the scene this
way:
Ensuring all infants a healthy start in life and
enhancing the health of their mothers must be
a top priority in the 1990s if we are to ensure
the future health of our nation. Progress on
infant mortality is slowing; maternal mortality
among Black and non-White mothers is increas-
ing; low birth weight may be on the rise; and
not enough women are getting early prenatal
care. It is a situation that raises great concern
about the health of America's future genera-
tions. (~044)
Much of the testimony on maternal and infant care
170 Healthy People 2000: Citizens Chart the Course
echoed this view that the United States must make
maternal and infant health ~ national priority.
Several witnesses called for a policy to ensure that
pregnant women and their infants have access to
adequate care; the United States is one of the few
industrialized nations without such a policy.
The objectives proposed for the year 2000, many of
them carryovers from the 1990 Objectives, are related
to both process and outcome. In the first category,
there is emphasis on adequate prenatal care and
reducing risk factors in pregnant women; in the
second category, there are reductions in the propor-
tion of low-birth-weight babies and in infant mortality
rates.
Witnesses noted that adolescents, Blacks, and
Hispanics should be targeted for intervention. One
witness said that the 1990 objectives calling for
reductions in the number of women who get no
prenatal care should be replaced with measures of
inadequate prenatal care. (#044; #108; #316)
Yet over and over again, the testimony made clear
that well-laid plans can go only so far. Commitment
and the resources to back it up are required if the
strategies are to translate into improvements in
maternal and infant health.
PRENATAL CARE
Research has clarified the link between early and
regular prenatal care and improved pregnancy out-
come. Low birth weight, for example, has been
shown to occur more often when prenatal care is
inadequate. Yet witnesses repeatedly commented that
too many mothers, particularly in minority and
adolescent populations, are not receiving such care.
According to testimony from the American College
of Obstetricians and Gynecologists (ACOG), 76
percent of pregnant women receive prenatal care in
the first trimester; 6 percent have their first visit
during the third trimester. Among Blacks, however,
only 62 percent begin prenatal care in the first
trimester, and 10 percent do not begin until the third
trimester. Only about 60 percent of Hispanic women
receive prenatal care during their first trimester, and
12 percent of Hispanic mothers who delivered in 1980
received no prenatal care until the third trimester."
(#279; #308) Medicaid patients and the uninsured
OCR for page 171
are more likely to get insufficient care, defined as
eight or fewer visits or care that begins in the second
or third trimester.2 (#279)
According to the ACOG? the percentages of
pregnant adolescents who receive first trimester care
are even lower: 36 percent of mothers younger than
15, and 34 percent of mothers 15-19 years old.3
Even those adolescents who start early do not neces-
sarily maintain an appropriate care schedule through-
out their pregnancy. (#279)
Yet although many testifiers discussed "adequate"
prenatal care as the ideal to be attained, agreement
could not be reached on how much care, provided
when, and of what kind or quality equates with
"adequate." For example, the ACOG refers to a 1987
General Accounting Office (GAO) report on prenatal
care among Medicaid recipients and uninsured women
that offers one definition:
There is a need to adopt a simple, straightfor-
ward definition of adequate prenatal care. In
the GAO report, insufficient care was defined as
either eight or fewer visits or beginning care in
the second or third trimester. There is a clear
need for standard definitions of a prenatal visit
to provide a basis for national consistency in
future assessment of trends in this area.4
(~279J
After testimony was submitted, the Public Health
Service published a report on the appropriate content
of prenatal care. The report made specific recom-
mendations about enriching care and changing the
visit schedule according to presenting risk factors and
previous pregnancies. In outline, the study suggests
a preconception visit, followed by at least nine other
visits. The first visit should be within the first trimes-
ter (six to eight weeks).5
Prenatal care and other public education efforts
should be used to alert pregnant women to prevent-
able risk factors for low birth weight and poor preg-
nancy outcome. Risk factors cited in the testimony
include smoking, alcohol use, drug abuse, sexually
transmitted disease, poor nutrition, and psychosocial
factors. Smoking and poor nutrition are associated
with low birth weight and other problems in the
neonate. Several witnesses addressed the need to
reduce smoking and improve nutrition among preg-
nant women. Excessive alcohol intake can cause fetal
alcohol syndrome. Lyn Weiner and Barbara Morse of
Boston University School of Medicine say that the
condition is underdiagnosed and this is hindering
early intervention and appropriate treatment. (#542J
Congenital syphilis is on the increase, according to
witnesses; Michael Jarrett, Commissioner of the South
Carolina Department of Health and Environmental
Control, proposes that efforts be made to identify and
treat women with syphilis during pregnancy. (~108)
Many of these risk factors were addressed in the
1990 Objectives. Some witnesses say that more
attention should be paid to reducing cocaine use
among pregnant women and to the importance of
psychosocial evaluation and care during pregnancy in
the Year 2000 Health Objectives. (~418; #421)
Modern technology, although admittedly expensive,
has been extremely useful in detecting high-risk
pregnancies. According to Robert Welch and Robert
Sokol of the Hutzel Hospital in Detroit and Wayne
State University, one "major difference between our
prenatal outcome in the U.S. versus European coun-
tries is that patients in many European countries have
universal ultrasound screening early in pregnancy."
Welch and Sokol suggest that uniform ultrasound
testing be performed during pregnancy and that
maternal serum alpha-fetoprotein testing be done in
100 percent of pregnancies. (~421J
Other important issues in prenatal care, including
availability of providers, financial constraints, and
outreach programs, are treated in the implementation
section of this chapter.
MATERNAL MORTALITY AND COMPLICATIONS
Delivery has its own set of preventive strategies.
Several witnesses expressed concern about maternal
mortality rates, particularly among non-White and
poor mothers. (#044; #199; #383) Black and other
non-White mothers are more than three times as
likely to die as White mothers, according to figures
cited by the Children's Defense Fund.6
In its testimony, the March of Dimes Birth Defects
Foundation notes that up to 75 percent of maternal
mortality may be preventable and suggests that the
disparity in rates may be due to minority women's
lack of access to, or underutilization of, obstetrical
services.7 The March of Dimes recommends expand-
ing access to early prenatal care by expanding funding
for the Maternal and Child Health Block Grant, and
by expanding Medicaid to provide services for more
pregnant women, infants, and children. (~044)
Kristine Siefert, representing the National Association
of Social Workers, agrees that much maternal mor-
tali~ can be prevented. She also says that maternal
mortality review committees should be reinstated
Maternal and infant Health 171
OCR for page 172
where they have been discontinued. These commit-
tees should address social as well as medical factors
when they assess whether a death could have been
prevented. By the year 2000, according to Siefert, the
maternal mortality rate should not exceed 3 per
100,000 live births, half of the current rate. (~199)
NEWBORN CARE
Eunice Ernst, representing the National Association
of Childbearing Centers, calls for the expansion of
childbirthing centers outside of hospitals. (#060) On
the other hand, delivering high-risk babies at centers
where special needs can be met is also important; an
objective proposed by Roger Rosenblatt of the
University of Washington is that 75 percent of all
births involving newborns weighing less than 1,500
grams occur at Level III perinatal referral centers.
(#316)
Several witnesses called for more screening of
newborns. Richard Schwarz of the State University of
New York Health Science Center at Brooklyn
proposes as a goal the development of an accurate
antigen test to identify infants infected with the
human immunodeficiency virus so that early interven-
tion is possible. (#442) The value of newborn
screening for metabolic disorders, as identified in the
1990 Objectives, was underscored. Jarrett says that
newborns also should be screened for sickle cell
anemia and other hemoglobinopathies. (#108)
David Wirtschafter of Southern California Kaiser
Permanente says that better communication Is needed
between parents and providers about "rescue" tech-
nologies for seriously ill newborns. (#582J Several
statements note the need for follow-up of infants with
special needs. (#324; #371) The importance of
genetic counseling for parents of affected infants or
for those at risk of bearing affected children is noted
by William Montgomery of the American Academy of
Pediatrics and others. (#722) Improved parenting
education, also mentioned in this connection, is
discussed in detail in Chapter 14
Many witnesses representing breast-feeding
organizations, such as the La Leche League or the
International Lactation Consultant Association,
focused their testimony entirely on breast-feeding.
They testified that it is healthier and less expensive
than bottle feeding. Allan Cunningham, of Columbia
University College of Physicians and Surgeons and the
Mary Imogene Bassett Hospital, and others say
research suggests that it may have long-term as well
as short-term medical and psychological benefits.
172 Healthy People 2000: Citizens Chart the Course
(#046)
Many of these testifiers proposed that by the year
2000, 85 percent of women be breast-feeding when
they leave the hospital, and 50 percent after six
months. This is a slight increase over the 1990
targets, which they said would not be met. Some
testifiers suggested that the year 2000 goals be stated
such that no ethnic group or region falls below a
given percentage. (~158)
Increased public and professional awareness is
needed to meet this goal. Witnesses urge increased
emphasis in medical schools and continuing medical
education about the benefits of breast-feeding.
Deborah Bublitz, representing La Leche League, says
it is also essential to get hospitals to endorse breast-
feeding as the feeding method of choice among new
mothers.
Establish breastfeeding as the primary house
formula in all hospitals, with formula only as a
supplement. To provide this, a support network
that works both in the hospital and an outreach
program after the hospital must be actively
implemented. (~033)
Media messages and other techniques to educate the
public also are needed. Many feel that employer
policies should make breast-feeding easier, and they
call for special areas for breast-feeding in the work-
place and in public settings. They also raise the
issues of marketing practices of infant formula com-
panies and company grants to hospitals linked to use
of their products. (#010; #049)
IMPLEMENTATION
According to witnesses, if our nation's infant mortality
rates, maternal mortality rates, and percentage of low-
birth-weight infants are to improve, a varieW of
barriers must be overcome so that all can have easy,
affordable access to care. A need for better and more
consistent data also was expressed.
Availability of Providers
Several witnesses expressed concern that the malprac-
tice environment is causing obstetricians and other
providers to discontinue or limit their obstetrical
practices. This makes it more difficult for some
wome~particularly low-income women and those in
rural areas-to obtain needed services. (#215; #244;
#360; #726j These witnesses recommended capping
OCR for page 173
malpractice awards and using alternative practitioners
such as rural midwives.
The closure of many community hospitals also has
affected access. Many hospitals that are closing are in
rural or indigent areas where services already are
limited. (#003)
In addition, testifiers reported that some physicians
are refusing to treat Medicaid patients because of
what they consider inadequate reimbursement rates.
One witness suggested that the Year 2000 Health
Objectives include a goal about physicians accepting
Medicaid patients. (~316)
According to numerous witnesses, licensed, quali-
fied midwives and nurse midwives can do much to
alleviate the problems related to a poor supply of
providers. The American College of Nurse-Midwives
(ACNM) says that studies have demonstrated that
nurse midwives have reduced infant mortality rates
significantly.8 (#003) Katherine Carr, who represent-
ed ACNM at a hearing, identifies several reasons why
they may be especially effective in providing prenatal
care.
Midwives are experts in the psychosocial, as well
as the physical assessment, aspects of prenatal
care. Midwives provide nutritional and other
educational counseling and communicate caring
to their clients. It has been found that the
amount of caring perceived by the woman in the
services provided may actually influence her
outcomes. It's also been hypothesized that
perception of caring influences the rate of
litigation. (~690)
Carr also says that increasing the use of qualified
midwives as part of the health care team in deliveries,
especially for high-risk populations, could lead to
reductions in infant mortality rates. Currently, mid-
wives attend less than 4 percent of births in the
United States. Carr suggests that by the year 2000,
10 percent of U.S. births be attended by midwives.
Restrictions on the practice of qualified, licensed
midwives and certified nurse midwives keep them
from realizing their potential, she says. (~690J
Many in the medical community, especially, ex-
pressed reservations about this recommendation.
Although most agreed that these certified nurse
midwives and other licensed, qualified midwives can
contribute significantly to providing prenatal care,
concern was expressed about their effectiveness in
performing solo deliveries; however, there was support
for their role in deliveries when they are backed up
by an obstetrician. (~421) Several testifiers also felt
strongly that there is no role for "lay" midwives. This
latter group has no formal training and should not be
confused or equated with licensed or certified mid-
wives. (#421; #801)
Even among those who were optimistic about the
potential of licensed and certified midwives to supple-
ment physicians in prenatal and delivery care, espe-
cially among the undersexed, there was recognition
that the existing pool of these professionals is rela-
tively small; there are approximately 2,500 certified
nurse midwives in the United States today. (#268;
#316) Roger Rosenblatt of the University of Wash-
ington reports that studies in that state show that
midwives are less likely to take care of undersexed
population groups than general and family physicians,
while costing about the same. (i,316)
Financial Constraints
To a large extent, states have been unable to close
gaps in access because their public health budgets
have been tightened. Marty witnesses say that in-
creased funding of maternal and child health block
grants and of the Women, Infants, and Children sup-
plemental feeding program, as well as extension of
Medicaid benefits to more women and infants, is
critical to the effort to provide adequate prenatal
care. Prenatal care is a cost-effective investment, they
emphasize. The Michigan Department of Public
Health estimates that for every dollar spent to provide
prenatal care to uninsured women, more than $6 is
saved in expenditures for neonatal intensive care.
The average Michigan Medicaid hospital payment for
normal newborns in 1986 was $813; for newborns with
health problems the cost ranged from $1,940 for full-
term to $7,503 for premature newborns with major
problems. (#397)
Nurse midwives, nurse practitioners, visiting nurses,
and other qualified, licensed midwives can provide
effective prenatal care at a lower cost than physicians
and should be used more to address unmet needs,
according to representatives of those groups. (#003;
#074; #268; #383; #444; #690)
However, state financing mechanisms often do not
pay enough to cover even basic care and delivery
costs. In Colorado, for example, reimbursement rates
for Medicaid patients (vaginal delivery, including
prenatal care) for 1987-1988 were $510; fees for
patients covered by another state program are $309
per delivery. In looking at these figures, Ned Calonge
of the University of Colorado Health Sciences Center
Maternal and Infant Health 173
OCR for page 174
believes that "family physicians could have strong
economic incentives for stopping obstetrical services,
especially to Medicaid and indigent patients, and
obstetricians already face similar economic pressures."
(~244)
Need for Outreach Programs
Not all the barriers to obtaining prenatal care involve
the availability of services, however. Sociocultural
barriers also keep pregnant women from using avail-
able services and require special outreach efforts to
encourage women to take advantage of services.
Edna Batiste describes how the Primary Care
Network of the Detroit Department of Health is
attempting to provide prenatal services to those who
need them. However, it is not easy, she says. The
recommendation of the American College of Obstetri-
cians and Gynecologists for 12 or more prenatal visits,
beginning in the first trimester, "is not only difficult
but almost impossible to accomplish" in the inner-
cibr population she serves. "Their lifestyles and
multiplicity of problems simply will not allow this."
There are intrinsic barriers of lifestyle, life experience
or lack of it, educational levels, attitudes, and beliefs.
(~016)
Batiste and others emphasize the importance of
outreach efforts to adolescent, minority, and low-
income groups who are not obtaining prenatal care.
Culturally sensitive material and providers are re-
quired. Jo McNeil representing the American Nurses'
Association says that one way to reduce poor out-
comes among low-income pregnant women is to work
with public assistance agencies already serving that
population.
REFERENCES
These women usually request financial help and
can be identified and given health care
assistance as quicldy as they can be given funds
for housing and food, if the agencies had a
system of working this out together. By asking
the client to come in and get her check, at least
a monthly opportunity would be available for
group education. (~359)
()utreach programs also need to be designed so
that pregnant women and new mothers are motivated
to take advantage of them. The ACOG says, "We
have to develop innovative methods of education" if
we are to reach lower socioeconomic women with
information about nutrition. (#279) The National
Mental Health Association calls for "psycho-socia1
support and intervention to pregnant women and to
families with infants. (~418)
Data Needs
In addition to concerns expressed about the need for
a widely accepted and practical definition of
Adequate" prenatal care, several witnesses pointed out
other data needs.
Miriam Orleans of the University of Colorado
School of Medicine asks, What goes on in prenatal
care? What works, what doesn't? She suggests that
"by 1990 we increase our efforts to conduct ran-
domized controlled trials in order to evaluate our in-
terventions. We increasingly demand trials of obstet-
rical interventions, but are far less rigorous about
programs and social interventions." (#168) An
example of a specific type of data need is identified
by Weiner and Morse, who propose the establishment
at the Centers for Disease Control of a national
registry to measure the incidence of fetal alcohol
syndrome. (#542)
1. National Center for Health Statistics: Health United States, 1989 (DHHS Publication No. [PHS] 90-1232),
1990
2. U.S. General Accounting Office: Prenatal care: Medicaid recipients and uninsured women obtain insufficient
care. Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee
on Government Operations, House of Representatives. GAO/HAD 87-137, September 1987
3. Hughes D, Johnson K, Rosenbaum S. et al.: The Health of America's Children: Maternal and Child Health
Data Book. Washington, D.C.: Children's Defense Fund, 1988
174 Healthy People 2000: Citizens Chart the Course
OCR for page 175
5. Public Health Service: Caring for Our Future: The Content of Prenatal Care. A Report of the PHS Expert
Panel on the Content of Prenatal Care. Washington, D.C.: U.S. Government Printing Office, 1989
6. Hughes D et al.: op. cit.' reference 3
7. Ibid.
8. Thompson, J: Nurse midwifery care 1925 to 1984. Annual Review of Nursing Research, vol. 4. Edited by HH
Werley, JJ Fitzpatrick, R Taunton. New York: Springer-Verlag, 1986
TESTIFIERS CITED IN CHAPTER 22
003 Alden, John; American College of Nurse-Midwives
010 Auerbach, Kathleen; University of Chicago, Wyler Children's Hospital
016 Batiste, Edna; Detroit Department of Health
033 Bublitz, Deborah; University of Colorado Health Sciences Center
044 Corey, Maureen; March of Dimes Birth Defects Foundation
046 Cunningham, Allan; Columbia University
049 Desmarais, Linda; International Lactation Consultant Association
060 Ernst, Eunice K M.; National Association of Childbearing Centers
074 Grigsby, Sharon; The Visiting Nurse Foundation
108 Ja'Tett, Michael; South Carolina Department of Health and Environmental Control
1S8 Mulford, Christine; International Lactation Consultant Association of Eastern Pennslvania
168 Orleans, Miriam; University of Colorado Health Sciences Center
199 Siefert9 Kristine; University of Michigan
215 Turnock, Bernard; Illinois Department of Public Health
244 Calonge, Ned; University of Colorado Health Sciences Center
268 Work, Rebecca; University of Alabama at Birmingham
279 Davidson, Ezra; King-Drew Medical Center (Los Angeles)
308 Smith, Peggy B.; Baylor College of Medicine
316 Rosenblatt, Roger; University of Washington
324 Hill, L. Leighton; University of Texas Health Science Center at Houston
359 McNeil, Jo; South Puget Sound Community College
360 Kopelman, J. Joshua; The OB-GYN Associates (Denver)
371 Schiff, Donald; American Academy of Pediatrics
383 Demmin, Tish; Midwives' Alliance of North America
397 Gaines, George; Detroit Department of Health
418 Tableman, Betty; Michigan Department of Mental Health
421 Welch, Robert and Sokol, Robert; Wayne State Universin,,/Hutzel Hospital (Detroit)
442 Schwarz, Richard; State University of New York, Health Science Center at Brooklyn
444 Mendelsohn, Sally; Midwives' Alliance of North America
542 Weiner, Lyn and Morse, Barbara; Boston University
582 Wirtschafter, David; Southern California Kaiser Permanente
690 Carr, Katherine; American College of Nurse-Midwives
722 Montgomery, William; Mount Carmel Mergy Hospital (Detroit)
726 Wright, Terri; Detroit/Wayne County Infant Health Promotion Coalition
801 Schlotfeldt, Rozella; Cleveland Heights, Ohio
Maternal and Infant Health 175
Representative terms from entire chapter:
pregnant women
