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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

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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

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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

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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

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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

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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