# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 16 {#section-1 .Chapter-#}

# Maternal, Infant, and Child Health

Co-Lead Agencies: Centers for Disease Control and Prevention\
Health Resources and Services Administration

### Contents {#contents .Heading-Special}

[Goal Page 16-3](#goal)

[Overview Page 16-3](#overview)

[Issues and Trends Page 16-3](#issues-and-trends)

[Disparities Page 16-7](#disparities)

[Opportunities Page 16-8](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
16-9](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
16-10](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
16-12](#healthy-people-2010-objectives)

[Fetal, Infant, Child, and Adolescent Deaths Page
16-12](#fetal-infant-child-and-adolescent-deaths)

[Maternal Deaths and Illnesses Page
16-23](#maternal-deaths-and-illnesses)

[Prenatal Care Page 16-26](#prenatal-care)

[Obstetrical Care Page 16-29](#obstetrical-care)

[Risk Factors Page 16-32](#risk-factors)

[Developmental Disabilities and Neural Tube Defects Page
16-38](#developmental-disabilities-and-neural-tube-defects)

[Prenatal Substance Exposure Page 16-43](#prenatal-substance-exposure)

[Breastfeeding, Newborn Screening, and Service Systems Page
16-46](#breastfeeding-newborn-screening-and-service-systems)

[Related Objectives From Other Focus Areas Page
16-51](#related-objectives-from-other-focus-areas)

[Terminology Page 16-54](#terminology)

[References Page 16-56](#references)

##   {#section-2 .unnumbered}

## Goal

**Improve the health and well-being of women, infants,\
children, and families.**

## Overview

The health of mothers, infants, and children is of critical importance,
both as a reflection of the current health status of a large segment of
the U.S. population and as a predictor of the health of the next
generation. This focus area addresses a range of indicators of maternal,
infant, and child health---those primarily affecting pregnant and
postpartum women (including indicators of maternal illness and death)
and those that affect infants' health and survival (including infant
mortality rates; birth outcomes; prevention of birth defects; access to
preventive care; and fetal, perinatal, and other infant deaths).

Infant mortality is an important measure of a nation's health and a
worldwide indicator of health status and social well-being. As of 1995,
the U.S. infant mortality rates ranked 25th among industrialized
nations.[^1] In the past decade, critical measures of increased risk of
infant death, such as new cases of low birth weight (LBW) and very low
birth weight (VLBW), actually have increased in the United States. In
addition, the disparity in infant mortality rates between whites and
specific racial and ethnic groups (especially African Americans,
American Indians or Alaska Natives, Native Hawaiians, and Puerto Ricans)
persists. Although the overall infant mortality rate has reached record
low levels, the rate for African Americans remains twice that of
whites.[^2]

### Issues and Trends

In 1997, 28,045 infants died before their first birthday, for an overall
rate of 7.2 deaths per 1,000 live births. This rate has declined
steadily over the past 20 years; in 1975, the infant mortality rate was
over 15 per 1,000 live births.Error: Reference source not found In 1997,
two-thirds of all infant deaths took place during the first 28 days of
life (the neonatal period). The overall neonatal mortality rate in 1997
was 4.8 per 1,000 live births.Error: Reference source not found The
remaining one-third of infant deaths took place during the postneonatal
period from an infant's 29th day of life until the first birthday. The
U.S. postneonatal mortality rate in 1997 was 2.4 deaths per 1,000 live
births.Error: Reference source not found

Four causes account for more than half of all infant deaths: birth
defects, disorders relating to short gestation and unspecified LBW,
sudden infant death syndrome (SIDS), and respiratory distress syndrome.
The leading causes of neonatal death in 1997 were birth defects,
disorders related to short gestation and LBW, respiratory distress
syndrome, and maternal complications of pregnancy. After the first month
of life, SIDS is the leading cause of infant death, accounting for about
one-third of all deaths during this period. Maternal age also is a risk
factor for infant death. Mortality rates are highest among infants born
to young teenagers (aged 16 years and under) and to mothers aged 44
years and older.

The death of fetuses before birth is another important indicator of
perinatal health. In 1996, nearly 7 fetal deaths were reported for every
1,000 live births and fetal deaths combined, representing a slight
decline from the fetal mortality rate of 7.6 per 1,000 in 1987.Error:
Reference source not found Fetal death sometimes is associated with
pregnancies complicated by such risk factors as problems with amniotic
fluid levels and maternal blood disorders.[^3] Early, comprehensive, and
risk-appropriate care to manage such conditions has contributed to
reductions in fetal mortality rates.
![](media/image2.wmf){width="4.449305555555555in" height="5.4375in"}

Short gestation and LBW are among the leading causes of neonatal death,
accounting for 20 percent of neonatal deaths. In 1998, a total of 11.6
percent of births were preterm, and 7.6 percent were LBW.[^4] Included
in these statistics were VLBW infants weighing less than 1,500 grams
(3.3 pounds). The rate of VLBW births was 1.4 percent in 1998. The VLBW
rate has increased slightly since 1990 among whites and other population
groups including African Americans, Puerto Ricans, and American
Indians.Error: Reference source not found

LBW is associated with long-term disabilities, such as cerebral palsy,
autism, mental retardation, vision and hearing impairments, and other
developmental disabilities. (See Focus Area 6. Disability and Secondary
Conditions and Focus Area 28. Vision and Hearing.) Despite the low
proportion of pregnancies resulting in LBW babies, expenditures for the
care of LBW infants total more than half of the costs incurred for all
newborns. In 1988, the cost of a normal, healthy delivery averaged
\$1,900, whereas hospital costs for LBW infants averaged \$6,200.[^5]

The general category of LBW infants includes both those born too early
(preterm infants) and those who are born at full term but who are too
small, a condition known as intrauterine growth retardation (IUGR).
Maternal characteristics that are risk factors associated with IUGR
include maternal LBW, prior LBW birth history, low prepregnancy weight,
cigarette smoking, multiple births, and low pregnancy weight gain.
Cigarette smoking is the greatest known risk factor.[^6]

VLBW usually is associated with preterm birth. Relatively little is
known about risk factors for preterm birth, but the primary risk factors
are prior preterm birth and spontaneous abortion, low prepregnancy
weight, and cigarette smoking.**^6^** These risk factors account for
only one-third of all preterm births.

The use of alcohol, tobacco, and illegal substances during pregnancy is
a major risk factor for LBW and other poor infant outcomes. Alcohol use
is linked to fetal death, LBW, growth abnormalities, mental retardation,
and fetal alcohol syndrome (FAS).[^7] Overall rates of alcohol use
during pregnancy have increased during the 1990s, and the proportion of
pregnant women using alcohol at higher and more hazardous levels has
increased substantially. Smoking during pregnancy is linked to LBW,
preterm delivery, SIDS, and respiratory problems in newborns. In
addition to the human cost of these conditions, the economic cost of
services to substance-exposed infants is great: health expenditures
related to FAS are estimated to be from \$75 million to \$9.7 billion
each year.Error: Reference source not found Over \$500 million a year is
spent on medical expenses for infants exposed to cocaine in utero.[^8]
Smoking-attributable costs of complicated births in 1995 were estimated
at \$1.4 billion (11 percent of costs for all complicated births, based
on smoking prevalence during pregnancy of 19 percent) and \$2.0 billion
(15 percent for all complicated births, based on smoking prevalence
during pregnancy of 27 percent).[^9]

Finally, breastfeeding is an important contributor to overall infant
health because human breast milk presents the most complete form of
nutrition for infants; therefore, the American Academy of Pediatrics
recommends that infants be breastfed for approximately the first 6
months of life.[^10] (The American Academy of Pediatrics recommends that
women who test positive for human immunodeficiency virus (HIV) not
breastfeed to help prevent transmission of the virus to their
infants.)[^11] Breastfeeding rates have increased over the years,
particularly in early infancy. However, breastfeeding rates among women
of all races decrease substantially by 5 to 6 months postpartum. The
1998 rates at 5 to 6 months were only 31 percent among white women, 19
percent among African American women, and 28 percent among Hispanic
women.[^12]

Also important to child health are the prevention and treatment of
disabilities in children. Twelve percent of all children under age 18
years have a disability (defined as a limitation in one or more
functional areas). In 1994, 10.6 percent of all children aged 5 to 17
years had limitations in learning ability, 6 percent had limitations in
communication, 1.3 percent had limitations in mobility, and 0.9 percent
had limitations in personal care.[^13] The burden of childhood
disability is compounded because affected children live with their
disabling conditions many more years than do persons acquiring
disability later in life. In 1992, asthma and mental retardation were
the most common disabling conditions, accounting for 40 percent of all
activity limitations.[^14] Other major disabling conditions in childhood
include speech impairment, hearing impairment, cerebral palsy, epilepsy,
and leg impairment. (See Focus Area 6. Disability and Secondary
Conditions and Focus Area 28. Vision and Hearing.)

The objectives in this focus area cover the broad array of childhood
conditions and genetic disorders. Examples of preventable birth defects
are spina bifida and other neural tube defects (NTDs). The occurrence of
these disorders could be reduced by more than half if women consumed
adequate folic acid before and during pregnancy.[^15]

All States require newborns to be screened for genetic conditions, such
as phenylketonuria (PKU) and hypothyroidism; the majority of States also
require screening for sickle cell disease. Although not necessarily
preventable, these conditions are susceptible to intervention after
delivery. For example, nutritional interventions in infancy can prevent
mental retardation in children with PKU, penicillin can prevent
infection in children with sickle cell disease, and hormone replacement
can prevent mental retardation in children with hypothyroidism. Thus,
adequate screening of newborns is the first step toward prevention of
illness, disability, and death.

In addition to infant deaths and health conditions, the effect of
pregnancy and childbirth on women is an important indicator of women's
health. In 1997, a total of 327 maternal deaths were reported by vital
statistics.[^16] While this number is small, maternal death remains
significant because a high proportion of these deaths are preventable
and because of the impact of women's premature death on families. The
maternal mortality ratio among African American women consistently has
been three to four times that of white women. Ectopic pregnancy is an
important cause of pregnancy-related illness and disability in the
United States and the leading cause of maternal death in the first
trimester. The risk of ectopic pregnancy increases with age; women of
all races aged 35 to 44 years are at more than three times the risk of
ectopic pregnancy than are women aged 15 to 24 years.[^17] Preeclampsia
and eclampsia also are important causes of maternal death. Other causes
of maternal death are hemorrhage, embolism, infection, and
anesthesia-related complications.

The rates of many of these indicators have shown improvement over the
past decade. The rate of infant mortality declined more than 27 percent
between 1987 and 1997. The rate of fetal mortality declined 8 percent
between 1987 and 1995.Error: Reference source not found Other indicators
show less progress. The LBW rate increased 10 percent between 1987 and
1998.Error: Reference source not found The rate of FAS has risen
steeply, especially among African Americans.[^18] In addition, the
maternal mortality rate has not declined since 1982, nor has the
disparity between African American and white women.Error: Reference
source not found**^,^** [^19]

Despite these unfavorable trends, evidence is encouraging about
increases in women's use of health practices that can help their own
health and that of their infants. The percentage of pregnant women who
start prenatal care early increased 9.2 percent between 1987 and 1998.
The percentage of mothers who breastfeed their newborns also went up
18.5 percent between 1988 and 1998, with greater gains among African
American and Hispanic women. Other maternal health practices have shown
less improvement: in 1992--94, the proportion of women of childbearing
age reporting consumption of the recommended level of folic acid (400
micrograms) was 21 percent.

### Disparities

Many of these conditions and risk factors disproportionately affect
certain racial and ethnic groups. The disparities between white and
nonwhite groups in infant death, maternal death, and LBW are wide and,
in many cases, are growing. Specifically:

-   The 1997 infant mortality rate among African American infants was
    2.3 times that of white infants. Although infant mortality rates
    have declined within both racial groups, the proportional
    discrepancy between African Americans and whites remains largely
    unchanged.Error: Reference source not found

-   The rate of maternal mortality among African Americans is 20.3 per
    100,000 live births, nearly four times the white rate of 5.1 per
    100,000. African American women continue to be three to four times
    more likely than white women to die of pregnancy and its
    complications. The maternal death differential between African
    Americans and whites is highest for pregnancies that did not end in
    live birth (ectopic pregnancy, spontaneous and induced abortions,
    and gestational trophoblastic disease).Error: Reference source not
    found

-   Rates of LBW for white women have risen from 5.7 percent of births
    in 1990 to 6.5 percent in 1998. Among African Americans, the LBW
    rate has declined slightly in the 1990s but remains twice as high as
    that of whites---13 percent in 1998. African Americans also are more
    likely to have other risk factors, such as young maternal age, high
    birth order (that is, having many live births), less education, and
    inadequate prenatal care. Puerto Ricans also are especially likely
    to have LBW infants.Error: Reference source not found

-   American Indians or Alaska Natives and African Americans account for
    a disproportionate share of FAS deaths. In 1990, the rates of FAS
    among American Indians or Alaska Natives and African Americans were
    5.2 and 1.4 per 1,000 live births, respectively, compared with 0.4
    per 1,000 among the population as a whole.Error: Reference source
    not found

African American and Hispanic women also are less likely than whites to
enter prenatal care early. For both African American and white women,
the proportion entering prenatal care in the first trimester rises with
maternal age until the late thirties, then begins to decline. For
example, in 1998, 57 percent of African American women under age 18
years began care early, compared with 66 percent of white women of the
same age. Among women aged 18 to 24 years, 68 percent of African
Americans received care in their first trimester, compared to 76 percent
of white women. Among women aged 25 to 39 years, 79 percent of African
American women entered care early, compared with 89 percent of white
women.Error: Reference source not found

Women in certain racial and ethnic groups also are less likely than
white women to breastfeed their infants. In the early postpartum period,
45 percent of African American mothers and 66 percent of Hispanic
mothers breastfed in 1998, compared with 68 percent of white women.
These differences persist at 5 to 6 months postpartum, when 19 percent
of African American women, 28 percent of Hispanic women, and 31 percent
of white women breastfed.Error: Reference source not found

### Opportunities

Many of the risk factors mentioned can be mitigated or prevented with
good preconception and prenatal care. First, preconception screening and
counseling offer an opportunity to identify and mitigate maternal risk
factors before pregnancy begins. Examples include daily folic acid
consumption (a protective factor) and alcohol use (a risk factor).
During preconceptional counseling, healthcare providers also can refer
women for medical and psychosocial or support services for any risk
factors identified. Counseling needs to be culturally appropriate and
linguistically competent. Prenatal visits offer an opportunity to
provide information about the adverse effects of substance use,
including alcohol and tobacco during pregnancy, and serve as a vehicle
for referrals to treatment services. The use of timely, high-quality
prenatal care can help to prevent poor birth outcomes and improve
maternal health by identifying women who are at particularly high risk
and taking steps to mitigate risks, such as the risk of high blood
pressure or other maternal complications. Interventions targeted at
prevention and cessation of substance use during pregnancy may be
helpful in further reducing the rate of preterm delivery and low birth
weight.[^20]**^,^** [^21]**^,^** [^22] Further promotion of folic acid
intake can help to reduce the rate of NTDs.[^23]**^,^** [^24]

Other actions taken after birth can significantly improve infants'
health and chances of survival. Breastfeeding has been shown to reduce
rates of infection in infants and to improve long-term maternal
health.[^25]**^,^** [^26]**^,^** [^27]**^,^** [^28]**^,^** [^29]**^,^**
[^30]**^,^** [^31]**^,^** [^32]**^,^** [^33]**^,^** [^34]**^,^**
[^35]**^,^** [^36]**^,^** [^37]**^,^** [^38] SIDS may be preventable as
well; studies show that putting infants to sleep on their backs can help
to prevent SIDS.[^39]

## Interim Progress Toward Year 2000 Objectives

Of the 17 maternal and infant health objectives included in Healthy
People 2000, progress has been made toward the target in 8 objectives,
and movement has been away from the target in 5 objectives. Notable
gains have been made in the areas of infant death, fetal death, cesarean
birth (particularly repeat cesareans), breastfeeding, early use of
prenatal care, hospitalization for complications of pregnancy,
abstinence from tobacco use during pregnancy, and screening for fetal
abnormalities and genetic disorders. However, no progress or movement in
the wrong direction has occurred in the areas of maternal death, FAS,
and LBW. For the other objectives, progress has been mixed, or data
remain unavailable. Child health objectives were not included in the
Maternal and Infant focus area in Healthy People 2000.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Maternal, Infant, and Child Health {#maternal-infant-and-child-health-1 .Heading-Special-Sub}

**Goal:** Improve the health and well-being of women, infants,
children,\
and families.

  ----------------- --------------------------------------------------------------
  **Number**        **Objective Short Title**

  **Fetal, Infant,  
  Child, and        
  Adolescent        
  Deaths**          

  16-1              Fetal and infant deaths

  16-2              Child deaths

  16-3              Adolescent and young adult deaths

  **Maternal Deaths 
  and Illnesses**   

  16-4              Maternal deaths

  16-5              Maternal illness and complications due to pregnancy

  **Prenatal Care** 

  16-6              Prenatal care

  16-7              Childbirth classes

  **Obstetrical     
  Care**            

  16-8              Very low birth weight infants born at level III hospitals

  16-9              Cesarean births

  **Risk Factors**  

  16-10             Low birth weight and very low birth weight

  16-11             Preterm births

  16-12             Weight gain during pregnancy

  16-13             Infants put to sleep on their backs

  **Developmental   
  Disabilities and  
  Neural Tube       
  Defects**         

  16-14             Developmental disabilities

  16-15             Spina bifida and other neural tube defects

  16-16             Optimum folic acid levels

  **Prenatal        
  Substance         
  Exposure**        

  16-17             Prenatal substance exposure

  16-18             Fetal alcohol syndrome
  ----------------- --------------------------------------------------------------

  ------------------ --------------------------------------------------------------
  **Breastfeeding,   
  Newborn Screening, 
  and Service        
  Systems**          

  16-19              Breastfeeding

  16-20              Newborn bloodspot screening

  16-21              Sepsis among children with sickle cell disease

  16-22              Medical homes for children with special health care needs

  16-23              Service systems for children with special health care needs
  ------------------ --------------------------------------------------------------

## Healthy People 2010 Objectives

### Fetal, Infant, Child, and Adolescent Deaths

16-1. Reduce fetal and infant deaths.

Target and baseline:

+------------+--------------------------------+-----------+-----------+
| Objective  | Reduction in Fetal and Infant  | 1997      | 2010      |
|            | Deaths                         | Baseline  | Target    |
+------------+--------------------------------+-----------+-----------+
|            |                                | ##        |           |
|            |                                | ##### Per |           |
|            |                                |  1,000 Li |           |
|            |                                | ve Births |           |
|            |                                |  Plus Fet |           |
|            |                                | al Deaths |           |
+------------+--------------------------------+-----------+-----------+
| **16-1a.** | Fetal deaths at 20 or more     | 6.8       | 4.1       |
|            | weeks of\                      |           |           |
|            | gestation                      |           |           |
+------------+--------------------------------+-----------+-----------+
| **16-1b.** | Fetal and infant deaths during | 7.5       | 4.5       |
|            | perinatal period (28 weeks of  |           |           |
|            | gestation to 7 days or more    |           |           |
|            | after birth)                   |           |           |
+------------+--------------------------------+-----------+-----------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------+-------------------+------------------+
| **Live Births Plus Fetal     | **16-1a.\         | **16-1b.\        |
| Deaths, 1997**               | Fetal Deaths at   | Fetal and Infant |
|                              | 20 or More Weeks  | Deaths During\   |
|                              | of\               | Perinatal        |
|                              | Gestation**       | Period**         |
+==============================+===================+==================+
|                              | Rate per 1,000    |                  |
+------------------------------+-------------------+------------------+
| > **TOTAL**                  | 6.8               | 7.5              |
+------------------------------+-------------------+------------------+
| **Mother's race and          |                   |                  |
| ethnicity**                  |                   |                  |
+------------------------------+-------------------+------------------+
| > American Indian or Alaska  | 6.7               | 7.9              |
| > Native                     |                   |                  |
+------------------------------+-------------------+------------------+
| > Asian or Pacific Islander  | 4.8               | 4.6              |
+------------------------------+-------------------+------------------+
| > Asian                      | 4.2               | 4.6              |
+------------------------------+-------------------+------------------+
| > Native Hawaiian and other\ | 6.2               | 7.3              |
| > Pacific Islander           |                   |                  |
+------------------------------+-------------------+------------------+
| > Black or African American  | 12.5              | 13.4             |
+------------------------------+-------------------+------------------+
| > White                      | 5.8               | 6.4              |
+------------------------------+-------------------+------------------+
|                              |                   |                  |
+------------------------------+-------------------+------------------+
| > Hispanic or Latino         | 5.9               | 6.5              |
+------------------------------+-------------------+------------------+
| > Not Hispanic or Latino     | DNA               | 7.2              |
+------------------------------+-------------------+------------------+
| > Black or African American  | 9.6               | 12.7             |
+------------------------------+-------------------+------------------+
| > White                      | 5.2               | 6.0              |
+------------------------------+-------------------+------------------+
| ###### Gender                |                   |                  |
+------------------------------+-------------------+------------------+
| > Female                     | DNA               | DNA              |
+------------------------------+-------------------+------------------+
| > Male                       | DNA               | DNA              |
+------------------------------+-------------------+------------------+
| **Mother's education level** |                   |                  |
+------------------------------+-------------------+------------------+
| > Less than high school      | 6.5               | DNA              |
+------------------------------+-------------------+------------------+
| > High school graduate       | 6.7               | DNA              |
+------------------------------+-------------------+------------------+
| > At least some college      | 4.8               | DNA              |
+------------------------------+-------------------+------------------+
| **Mother's disability        |                   |                  |
| status**                     |                   |                  |
+------------------------------+-------------------+------------------+
| > Mothers with disabilities  | DNC               | DNC              |
+------------------------------+-------------------+------------------+
| > Mothers without            | DNC               | DNC              |
| > disabilities               |                   |                  |
+------------------------------+-------------------+------------------+
| ###### Select populations    |                   |                  |
+------------------------------+-------------------+------------------+
| Mother's age groups          |                   |                  |
+------------------------------+-------------------+------------------+
| > Under 15 years             | 14.2              | DNA              |
+------------------------------+-------------------+------------------+
| > 15 to 19 years             | 7.8               | DNA              |
+------------------------------+-------------------+------------------+
| > 20 to 24 years             | 6.4               | DNA              |
+------------------------------+-------------------+------------------+
| > 25 to 29 years             | 6.0               | DNA              |
+------------------------------+-------------------+------------------+
| > 30 to 34 years             | 6.3               | DNA              |
+------------------------------+-------------------+------------------+
| > 35 years and older         | 8.9               | DNA              |
+------------------------------+-------------------+------------------+
| Fetal weight                 |                   |                  |
+------------------------------+-------------------+------------------+
| > \>2,499 g                  | 1.3               | DNA              |
+------------------------------+-------------------+------------------+
| > 1,500 to 2,499 g           | 16.8              | DNA              |
+------------------------------+-------------------+------------------+
| > \<1,500 g                  | 213.1             | DNA              |
+------------------------------+-------------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Target and baseline:

+----------+-----------------------------+-------------+-------------+
| O        | Reduction in Infant Deaths  | 1998        | 2010 Target |
| bjective |                             | Baseline    |             |
+----------+-----------------------------+-------------+-------------+
|          |                             | #           |             |
|          |                             | ###### Rate |             |
|          |                             |  per 1,000  |             |
|          |                             | Live Births |             |
+----------+-----------------------------+-------------+-------------+
| **       | All infant deaths (within 1 | 7.2         | 4.5         |
| 16-1c.** | year)                       |             |             |
+----------+-----------------------------+-------------+-------------+
| **       | Neonatal deaths (within the | 4.8         | 2.9         |
| 16-1d.** | first 28 days of life)      |             |             |
+----------+-----------------------------+-------------+-------------+
| **       | Postneonatal deaths         | 2.4         | 1.2         |
| 16-1e.** | (between 28 days and 1      |             |             |
|          | year)                       |             |             |
+----------+-----------------------------+-------------+-------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------+------------+------------+------------+
| **Live Births, 1998**       | **16-1c.\  | **16-1d.\  | **16-1e.\  |
|                             | All Infant | Neonatal   | Po         |
|                             | Deaths\    | Deaths\    | stneonatal |
|                             | (\<1       | (\<28      | Deaths\    |
|                             | year)**    | days)**    | (28 to 364 |
|                             |            |            | days)**    |
+=============================+============+============+============+
|                             | Rate per   |            |            |
|                             | 1,000      |            |            |
+-----------------------------+------------+------------+------------+
| > **TOTAL**                 | 7.2        | 4.8        | 2.4        |
+-----------------------------+------------+------------+------------+
| **Mother's race and         |            |            |            |
| ethnicity**                 |            |            |            |
+-----------------------------+------------+------------+------------+
| > American Indian or        | 9.3        | 5.0        | 4.3        |
| > Alaska\                   |            |            |            |
| > Native                    |            |            |            |
+-----------------------------+------------+------------+------------+
| > Asian or Pacific Islander | 5.5        | 3.9        | 1.7        |
+-----------------------------+------------+------------+------------+
| > Asian                     | 5.0        | 3.6        | 1.3        |
+-----------------------------+------------+------------+------------+
| > Native Hawaiian and other | 10.0       | 6.7        | 3.3        |
| > Pacific Islander          |            |            |            |
+-----------------------------+------------+------------+------------+
| > Black or African American | 13.8       | 9.4        | 4.4        |
+-----------------------------+------------+------------+------------+
| > White                     | 6.0        | 4.0        | 2.0        |
+-----------------------------+------------+------------+------------+
|                             |            |            |            |
+-----------------------------+------------+------------+------------+
| > Hispanic or Latino        | 5.8        | 3.9        | 1.9        |
+-----------------------------+------------+------------+------------+
| > Not Hispanic or Latino    | 7.5        | 5.0        | 2.5        |
+-----------------------------+------------+------------+------------+
| > Black or African American | 13.9       | 9.4        | 4.5        |
+-----------------------------+------------+------------+------------+
| > White                     | 6.0        | 3.9        | 2.0        |
+-----------------------------+------------+------------+------------+
| ###### Gender               |            |            |            |
+-----------------------------+------------+------------+------------+
| > Female                    | 6.5        | 4.4        | 2.2        |
+-----------------------------+------------+------------+------------+
| > Male                      | 7.8        | 5.2        | 2.6        |
+-----------------------------+------------+------------+------------+
| **Mother's education        |            |            |            |
| level**                     |            |            |            |
+-----------------------------+------------+------------+------------+
| > Less than high school     | 9.1        | 5.2        | 3.8        |
+-----------------------------+------------+------------+------------+
| > High school graduate      | 7.7        | 5.1        | 2.6        |
+-----------------------------+------------+------------+------------+
| > At least some college     | 5.3        | 3.8        | 1.5        |
+-----------------------------+------------+------------+------------+
| **Mother's disability       |            |            |            |
| status**                    |            |            |            |
+-----------------------------+------------+------------+------------+
| > Mothers with disabilities | DNC        | DNC        | DNC        |
+-----------------------------+------------+------------+------------+
| > Mothers without           | DNC        | DNC        | DNC        |
| > disabilities              |            |            |            |
+-----------------------------+------------+------------+------------+
| ###### Select populations   |            |            |            |
+-----------------------------+------------+------------+------------+
| Mother's age groups         |            |            |            |
+-----------------------------+------------+------------+------------+
| > Under 15 years            | 18.4       | 12.6       | 5.8        |
+-----------------------------+------------+------------+------------+
| > 15 to 19 years            | 10.0       | 6.1        | 3.9        |
+-----------------------------+------------+------------+------------+
| > 20 to 24 years            | 7.8        | 4.8        | 3.0        |
+-----------------------------+------------+------------+------------+
| > 25 to 29 years            | 6.3        | 4.3        | 2.0        |
+-----------------------------+------------+------------+------------+
| > 30 to 34 years            | 6.0        | 4.4        | 1.6        |
+-----------------------------+------------+------------+------------+
| > 35 years and older        | 7.1        | 5.2        | 1.9        |
+-----------------------------+------------+------------+------------+
| Fetal weight                |            |            |            |
+-----------------------------+------------+------------+------------+
| > \>2,499 g                 | 2.6        | 0.9        | 1.7        |
+-----------------------------+------------+------------+------------+
| > 1,500 to 2,499 g          | 16.5       | 9.6        | 6.8        |
+-----------------------------+------------+------------+------------+
| > \<1,500 g                 | 250.0      | 221.5      | 28.5       |
+-----------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Target and baseline:

+----------+--------------------------+---------------+---------------+
| O        | Reduction in Infant      | 1998\         | 2010\         |
| bjective | Deaths\                  | Baseline      | Target        |
|          | Related to Birth Defects |               |               |
+----------+--------------------------+---------------+---------------+
|          |                          | #######       |               |
|          |                          | Rate per 1,00 |               |
|          |                          | 0 Live Births |               |
+----------+--------------------------+---------------+---------------+
| **       | All birth defects        | 1.6           | 1.1           |
| 16-1f.** |                          |               |               |
+----------+--------------------------+---------------+---------------+
| **       | Congenital heart defects | 0.53          | 0.38          |
| 16-1g.** |                          |               |               |
+----------+--------------------------+---------------+---------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------------+-----------------+----------------+
| **Live Births, 1998 (unless       | **16-1f.\       | **16-1g.\      |
| noted)**                          | All Infant      | All Infant     |
|                                   | Deaths From All | Deaths From    |
|                                   | Birth\          | Congenital     |
|                                   | Defects**       | Heart          |
|                                   |                 | Defects**      |
+===================================+=================+================+
|                                   | Rate per 1,000  |                |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 1.6             | 0.53           |
+-----------------------------------+-----------------+----------------+
| **Mother's race and ethnicity**   |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | 1.7             | 0.67           |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | 1.5             | 0.50           |
+-----------------------------------+-----------------+----------------+
| > Asian                           | 1.5             | 0.48           |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | DSU             | DSU            |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 1.8             | 0.60           |
+-----------------------------------+-----------------+----------------+
| > White                           | 1.5             | 0.51           |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | 1.5             | 0.47           |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | 1.6             | 0.54           |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 1.8             | 0.61           |
+-----------------------------------+-----------------+----------------+
| > White                           | 1.5             | 0.53           |
+-----------------------------------+-----------------+----------------+
| **Gender**                        |                 |                |
+-----------------------------------+-----------------+----------------+
| > Female                          | 1.6 (1995)      | DNA            |
+-----------------------------------+-----------------+----------------+
| > Male                            | 1.8 (1995)      | DNA            |
+-----------------------------------+-----------------+----------------+
| **Mother's education level**      |                 |                |
+-----------------------------------+-----------------+----------------+
| > Less than high school           | 1.8             | 0.58           |
+-----------------------------------+-----------------+----------------+
| > High school graduate            | 1.6             | 0.58           |
+-----------------------------------+-----------------+----------------+
| > At least some college           | 1.4             | 0.45           |
+-----------------------------------+-----------------+----------------+
| **Disability status** (of infant) |                 |                |
+-----------------------------------+-----------------+----------------+
| > Persons with disabilities       | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Persons without disabilities    | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

**16-1h.** Reduce deaths from sudden infant death syndrome (SIDS).

**Target:** 0.25 deaths per 1,000 live births.

**Baseline:** 0.72 deaths per 1,000 live births were from SIDS in 1998.

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Live Births, 1998**                          | **16-1h.**          |
|                                                |                     |
|                                                | **SIDS Deaths**     |
+================================================+=====================+
|                                                | Rate per 1,000      |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 0.72                |
+------------------------------------------------+---------------------+
| **Mother's race and ethnicity**                |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 1.52                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 0.39                |
+------------------------------------------------+---------------------+
| > Asian                                        | 0.27                |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 1.38                |
+------------------------------------------------+---------------------+
| > White                                        | 0.60                |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 0.37                |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 0.80                |
+------------------------------------------------+---------------------+
| > Black or African American                    | 1.40                |
+------------------------------------------------+---------------------+
| > White                                        | 0.66                |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | DNA                 |
+------------------------------------------------+---------------------+
| > Male                                         | DNA                 |
+------------------------------------------------+---------------------+
| **Mother's education level**                   |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 1.30                |
+------------------------------------------------+---------------------+
| > High school graduate                         | 0.79                |
+------------------------------------------------+---------------------+
| > At least some college                        | 0.38                |
+------------------------------------------------+---------------------+
| **Disability status** (of infant)              |                     |
+------------------------------------------------+---------------------+
| > Persons with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Persons without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Infant death is a critical indicator of the health of a population. It
reflects the overall state of maternal health as well as the quality and
accessibility of primary health care available to pregnant women and
infants. Despite steady declines in the 1980s and 1990s, the rate of
infant mortality in the United States remains among the highest in the
industrialized world.Error: Reference source not found Moreover, the
rate of decline in infant mortality has slowed since the 1970s, when
major advances in neonatal care contributed to steep reductions in the
neonatal mortality rate. However, the rapid decline in this rate slowed
during the 1980s. In the early 1990s, the introduction of synthetic
surfactant contributed to declines in neonatal mortality rates through
decreased new cases of intraventricular hemorrhage and decreased
severity of respiratory disease in preterm, very small
infants.[^40]**^,^** [^41]

The health of infants depends in large part on their health in utero. A
fetus with severe defects or growth problems may not be delivered alive.
Because only live births are counted in infant mortality rates,
perinatal and fetal mortality rates provide a more complete picture of
perinatal health than does the infant mortality rate alone.

Fetal death often is associated with maternal complications of
pregnancy, such as problems with amniotic fluid levels and blood
disorders. Rates of fetal mortality are 35 percent greater than average
in women who use tobacco during pregnancy and 77 percent higher in women
who use alcohol.Error: Reference source not found Fetal mortality rates
also are high when birth defects, such as anencephalus, renal agenesis,
and hydrocephalus, are present.Error: Reference source not found The
baseline fetal mortality rate of 6.8 per 1,000 represents only a 6.7
percent reduction since 1990, an average rate of decline of 1.3 percent
per year. The fetal mortality rate among African Americans was 12.7 per
1,000 in 1995, 1.8 times that of the population as a whole. Moreover,
this gap has widened since 1990. The rate among African Americans
declined by only 4.5 percent over this period, a decline of less than 1
percent per year.Error: Reference source not found Targeting prenatal
risk screening and intervention to high-risk groups, particularly
African American women, is critical to reducing this gap.

The perinatal mortality rate includes both deaths of live-born infants
through the first 7 days of life and fetal deaths after 28 weeks of
gestation. This rate is a useful overall measure of perinatal health and
the quality of health care provided to pregnant women and newborns. The
rate of perinatal mortality has declined by 40 percent since 1980.Error:
Reference source not found The gap between African Americans and whites
has increased, however, with the rate among African Americans now more
than twice that of whites.Error: Reference source not found

The infant mortality rate is made up of two components: neonatal
mortality (death in the first 28 days of life) and postneonatal
mortality (death from the infants' 29th day but within the first year).
The leading causes of neonatal death include birth defects, disorders
related to short gestation and LBW, and pregnancy complications. Of
these, the most likely to be preventable are those related to preterm
birth and LBW, which represent approximately 20 percent of neonatal
deaths. Postneonatal death reflects events experienced in infancy,
including SIDS, birth defects, injuries, and homicide. Birth defects,
many of which are unlikely to be preventable given current scientific
knowledge, account for approximately 17 percent of postneonatal deaths;
the remainder are likely to stem from preventable causes.

SIDS is the leading cause of postneonatal death among all racial and
ethnic groups, representing nearly one-third of all cases of
postneonatal death. Moreover, the rate of SIDS among African Americans
is 1.4 per 1,000 live births, twice that of whites. Therefore, a
reduction in the rate of death from SIDS, particularly among African
Americans, would contribute greatly to reducing the overall infant
mortality rate and particularly to closing the racial gap in
postneonatal death. The 2010 target should be achievable with continued
education. (See objective 16-13 for further discussion of interventions
that can help to prevent SIDS).

Rates of death from birth defects can be reduced either by preventing
the occurrence of the defect itself or by providing the necessary care
to prevent death. In the case of NTDs, the birth defects themselves can
be prevented (see objectives 16-17 and 16-18). Death from birth defects
that are not so easily prevented, such as heart problems, can be reduced
with access to appropriate medical care. (Respiratory distress syndrome,
another leading cause of infant death, is not a birth defect but a
consequence of prematurity.)

A particular issue in the reduction of infant death is the reduction of
disparities among select populations, particularly as defined by race
and ethnicity, maternal age, and infant birth weight. The gap between
whites and African Americans in infant death is large and has not
diminished since 1990.

16-2. Reduce the rate of child deaths.

Target and baseline:

+----------+----------------------------+--------------+--------------+
| O        | Reduction in Deaths of     | 1998         | 2010 Target  |
| bjective | Children                   | Baseline     |              |
+----------+----------------------------+--------------+--------------+
|          |                            | ####### Rate |              |
|          |                            |  per 100,000 |              |
+----------+----------------------------+--------------+--------------+
| **       | Children aged 1 to 4 years | 34.6         | 18.6         |
| 16-2a.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
| **       | Children aged 5 to 9 years | 17.7         | 12.3         |
| 16-2b.** |                            |              |              |
+----------+----------------------------+--------------+--------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------------+-----------------+----------------+
| **Children, 1998**                | **16-2a.\       | **16-2b.\      |
|                                   | Deaths of\      | Deaths of\     |
|                                   | Children Aged\  | Children Aged\ |
|                                   | 1 to 4 Years**  | 5 to 9 Years** |
+===================================+=================+================+
|                                   | Rate per        |                |
|                                   | 100,000         |                |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 34.6            | 17.7           |
+-----------------------------------+-----------------+----------------+
| **Race and ethnicity**            |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | 59.2            | 22.3           |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | 18.7            | 12.4           |
+-----------------------------------+-----------------+----------------+
| > Asian                           | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | DNC             | DNC            |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 61.6            | 29.0           |
+-----------------------------------+-----------------+----------------+
| > White                           | 30.1            | 15.7           |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | 30.4            | 15.7           |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | 35.3            | 18.0           |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 64.7            | 30.6           |
+-----------------------------------+-----------------+----------------+
| > White                           | 29.4            | 15.3           |
+-----------------------------------+-----------------+----------------+
| ###### Gender                     |                 |                |
+-----------------------------------+-----------------+----------------+
| > Female                          | 31.4            | 15.3           |
+-----------------------------------+-----------------+----------------+
| > Male                            | 37.6            | 20.0           |
+-----------------------------------+-----------------+----------------+
| ###### Family income level        |                 |                |
+-----------------------------------+-----------------+----------------+
| > Poor                            | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Near poor                       | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Middle/high income              | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| **Disability status**             |                 |                |
+-----------------------------------+-----------------+----------------+
| > Persons with disabilities       | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Persons without disabilities    | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The deaths of children after infancy also present a public health
concern and an opportunity for prevention. In 1997, 13,562 children aged
1 to 14 years died, representing a death rate of 25.1 per 100,000
children in that age group. The leading cause of death for children of
all ages is injury, which accounts for 13.1 deaths per 100,000 preschool
children (aged 1 to 4 years) and 8.7 deaths per 100,000 school-aged
children (aged 5 to 14 years). Among children aged 1 to 4 years, the
leading injury-related causes of death are motor vehicle crashes,
drownings, and fires and burns. Among those aged 5 to 14 years, the
leading causes of death include motor vehicle crashes and firearms
(including unintentional deaths, homicides, and suicides). These deaths
are, for the most part, preventable. Other leading causes of death among
children that are less likely to be preventable include birth defects
(representing 3.8 deaths per 100,000 children aged 1 to 4 years and 1.2
deaths per 100,000 children aged 5 to 14 years), malignant neoplasms
(representing 2.9 deaths per 100,000 children aged 1 to 4 years and 2.7
deaths per 100,000 children aged 5 to 14 years), and diseases of the
heart (representing 1.4 deaths per 100,000 children aged 1 to 4 years
and 0.8 deaths per 100,000 children aged 5 to 14 years).Error: Reference
source not found

16-3. Reduce deaths of adolescents and young adults.

Target and baseline:

+----------+-----------------------------+--------------+-------------+
| O        | Reduction in Deaths of\     | 1998\        | 2010\       |
| bjective | Adolescents and Young       | Baseline     | Target      |
|          | Adults                      |              |             |
+----------+-----------------------------+--------------+-------------+
|          |                             | ####### Rate |             |
|          |                             |  per 100,000 |             |
+----------+-----------------------------+--------------+-------------+
| **       | Adolescents aged 10 to 14   | 22.1         | 16.8        |
| 16-3a.** | years                       |              |             |
+----------+-----------------------------+--------------+-------------+
| **       | Adolescents aged 15 to 19   | 70.6         | 39.8        |
| 16-3b.** | years                       |              |             |
+----------+-----------------------------+--------------+-------------+
| **       | Young adults aged 20 to 24  | 95.3         | 49.0        |
| 16-3c.** | years                       |              |             |
+----------+-----------------------------+--------------+-------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+-------------------------------+------------+------------+------------+
| **Adolescents and Young       | **16-3a.\  | **16-3b.\  | **16-3c.\  |
| Adults, 1998**                | Deaths of  | Deaths of  | Deaths of  |
|                               | A          | A          | Young      |
|                               | dolescents | dolescents | Adults     |
|                               | Aged 10 to | Aged 15 to | Aged 20 to |
|                               | 14 Years** | 19 Years** | 24 Years** |
+===============================+============+============+============+
|                               | Rate per   |            |            |
|                               | 100,000    |            |            |
+-------------------------------+------------+------------+------------+
| > **TOTAL**                   | 22.1       | 70.6       | 95.3       |
+-------------------------------+------------+------------+------------+
| **Race and ethnicity**        |            |            |            |
+-------------------------------+------------+------------+------------+
| > American Indian or Alaska   | 26.7       | 90.5       | 146.1      |
| > Native                      |            |            |            |
+-------------------------------+------------+------------+------------+
| > Asian or Pacific Islander   | 17.9       | 39.9       | 49.1       |
+-------------------------------+------------+------------+------------+
| > Asian                       | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Native Hawaiian and other\  | DNC        | DNC        | DNC        |
| > Pacific Islander            |            |            |            |
+-------------------------------+------------+------------+------------+
| > Black or African American   | 29.9       | 97.2       | 160.3      |
+-------------------------------+------------+------------+------------+
| > White                       | 20.8       | 66.6       | 84.9       |
+-------------------------------+------------+------------+------------+
|                               |            |            |            |
+-------------------------------+------------+------------+------------+
| > Hispanic or Latino          | 19.1       | 67.6       | 99.6       |
+-------------------------------+------------+------------+------------+
| > Not Hispanic or Latino      | 22.6       | 70.7       | 94.0       |
+-------------------------------+------------+------------+------------+
| > Black or African American   | 31.3       | 100.8      | 165.8      |
+-------------------------------+------------+------------+------------+
| > White                       | 20.8       | 65.3       | 80.2       |
+-------------------------------+------------+------------+------------+
| **Gender**                    |            |            |            |
+-------------------------------+------------+------------+------------+
| > Female                      | 17.2       | 40.8       | 46.5       |
+-------------------------------+------------+------------+------------+
| > Male                        | 26.9       | 98.7       | 142.3      |
+-------------------------------+------------+------------+------------+
| ###### Family income level    |            |            |            |
+-------------------------------+------------+------------+------------+
| > Poor                        | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Near poor                   | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Middle/high income          | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| **Disability status**         |            |            |            |
+-------------------------------+------------+------------+------------+
| > Persons with disabilities   | DNC        | DNC        | DNC        |
+-------------------------------+------------+------------+------------+
| > Persons without             | DNC        | DNC        | DNC        |
| > disabilities                |            |            |            |
+-------------------------------+------------+------------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The deaths of young adolescents, older adolescents, and young adults are
more likely to be due to external causes than to congenital diseases.
There were 4,261 deaths among adolescents aged 10 to 14 years in 1998,
for a mortality rate of 22.1 per 100,000. The leading cause of death for
adolescents in this age group was motor vehicle crashes at 5.4 deaths
per 100,000 or 24.3 percent of the total mortality. Other unintentional
injuries (such as falls, drownings, and poisonings) caused 3.5 deaths
per 100,000 (15.9 percent); homicides caused 1.5 deaths per 100,000 (6.8
percent); suicides caused 1.6 deaths per 100,000 (7.4 percent); and AIDS
caused 0.1 deaths per 100,000 (0.6 percent). Fifty-five percent of the
total deaths in this age group, therefore, can be attributed to
unnecessary (that is, preventable) causes. Other causes of death for
this age group that are less amenable to prevention strategies given
current scientific knowledge include malignant neoplasms, which caused
2.7 deaths per 100,000 (12.3 percent); birth defects, which caused 0.9
deaths per 100,000 (4.1 percent); diseases of the heart, which caused
0.9 deaths per 100,000 (4.0 percent); and a combination of other causes,
which caused 5.5 deaths per 100,000 (25 percent).Error: Reference source
not found**^,^** [^42]

There were 13,788 deaths in 1998 among adolescents aged 15 to 19 years,
for a death rate of 70.6 per 100,000. The leading cause of death for
adolescents in this age group was motor vehicle crashes at 28.4 deaths
per 100,000 or 37.4 percent of total deaths. Other unintentional
injuries (such as falls, drownings, and poisonings) caused 7.3 deaths
per 100,000 (10.4 percent); homicides caused 11.8 deaths per 100,000
(16.8 percent); suicides caused 8.9 deaths per 100,000 (12.6 percent);
and AIDS caused 0.1 deaths per 100,000 (0.2 percent). Consequently, a
majority (77 percent) of the total deaths in this age group can be
attributed to unnecessary (that is, preventable) causes. The remaining
23 percent of deaths among adolescents aged 15 to 19 years resulted
mostly from malignant neoplasms, which caused 3.7 deaths per 100,000
(5.2 percent); diseases of the heart, which caused 2.1 deaths per
100,000 (3.0 percent); birth defects, which caused 1.1 deaths per
100,000 (1.6 percent); and a combination of other causes, which caused
9.1 deaths per 100,000 (12.9 percent).

Young adults aged 20 to 24 years had a death rate of 95.3 per 100,000 in
1998---a rate 331 percent higher than adolescents aged 10 to 14 years
and 35 percent higher than adolescents aged 15 to 19 years. The leading
cause of death for persons aged 20 to 24 years was motor vehicle crashes
at 27.5 deaths per 100,000 or 28.9 percent of the total deaths. Other
unintentional injuries (such as falls, drownings, and poisonings) caused
10.7 deaths per 100,000 (11.2 percent); homicides caused 18.1 deaths per
100,000 (19 percent); suicides caused 13.6 deaths per 100,000 (14.2
percent); and AIDS caused 1.0 deaths per 100,000 (1.4 percent).
Consequently, a majority (74 percent) of the total deaths in this age
group can be attributed to unnecessary (that is, preventable) causes.
The remaining 26 percent of deaths among young adults aged 20 to 24
years resulted mostly from malignant neoplasms, which caused 5.5 deaths
per 100,000 (5.8 percent); diseases of the heart, which caused 3.6
deaths per 100,000 (3.8 percent); birth defects, which caused 1.3 deaths
per 100,000 (1.4 percent); and a combination of other causes, which
caused 13.9 deaths per 100,000 (14.6 percent).

The data on deaths, however, do not adequately reflect consequences of
sexual behaviors established as individuals in this age group become
sexually mature. Illustratively, it is likely that most of the new HIV
infections that are diagnosed each year occur among those between age 13
and 21 years. Further, about 3 million new and sexually transmitted
disease infections (STDs) in addition to HIV occur among teenagers each
year. In addition, about 1 million teenagers become pregnant each year.
(See Focus Area 13. HIV and Focus Area 25. Sexually Transmitted
Diseases.)

### Maternal Deaths and Illnesses

16-4. Reduce maternal deaths.

**Target:** 3.3 maternal deaths per 100,000 live births.

**Baseline:** 7.1 maternal deaths per 100,000 live births occurred in
1998.

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Live Births, 1998**                          | **Maternal Deaths** |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 7.1                 |
+------------------------------------------------+---------------------+
| **Mother's race and ethnicity**                |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 17.1                |
+------------------------------------------------+---------------------+
| > White                                        | 5.1                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 5.7                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 7.5                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 17.4                |
+------------------------------------------------+---------------------+
| > White                                        | 4.9                 |
+------------------------------------------------+---------------------+
| **Mother's education level**                   |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DNA                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | DNA                 |
+------------------------------------------------+---------------------+
| > At least some college                        | DNA                 |
+------------------------------------------------+---------------------+
| ###### Mother's disability status              |                     |
+------------------------------------------------+---------------------+
| > Mothers with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Mothers without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Mother's age groups                            |                     |
+------------------------------------------------+---------------------+
| > Under 20 years                               | DSU                 |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | 5.0                 |
+------------------------------------------------+---------------------+
| > 25 to 29 years                               | 6.7                 |
+------------------------------------------------+---------------------+
| > 30 to 34 years                               | 7.5                 |
+------------------------------------------------+---------------------+
| > 35 years and older                           | 14.5                |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

16-5. Reduce maternal illness and complications due to\
pregnancy.

Target and baseline:

+----------+-------------------------------+------------+------------+
| O        | Reduction in Maternal Illness | 1998\      | 2010\      |
| bjective | and Complications             | Baseline   | Target     |
+----------+-------------------------------+------------+------------+
|          |                               | ######     |            |
|          |                               | # Per 100  |            |
|          |                               | Deliveries |            |
+----------+-------------------------------+------------+------------+
| **       | Maternal complications        | 31.2       | 24         |
| 16-5a.** | during\                       |            |            |
|          | hospitalized labor and        |            |            |
|          | delivery                      |            |            |
+----------+-------------------------------+------------+------------+
| **       | Ectopic pregnancies           | Dev        |            |
| 16-5b.** |                               | elopmental |            |
+----------+-------------------------------+------------+------------+
| **       | Postpartum complications,     | Dev        |            |
| 16-5c.** | including postpartum          | elopmental |            |
|          | depression                    |            |            |
+----------+-------------------------------+------------+------------+

**Target setting method:** Better than the best.

**Data source:** National Hospital Discharge Survey, CDC, NCHS.

**Potential data source:** National Hospital Discharge Survey (NHDS),
CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Deliveries, 1998**                           | **16-5a.\           |
|                                                | Maternal\           |
|                                                | Complications\      |
|                                                | During\             |
|                                                | Hospitalized Labor  |
|                                                | and Delivery**      |
+================================================+=====================+
|                                                | Rate per 100\       |
|                                                | Deliveries          |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 31.2                |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 37.7                |
+------------------------------------------------+---------------------+
| > White                                        | 30.3                |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| > Mother's age group                           |                     |
+------------------------------------------------+---------------------+
| > Under 15 years                               | DSU                 |
+------------------------------------------------+---------------------+
| > 15 to 19 years                               | 34.4                |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | 30.4                |
+------------------------------------------------+---------------------+
| > 25 to 29 years                               | 29.7                |
+------------------------------------------------+---------------------+
| > 30 to 34 years                               | 31.1                |
+------------------------------------------------+---------------------+
| > 35 years and older                           | 32.7                |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

In 1997, 327 maternal deaths were reported by vital statistics, the
major causes of which were hemorrhage, ectopic pregnancy,
pregnancy-induced hypertension, embolism, infection, and other
complications of pregnancy and childbirth.[^43] The overall maternal
mortality rate has fluctuated between approximately 7 and 8 per 100,000
live births since 1982.[^44] Moreover, the gap between African Americans
and whites remains, with the maternal mortality rate among African
Americans 3.6 times that of whites in 1997. The rates among African
Americans have been at least three to four times higher than those of
whites since 1940. The rate among African Americans also has not
declined, fluctuating between about 18 and 22 per 100,000 live
births.Error: Reference source not found

Pregnancy and delivery can lead to serious physical and mental health
problems for women. In the past, maternal illness and complications were
monitored through objectives relating to the ratio of antenatal
hospitalizations for pregnancy complications to the total number of
deliveries. This ratio has become a less useful measure, however, as
rates of antenatal hospitalization in general have declined due to
managed care and its emphasis on outpatient treatment.[^45] Therefore,
attention should be focused on the major causes of maternal illness and
complications, particularly those most likely to be associated with
maternal death, such as ectopic pregnancy. Pelvic inflammatory disease
caused by chlamydia and gonorrhea is the leading cause of preventable
tubal scarring that can result in ectopic pregnancy. (See Focus Area 25.
Sexually Transmitted Diseases.) The outcomes of interest should include
not only prenatal illness and complications and complications during
labor and delivery but also postpartum complications. Postpartum
depression, for example, is disabling for a new mother and can
compromise her ability to care for her infant.

### Prenatal Care

16-6. Increase the proportion of pregnant women who receive early and
adequate prenatal care.

Target and baseline:

+----------+--------------------------------+------------+------------+
| O        | Increase in Maternal Prenatal  | 1998       | 2010       |
| bjective | Care                           | Baseline   | Target     |
+----------+--------------------------------+------------+------------+
|          |                                | ####### Pe |            |
|          |                                | rcent of L |            |
|          |                                | ive Births |            |
+----------+--------------------------------+------------+------------+
| **       | Care beginning in first        | 83         | 90         |
| 16-6a.** | trimester of pregnancy         |            |            |
+----------+--------------------------------+------------+------------+
| **       | Early and adequate prenatal    | 74         | 90         |
| 16-6b.** | care                           |            |            |
+----------+--------------------------------+------------+------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

+-----------------------------------+-----------------+----------------+
| **Live Births, 1998**             | **Maternal      |                |
|                                   | Prenatal Care** |                |
+===================================+=================+================+
|                                   | **16-6a.\       | **16-6b.\      |
|                                   | First           | Early and\     |
|                                   | Trimester**     | Adequate**     |
+-----------------------------------+-----------------+----------------+
|                                   | Percent         |                |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 83              | 74             |
+-----------------------------------+-----------------+----------------+
| **Mother's race and ethnicity**   |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | 69              | 57             |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | 83              | 74             |
+-----------------------------------+-----------------+----------------+
| > Asian                           | 86              | 76             |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | 75              | 67             |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 73              | 67             |
+-----------------------------------+-----------------+----------------+
| > White                           | 85              | 76             |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | 74              | 66             |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | 85              | 76             |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 73              | 67             |
+-----------------------------------+-----------------+----------------+
| > White                           | 88              | 79             |
+-----------------------------------+-----------------+----------------+
| **Mother's education level**      |                 |                |
+-----------------------------------+-----------------+----------------+
| > Less than high school           | 68              | 61             |
+-----------------------------------+-----------------+----------------+
| > High school graduate            | 81              | 74             |
+-----------------------------------+-----------------+----------------+
| > At least some college           | 91              | 82             |
+-----------------------------------+-----------------+----------------+
| **Mother's disability status**    |                 |                |
+-----------------------------------+-----------------+----------------+
| > Mothers with disabilities       | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Mothers without disabilities    | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| ###### Select populations         |                 |                |
+-----------------------------------+-----------------+----------------+
| > Mother's age groups             |                 |                |
+-----------------------------------+-----------------+----------------+
| > Under 15 years                  | 48              | 48             |
+-----------------------------------+-----------------+----------------+
| > 15 to 19 years                  | 69              | 64             |
+-----------------------------------+-----------------+----------------+
| > 20 to 24 years                  | 78              | 70             |
+-----------------------------------+-----------------+----------------+
| > 25 to 29 years                  | 86              | 77             |
+-----------------------------------+-----------------+----------------+
| > 30 to 34 years                  | 89              | 79             |
+-----------------------------------+-----------------+----------------+
| > 35 years and older              | 88              | 79             |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Prenatal care includes three major components: risk assessment,
treatment for medical conditions or risk reduction, and education. Each
component can contribute to reductions in perinatal illness, disability,
and death by identifying and mitigating potential risks and helping
women to address behavioral factors, such as smoking and alcohol use,
that contribute to poor outcomes. Prenatal care is more likely to be
effective if women begin receiving care early in pregnancy. Since 1990,
the proportion of infants whose mothers entered prenatal care in the
first trimester increased 8.8 percent, from 76 percent to 83 percent.
Among African Americans, this proportion grew 19 percent and among
Hispanics, 22 percent.Error: Reference source not found Thus, increases
in early entry into prenatal care have been concentrated in those
populations whose perinatal illness and disability rates and mortality
rates are highest and who are most likely to have low incomes. These
increases are likely due, in part, to increased access to Medicaid
coverage for pregnancy-related services and improved outreach by
Medicaid programs.[^46] In addition, the likelihood of early entry into
prenatal care rises with age. The risk of poor birth outcomes is
greatest among the youngest mothers (aged 15 years and under). Clearly,
therefore, continued work is needed to educate women, particularly young
women, about the need to begin prenatal care early in pregnancy.

Prenatal care should begin early and continue throughout pregnancy,
according to accepted standards of periodicity. For example, the
American College of Obstetricians and Gynecologists recommends that
women receive at least 13 prenatal visits during a full-term
pregnancy.[^47] Therefore, assessment of the adequacy of the care
pregnant women receive must include monitoring not only the month of
initiation of prenatal care but also the adequacy of the care they
receive throughout pregnancy. The Adequacy of Prenatal Care Utilization
Index (APNCU) measures two dimensions of care: the adequacy of
initiation of care and the adequacy of the use of prenatal services once
care has begun (by comparing actual use to the recommended number of
visits based on the month of initiation of care and the length of the
pregnancy).[^48] These dimensions are combined to classify each woman's
prenatal care history as inadequate, intermediate, adequate, or
adequate-plus. The baseline rates presented above include all women who
received either adequate or adequate-plus care.

Overall, nearly three-quarters of women receive adequate prenatal care.
However, this proportion varies across racial and ethnic groups. Certain
groups, such as American Indians or Alaska Natives and Samoans, are
particularly likely to receive less-than-adequate prenatal care. The
likelihood of receipt of adequate prenatal care rises with maternal age,
with fewer than half of pregnant women aged 15 years and under receiving
adequate care.Error: Reference source not found Prevention of unwanted
pregnancy in adolescents and education of women about the need for
early, continuous prenatal care are essential.

16-7. (Developmental) Increase the proportion of pregnant women who
attend a series of prepared childbirth classes.

**Potential data sources:** National Pregnancy and Health Survey, NIH,
NICHD; National Survey of Family Growth (NSFG) or National Health
Interview Survey (NHIS), CDC, NCHS.

As part of comprehensive prenatal care, a formal series of prepared
childbirth classes conducted by a certified childbirth educator is
recommended for all women by the Expert Panel on the Content of Prenatal
Care.[^49] These classes can help reduce women's pain[^50] and
anxiety[^51] as they approach childbirth, making delivery a more
pleasant experience and preparing women for what they will face as they
give birth. A full series of sessions is recommended for women who have
never attended. A refresher series of one or two classes is recommended
for women who attended during a previous pregnancy. At a minimum, the
childbirth classes should include information regarding the physiology
of labor and birth, exercises and self-help techniques for labor, the
role of support persons, family roles and adjustments, and preferences
for care during labor and birth. The classes also should include an
opportunity for the mother and her partner to have questions answered
about providers, prenatal care, and other relevant issues, as well as to
receive information regarding birth settings and cesarean childbirth.
Attendance is recommended during the third trimester of pregnancy so
that information learned will be used relatively soon after
presentation. Classes should begin at the 31st or 32nd week and be
completed no later than 38 weeks. The refresher class should be
completed at any time between 36 and 38 weeks.

### Obstetrical Care

16-8. Increase the proportion of very low birth weight (VLBW) infants
born at level III hospitals or subspecialty perinatal centers.

**Target:** 90 percent.

**Baseline:** 73 percent of VLBW infants were born at level III
hospitals or\
subspecialty perinatal centers in 1996--97.

**Target setting method:** 25 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** Title V Reporting System, HRSA, MCHB.

> **Data for population groups currently are not analyzed.**

Much research has demonstrated the benefits of delivering high-risk
infants in settings that have the technological capacity to care for
them. Specifically, research has shown that VLBW infants have lower
death rates when they are delivered at level III hospitals, which are
equipped to care for very small infants.[^52]**^,^** [^53]**^,^** [^54]
To ensure that high-risk pregnant women have access to appropriate
levels of obstetric care, many States have implemented perinatal
regionalization strategies and protocols for the transfer of high-risk
women to level III facilities. Evidence, however, indicates that these
systems may be eroding as health care networks and financing systems
change.Error: Reference source not found**^,^** [^55] The proportion of
VLBW infants who are delivered in the level III obstetric hospitals best
equipped to provide appropriate neonatal care should be measured to
monitor the continuing effectiveness of these systems and the
appropriateness of the level of care delivered to high-risk pregnant
women and infants.

16-9. Reduce cesarean births among low-risk (full term,\
singleton, vertex presentation) women.

Target and baseline:

+----------+-----------------------------+-------------+--------------+
| O        | Reduction in Cesarean       | 1998        | 2010 Target  |
| bjective | Births                      | Baseline    |              |
+----------+-----------------------------+-------------+--------------+
|          |                             | #######     |              |
|          |                             | Percent of  |              |
|          |                             | Live Births |              |
+----------+-----------------------------+-------------+--------------+
| **       | Women giving birth for the  | 18          | 15           |
| 16-9a.** | first time                  |             |              |
+----------+-----------------------------+-------------+--------------+
| **       | Prior cesarean birth        | 72          | 63           |
| 16-9b.** |                             |             |              |
+----------+-----------------------------+-------------+--------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------------+-----------------+----------------+
| **Cesarean Births to Low-Risk     | **Cesarean      |                |
| Women, 1998**                     | Birth**         |                |
+===================================+=================+================+
|                                   | **16-9a.\       | **16-9b.\      |
|                                   | Women Giving    | Prior Cesarean |
|                                   | Birth for the   | Birth**        |
|                                   | First Time**    |                |
+-----------------------------------+-----------------+----------------+
|                                   | Percent         |                |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 18              | 72             |
+-----------------------------------+-----------------+----------------+
| **Mother's race and ethnicity**   |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | 16              | 68             |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | 18              | 70             |
+-----------------------------------+-----------------+----------------+
| > Asian                           | 19              | 72             |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | 17              | 65             |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 21              | 73             |
+-----------------------------------+-----------------+----------------+
| > White                           | 18              | 72             |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | 18              | 76             |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | 18              | 71             |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 21              | 73             |
+-----------------------------------+-----------------+----------------+
| > White                           | 18              | 71             |
+-----------------------------------+-----------------+----------------+
| **Mother's education level**      |                 |                |
+-----------------------------------+-----------------+----------------+
| > Less than high school           | 14              | 72             |
+-----------------------------------+-----------------+----------------+
| > High school graduate            | 18              | 73             |
+-----------------------------------+-----------------+----------------+
| > At least some college           | 20              | 71             |
+-----------------------------------+-----------------+----------------+
| ###### Mother's disability status |                 |                |
+-----------------------------------+-----------------+----------------+
| > Mothers with disabilities       | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Mothers without disabilities    | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| ###### Select populations         |                 |                |
+-----------------------------------+-----------------+----------------+
| Mother's age groups               |                 |                |
+-----------------------------------+-----------------+----------------+
| > Under 15 years old              | 13              | DSU            |
+-----------------------------------+-----------------+----------------+
| > 15 to 19 years                  | 12              | 67             |
+-----------------------------------+-----------------+----------------+
| > 20 to 24 years                  | 16              | 70             |
+-----------------------------------+-----------------+----------------+
| > 25 to 29 years                  | 20              | 71             |
+-----------------------------------+-----------------+----------------+
| > 30 to 34 years                  | 24              | 72             |
+-----------------------------------+-----------------+----------------+
| > 35 years and older              | 32              | 75             |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

During the 1980s, rates of cesarean births rose steadily, with a peak
rate of 25 percent of deliveries reported in 1988. Since then, the rate
has been slowly decreasing, with the majority of the decline
attributable to a reduction in the rates of primary cesarean births. In
1989, the rate of vaginal births among women who had a previous cesarean
birth was 19 percent; in 1995 it increased to 28 percent.[^56] The
improvements are likely to be attributable to use of such strategies as
clearer guidelines for trials of labor and labor management, continual
labor support, and focused attention on physician practice
patterns.[^57] Expert opinion called for use of risk-adjusted rates of
cesarean births (that is, rates standardized by patient characteristics)
to monitor progress over time.[^58] (The targets presented here apply to
the population as a whole and are not intended to be used as practice
outcome objectives for individual physicians or institutions, as the
medical needs of the patients in each practice will vary.) In addition
to monitoring rates of cesarean births, the outcomes of these deliveries
(for both the mother and the infant) should be watched closely to assure
that changes in the mode of delivery do not put women or their infants
at risk.

### Risk Factors

16-10. Reduce low birth weight (LBW) and very low birth weight (VLBW).

Target and baseline:

+----------+-------------------------+---------------+----------------+
| O        | Reduction in Low and    | 1998\         | 2010\          |
| bjective | Very Low Birth Weight   | Baseline      | Target         |
+----------+-------------------------+---------------+----------------+
|          |                         | ##            |                |
|          |                         | ##### Percent |                |
+----------+-------------------------+---------------+----------------+
| **1      | Low birth weight (LBW)  | 7.6           | 5.0            |
| 6-10a.** |                         |               |                |
+----------+-------------------------+---------------+----------------+
| **1      | Very low birth weight   | 1.4           | 0.9            |
| 6-10b.** | (VLBW)                  |               |                |
+----------+-------------------------+---------------+----------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------+----------------+----------------+
| **Live Births, 1998 (unless        | **16-10a.\     | **16-10b.\     |
| noted)**                           | Low Birth\     | Very Low\      |
|                                    | Weight**       | Birth Weight** |
+====================================+================+================+
|                                    | Percent        |                |
+------------------------------------+----------------+----------------+
| > **TOTAL**                        | 7.6            | 1.4            |
+------------------------------------+----------------+----------------+
| **Mother's race and ethnicity**    |                |                |
+------------------------------------+----------------+----------------+
| > American Indian or Alaska Native | 6.8            | 1.2            |
+------------------------------------+----------------+----------------+
| > Asian or Pacific Islander        | 7.4            | 1.1            |
+------------------------------------+----------------+----------------+
| > Asian                            | 7.2            | 1.1            |
+------------------------------------+----------------+----------------+
| > Native Hawaiian and other        | 6.5            | 1.4            |
| > Pacific\                         |                |                |
| > Islander                         |                |                |
+------------------------------------+----------------+----------------+
| > Black or African American        | 13.0           | 3.1            |
+------------------------------------+----------------+----------------+
| > White                            | 6.5            | 1.1            |
+------------------------------------+----------------+----------------+
|                                    |                |                |
+------------------------------------+----------------+----------------+
| > Hispanic or Latino               | 6.4            | 1.1            |
+------------------------------------+----------------+----------------+
| > Not Hispanic or Latino           | 7.8            | 1.5            |
+------------------------------------+----------------+----------------+
| > Black or African American        | 13.2           | 3.1            |
+------------------------------------+----------------+----------------+
| > White                            | 6.6            | 1.1            |
+------------------------------------+----------------+----------------+
| **Gender**                         |                |                |
+------------------------------------+----------------+----------------+
| > Female                           | 8.1 (1997)     | 1.4 (1997)     |
+------------------------------------+----------------+----------------+
| > Male                             | 7.0 (1997)     | 1.4 (1997)     |
+------------------------------------+----------------+----------------+
| **Mother's education level**       |                |                |
+------------------------------------+----------------+----------------+
| > Less than high school            | 9.0            | 1.6            |
+------------------------------------+----------------+----------------+
| > High school graduate             | 7.9            | 1.5            |
+------------------------------------+----------------+----------------+
| > At least some college            | 6.5            | 1.3            |
+------------------------------------+----------------+----------------+
| **Mother's disability status**     |                |                |
+------------------------------------+----------------+----------------+
| > Mothers with disabilities        | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| > Mothers without disabilities     | DNC            | DNC            |
+------------------------------------+----------------+----------------+
| ###### Select populations          |                |                |
+------------------------------------+----------------+----------------+
| Mother's age groups                |                |                |
+------------------------------------+----------------+----------------+
| > Under 15 years                   | 13.1           | 3.3            |
+------------------------------------+----------------+----------------+
| > 15 to 19 years                   | 9.5            | 1.8            |
+------------------------------------+----------------+----------------+
| > 20 to 24 years                   | 7.5            | 1.4            |
+------------------------------------+----------------+----------------+
| > 25 to 29 years                   | 6.7            | 1.3            |
+------------------------------------+----------------+----------------+
| > 30 to 34 years                   | 7.0            | 1.4            |
+------------------------------------+----------------+----------------+
| > 35 years and older               | 8.7            | 1.7            |
+------------------------------------+----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

LBW is the risk factor most closely associated with neonatal death;
thus, improvements in infant birth weight can contribute substantially
to reductions in the infant mortality rate. Of all infants born at low
birth weight, the smallest (those weighing less than 1,500 grams) are at
highest risk of dying in their first year. However, some researchers
have proposed that further improvement in the survival of VLBW infants
is nearly impossible, and reduction in the underlying rate of VLBW
births is the only avenue toward reduction of neonatal mortality
rates.[^59] Another important issue is the long-term effects of LBW on
affected infants who survive their first year, as these infants are more
likely to experience long-term developmental and neurologic disabilities
than are infants of normal birth weight.[^60]**^,^** [^61] Recent
increases in LBW are due largely to preterm delivery related to
increases in multiple gestation.

Smoking accounts for 20 to 30 percent of all LBW births in the United
States. The effect of smoking on LBW rates appears to be attributable to
intrauterine growth retardation rather than to preterm delivery.Error:
Reference source not found VLBW is primarily associated with preterm
birth, which may be associated with the use of illicit drugs during
pregnancy.

16-11. Reduce preterm births.

Target and baseline:

+----------+-------------------------+----------------+---------------+
| O        | Reduction in Preterm    | 1998 Baseline  | 2010 Target   |
| bjective | Births                  |                |               |
+----------+-------------------------+----------------+---------------+
|          |                         | #              |               |
|          |                         | ###### Percent |               |
+----------+-------------------------+----------------+---------------+
| **1      | Total preterm births    | 11.6           | 7.6           |
| 6-11a.** |                         |                |               |
+----------+-------------------------+----------------+---------------+
| **1      | Live births at 32 to 36 | 9.6            | 6.4           |
| 6-11b.** | weeks of gestation      |                |               |
+----------+-------------------------+----------------+---------------+
| **1      | Live births at less     | 2.0            | 1.1           |
| 6-11c.** | than 32 weeks of        |                |               |
|          | gestation               |                |               |
+----------+-------------------------+----------------+---------------+

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System (NVSS), CDC, NCHS.

Note: The table below may continue to the following page.

+---------------------------------+-----------+------------+-----------+
| **Live Births, 1998**           | *         | **16-11b.\ | *         |
|                                 | *16-11a.\ | 32 to 36   | *16-11c.\ |
|                                 | Total\    | Weeks of   | Less Than |
|                                 | Preterm   | G          | 32 Weeks  |
|                                 | Births**  | estation** | of\       |
|                                 |           |            | Ge        |
|                                 |           |            | station** |
+=================================+===========+============+===========+
|                                 | Percent   |            |           |
+---------------------------------+-----------+------------+-----------+
| > **TOTAL**                     | 11.6      | 9.6        | 2.0       |
+---------------------------------+-----------+------------+-----------+
| **Mother's race and ethnicity** |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > American Indian or Alaska     | 12.2      | 10.2       | 2.0       |
| > Native                        |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Asian or Pacific Islander     | 10.4      | 8.9        | 1.4       |
+---------------------------------+-----------+------------+-----------+
| > Asian                         | 9.7       | 8.4        | 1.3       |
+---------------------------------+-----------+------------+-----------+
| > Native Hawaiian and other     | 11.9      | 9.7        | 2.0       |
| > Pacific Islander              |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Black or African American     | 17.5      | 13.4       | 4.1       |
+---------------------------------+-----------+------------+-----------+
| > White                         | 10.5      | 8.9        | 1.6       |
+---------------------------------+-----------+------------+-----------+
|                                 |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Hispanic or Latino            | 11.4      | 9.7        | 1.7       |
+---------------------------------+-----------+------------+-----------+
| > Not Hispanic or Latino        | 11.7      | 9.6        | 2.0       |
+---------------------------------+-----------+------------+-----------+
| > Black or African American     | 17.6      | 13.4       | 4.1       |
+---------------------------------+-----------+------------+-----------+
| > White                         | 10.2      | 8.7        | 1.5       |
+---------------------------------+-----------+------------+-----------+
| **Gender**                      |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Female                        | DNA       | DNA        | DNA       |
+---------------------------------+-----------+------------+-----------+
| > Male                          | DNA       | DNA        | DNA       |
+---------------------------------+-----------+------------+-----------+
| **Mother's education level**    |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Less than high school         | 13.7      | 11.2       | 2.4       |
+---------------------------------+-----------+------------+-----------+
| > High school graduate          | 12.0      | 9.9        | 2.1       |
+---------------------------------+-----------+------------+-----------+
| > At least some college         | 10.3      | 8.7        | 1.6       |
+---------------------------------+-----------+------------+-----------+
| **Mother's disability status**  |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Mothers with disabilities     | DNC       | DNC        | DNC       |
+---------------------------------+-----------+------------+-----------+
| > Mothers without disabilities  | DNC       | DNC        | DNC       |
+---------------------------------+-----------+------------+-----------+
| ###### Select populations       |           |            |           |
+---------------------------------+-----------+------------+-----------+
| Mother's age groups             |           |            |           |
+---------------------------------+-----------+------------+-----------+
| > Under 15 years                | 22.0      | 16.2       | 5.8       |
+---------------------------------+-----------+------------+-----------+
| > 15 to 19 years                | 13.8      | 11.1       | 2.7       |
+---------------------------------+-----------+------------+-----------+
| > 20 to 24 years                | 11.5      | 9.6        | 1.9       |
+---------------------------------+-----------+------------+-----------+
| > 25 to 29 years                | 10.6      | 8.9        | 1.7       |
+---------------------------------+-----------+------------+-----------+
| > 30 to 34 years                | 10.8      | 9.1        | 1.8       |
+---------------------------------+-----------+------------+-----------+
| > 35 years and older            | 12.9      | 10.8       | 2.2       |
+---------------------------------+-----------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Approximately two-thirds of LBW infants and 98 percent of VLBW infants
are born preterm. In addition, preterm birth is the leading cause of
those neonatal deaths not associated with birth defects. Survival rates
of infants have been shown to increase as gestational age advances, even
among very preterm infants.[^62]**^,^** [^63] Therefore, reduction in
preterm delivery holds the greatest promise for overall reduction in
infant illness, disability, and death. Because the specific causes of
preterm delivery are unclear, research is needed before tailored
interventions can be developed.[^64]**^,^** [^65] Preterm birth is
associated with a number of modifiable risk factors, including the use
of alcohol, tobacco, or other drugs during pregnancy[^66]**^,^** [^67]
and low prepregnancy weight or low weight gain during
pregnancy.[^68]**^,^** [^69] Other important risk factors for preterm
birth are vaginal infections[^70]**^,^** [^71]**^,^** [^72] and domestic
violence.[^73]

Rates of preterm delivery in the United States increased over the last
three decades of the 20th century.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Between 1989 and
1996, this increase was due largely to an increase in multiple
gestation. The gap between African American and white infants persists
as well, for reasons that are largely unexplained[^74] and that have
been shown to be independent of other known risk factors.Error:
Reference source not found**^,^** [^75] Risk factors that African
American women may disproportionately experience include short
interpregnancy intervals[^76] and exposure to psychosocial stress.Error:
Reference source not found**^,^** [^77]

16-12. (Developmental) Increase the proportion of mothers\
who achieve a recommended weight gain during their\
pregnancies.

**Potential data source:** National Vital Statistics System (NVSS), CDC,
NCHS.

Current evidence indicates that gestational weight gain, particularly
during the second and third trimesters, is an important determinant of
fetal growth. Inadequate weight gain during pregnancy is associated with
an increased risk of IUGR, LBW, and infant death.[^78]**^,^**
[^79]**^,^** [^80] Maternal weight gain is susceptible to intervention
and represents an avenue for prevention of poor birth outcomes. The
Institute of Medicine's 1990 guidelines for weight gain in pregnancy
recommend a graduated level of weight gain based on a woman's
prepregnancy body mass index (BMI) (that is, the ratio of her weight to
her height).Error: Reference source not found Under these guidelines, a
woman with normal BMI should gain 25 to 35 pounds during pregnancy.
Those with below-normal BMI should gain 28 to 40 pounds. Overweight
women should gain 15 to 25 pounds.

In 1988, approximately three-quarters of married women who delivered at
full term gained the recommended weight during pregnancy.Error:
Reference source not found Two groups of women who continue to gain less
than the recommended level of weight during pregnancy---teenagers and
African American women---also are at particularly high risk for having
LBW infants and other adverse pregnancy outcomes.

16-13. Increase the percentage of healthy full-term infants who are put
down to sleep on their backs.

**Target:** 70 percent.

**Baseline:** 35 percent of healthy full-term infants were put down to
sleep on their backs in 1996.

**Target setting method:** Better than the best.

**Data source:** National Infant Sleep Position Study, NIH, NICHD.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Infants, 1996**                              | **Put Down\         |
|                                                | To Sleep on Their   |
|                                                | Backs**             |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| ######## TOTAL                                 | 35                  |
+------------------------------------------------+---------------------+
| **Mother's race and ethnicity**                |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DNA                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DNA                 |
+------------------------------------------------+---------------------+
| Asian                                          | DNC                 |
+------------------------------------------------+---------------------+
| Native Hawaiian and other Pacific Islander     | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 17                  |
+------------------------------------------------+---------------------+
| > White                                        | 37                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 28                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | DNA                 |
+------------------------------------------------+---------------------+
| > Male                                         | DNA                 |
+------------------------------------------------+---------------------+
| **Mother's education level**                   |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DNC                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | DNC                 |
+------------------------------------------------+---------------------+
| > At least some college                        | DNC                 |
+------------------------------------------------+---------------------+
| **Mother's disability status**                 |                     |
+------------------------------------------------+---------------------+
| > Mothers with disabilities                    | DNC                 |
+------------------------------------------------+---------------------+
| > Mothers without disabilities                 | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Mother's age groups                            |                     |
+------------------------------------------------+---------------------+
| > Under 15 years                               | DNA                 |
+------------------------------------------------+---------------------+
| > 15 to 19 years                               | DNA                 |
+------------------------------------------------+---------------------+
| > 20 to 24 years                               | DNA                 |
+------------------------------------------------+---------------------+
| > 25 to 29 years                               | DNA                 |
+------------------------------------------------+---------------------+
| > 30 to 34 years                               | DNA                 |
+------------------------------------------------+---------------------+
| > 35 years and older                           | DNA                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Much research has shown that a nonprone sleeping position (that is,
sleeping on the side or back rather than the stomach) greatly decreases
the risk of SIDS among healthy full-term infants.[^81]**^,^** [^82]
However, healthy preterm infants have been shown to be more vulnerable
to respiratory problems when put to sleep on their backs.[^83] The
American Academy of Pediatrics has recommended that healthy full-term
infants be put down to sleep on their backs.[^84] The National Institute
of Child Health and Human Development and the Maternal and Child Health
Bureau instituted the "Back to Sleep" campaign in 1994 to educate
parents and physicians about this recommendation. While the percentage
of infants put to sleep on their stomachs dropped dramatically between
1992 and 1997, much of the improvement was in the percentage of infants
put to sleep on their sides. Although not as dangerous as the stomach,
from the side position infants may roll onto their stomachs. Therefore,
the objective focuses on increasing the percentage of infants who are
put down to sleep on their backs.

### Developmental Disabilities and Neural Tube Defects

16-14. Reduce the occurrence of developmental disabilities.

Target and baseline:

+----------+-----------------------------+-------------+-------------+
| O        | Reduction in Developmental\ | 1991--94\   | 2010\       |
| bjective | Disabilities in Children    | Baseline    | Target      |
+----------+-----------------------------+-------------+-------------+
|          |                             | #           |             |
|          |                             | ###### Rate |             |
|          |                             |  per 10,000 |             |
+----------+-----------------------------+-------------+-------------+
| **1      | Mental retardation          | 131\*       | 124         |
| 6-14a.** |                             |             |             |
+----------+-----------------------------+-------------+-------------+
| **1      | Cerebral palsy              | 32.2^†^     | 31.5        |
| 6-14b.** |                             |             |             |
+----------+-----------------------------+-------------+-------------+
| **1      | Autism spectrum disorder    | De          |             |
| 6-14c.** |                             | velopmental |             |
+----------+-----------------------------+-------------+-------------+
| **1      | Epilepsy                    | De          |             |
| 6-14d.** |                             | velopmental |             |
+----------+-----------------------------+-------------+-------------+

\*Children aged 8 years in metropolitan Atlanta, GA, having an IQ of 70
or less.

^†^Children aged 8 years in metropolitan Atlanta, GA.

**Target setting method:** 5 percent improvement.

**Data source:** Metropolitan Atlanta Developmental Disabilities
Surveillance\
Program (MADDSP), CDC, NCEH.

Note: The table below may continue to the following page.

+------------------------------------------+------------+-------------+
| **Children Aged 8 Years, Atlanta, GA,    | **16-14a.\ | **16-14b.\  |
| 1991--94**                               | Mental\    | Cerebral    |
|                                          | Ret        | Palsy**     |
|                                          | ardation** |             |
+==========================================+============+=============+
|                                          | Rate per   |             |
|                                          | 10,000     |             |
+------------------------------------------+------------+-------------+
| > **TOTAL**                              | 131        | 32.2        |
+------------------------------------------+------------+-------------+
| **Race and ethnicity**                   |            |             |
+------------------------------------------+------------+-------------+
| > American Indian or Alaska Native       | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| > Asian or Pacific Islander              | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| > Asian                                  | DNC        | DNC         |
+------------------------------------------+------------+-------------+
| > Native Hawaiian and other Pacific      | DNC        | DNC         |
| > Islander                               |            |             |
+------------------------------------------+------------+-------------+
| > Black or African American              | 210        | 38.4        |
+------------------------------------------+------------+-------------+
| > White                                  | 85         | 30.4        |
+------------------------------------------+------------+-------------+
|                                          |            |             |
+------------------------------------------+------------+-------------+
| > Hispanic or Latino                     | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| > Not Hispanic or Latino                 | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| > Black or African American              | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| > White                                  | DNA        | DNA         |
+------------------------------------------+------------+-------------+
| **Gender**                               |            |             |
+------------------------------------------+------------+-------------+
| > Female                                 | 107        | 30.8        |
+------------------------------------------+------------+-------------+
| > Male                                   | 154        | 35.5        |
+------------------------------------------+------------+-------------+
| **Family income level**                  |            |             |
+------------------------------------------+------------+-------------+
| > Poor                                   | DNC        | DNC         |
+------------------------------------------+------------+-------------+
| > Near poor                              | DNC        | DNC         |
+------------------------------------------+------------+-------------+
| > Middle/high income                     | DNC        | DNC         |
+------------------------------------------+------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Specific developmental disabilities will be monitored among school-aged
children since not all occurrences are manifested or recognized until
those ages. A reduction in the rate of LBW, as proposed in objective
16-10, can be expected to result in a lower number of occurrences of
most developmental disabilities, because LBW is such a strong risk
factor. Interventions to reduce the occurrence of some intrauterine
infections (for example, congenital rubella syndrome) and increased
access to genetic counseling should reduce prenatal causes of
developmental disabilities. The early identification and prophylactic
treatment of sickle cell disease are expected to reduce the occurrence
of postnatal cerebrovascular complications, which are known postnatal
causes of cerebral palsy and mental retardation. Increased safety belt
use and other measures to prevent unintentional childhood injury,
interventions to prevent child abuse, *Haemophilus influenzae*
immunization, and increased access to medical care to reduce meningitis
also will reduce the occurrences of developmental disabilities due to
postnatal causes.

The Metropolitan Atlanta Developmental Disabilities Surveillance Program
(MADDSP) is the only high-quality surveillance system that monitors the
number of cases of mental retardation and other developmental
disabilities. MADDSP is a regional data source from a principally urban
area, and therefore MADDSP findings cannot be generalized to the Nation;
in particular, MADDSP findings may not be representative of rural
regions. Efforts are under way to use MADDSP methods to build similar
data systems in other regions of the country.

16-15. Reduce the occurrence of spina bifida and other neural tube
defects (NTDs).

**Target:** 3 new cases per 10,000 live births.

**Baseline:** 6 new cases of spina bifida or another NTD per 10,000 live
births\
occurred in 1996.

**Target setting method:** 50 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** National Birth Defects Prevention Network (NBDPN), CDC,
NCEH.

+---------------------------------------------+------------------------+
| **Live Births, 1996**                       | **New Cases of\        |
|                                             | Spina Bifida or\       |
|                                             | Other NTDs**           |
+=============================================+========================+
|                                             | Rate per 10,000        |
+---------------------------------------------+------------------------+
| > **TOTAL**                                 | 6                      |
+---------------------------------------------+------------------------+
| **Mother's race and ethnicity**             |                        |
+---------------------------------------------+------------------------+
| > American Indian or Alaska Native          | DNA                    |
+---------------------------------------------+------------------------+
| > Asian or Pacific Islander                 | DNA                    |
+---------------------------------------------+------------------------+
| > Asian                                     | DNC                    |
+---------------------------------------------+------------------------+
| > Native Hawaiian and other Pacific         | DNC                    |
| > Islander                                  |                        |
+---------------------------------------------+------------------------+
| > Black or African American                 | DNA                    |
+---------------------------------------------+------------------------+
| > White                                     | DNA                    |
+---------------------------------------------+------------------------+
|                                             |                        |
+---------------------------------------------+------------------------+
| > Hispanic or Latino                        | DNC                    |
+---------------------------------------------+------------------------+
| > Not Hispanic or Latino                    | DNC                    |
+---------------------------------------------+------------------------+
| > Black or African American                 | DNC                    |
+---------------------------------------------+------------------------+
| > White                                     | DNC                    |
+---------------------------------------------+------------------------+
| **Gender**                                  |                        |
+---------------------------------------------+------------------------+
| > Female                                    | DNA                    |
+---------------------------------------------+------------------------+
| > Male                                      | DNA                    |
+---------------------------------------------+------------------------+
| **Mother's education level**                |                        |
+---------------------------------------------+------------------------+
| > Less than high school                     | DNC                    |
+---------------------------------------------+------------------------+
| > High school graduate                      | DNC                    |
+---------------------------------------------+------------------------+
| > At least some college                     | DNC                    |
+---------------------------------------------+------------------------+
| > College graduate                          | DNC                    |
+---------------------------------------------+------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

16-16. Increase the proportion of pregnancies begun with\
an optimum folic acid level.

Target and baseline:

+---------+--------------------------------+------------+-------------+
| Ob      | Increase in Pregnancies Begun\ | 1991--94\  | 2010\       |
| jective | With Optimum Folic Acid Level  | Baseline   | Target      |
+---------+--------------------------------+------------+-------------+
|         |                                | #####      |             |
|         |                                | ## Percent |             |
+---------+--------------------------------+------------+-------------+
| **16    | Consumption of at least 400 μg | 21         | 80          |
| -16a.** | of folic acid each day from    |            |             |
|         | fortified foods or dietary     |            |             |
|         | supplements by nonpregnant     |            |             |
|         | women aged 15 to 44 years      |            |             |
+---------+--------------------------------+------------+-------------+
|         |                                | ####       |             |
|         |                                | ### Number |             |
+---------+--------------------------------+------------+-------------+
| **16    | Median RBC folate level among  | 160 ng/ml  | 220 ng/ml   |
| -16b.** | nonpregnant women aged 15 to   |            |             |
|         | 44 years                       |            |             |
+---------+--------------------------------+------------+-------------+

**Target setting method:** Better than the best.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------------+-----------------+----------------+
| **Nonpregnant Women Aged 15 to 44 | **16-16a.\      | **16-16b.\     |
| Years, 1991--94**                 | Adequate Folic  | Median RBC\    |
|                                   | Acid**          | Folate Level** |
+===================================+=================+================+
|                                   | Percent         | ng/ml          |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 21              | 160            |
+-----------------------------------+-----------------+----------------+
| **Race and ethnicity**            |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | DSU             | DSU            |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | DSU             | DSU            |
+-----------------------------------+-----------------+----------------+
| > Asian                           | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | DNC             | DNC            |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 17              | 125            |
+-----------------------------------+-----------------+----------------+
| > White                           | 22              | 169            |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | DSU             | DSU            |
+-----------------------------------+-----------------+----------------+
| > Mexican American                | 13              | 158            |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | 22              | 159            |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 18              | 123            |
+-----------------------------------+-----------------+----------------+
| > White                           | 23              | 170            |
+-----------------------------------+-----------------+----------------+
| ###### Education level            |                 |                |
+-----------------------------------+-----------------+----------------+
| > Less than high school           | 12              | 145            |
+-----------------------------------+-----------------+----------------+
| > High school graduate            | 19              | 148            |
+-----------------------------------+-----------------+----------------+
| > At least some college           | 28              | 179            |
+-----------------------------------+-----------------+----------------+
| **Disability status**             |                 |                |
+-----------------------------------+-----------------+----------------+
| > Persons with disabilities       | 20              | 169            |
+-----------------------------------+-----------------+----------------+
| > Persons without disabilities    | 23              | 159            |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

NTDs, including spina bifida, occur when the fetal neural tube fails to
close fully, interrupting development of the central nervous system.
Approximately 50 percent of pregnancies affected with NTDs may be
prevented with adequate consumption of folic acid from 1 month before
conception through the first 3 months of pregnancy.Error: Reference
source not found In 1992, the U.S. Public Health Service (PHS)
recommended that all women of childbearing age consume 400 micrograms of
folic acid daily.Error: Reference source not found For women who already
have had an NTD-affected pregnancy, PHS recommends that women consult
with a health care professional about taking a much larger amount of
folic acid---4,000 micrograms (4.0 milligrams)---when planning a
pregnancy.Error: Reference source not found In 1998, the Institute of
Medicine further recommended that to reduce the risk of an NTD-affected
pregnancy, all women capable of becoming pregnant should consume 400
micrograms of folic acid daily, from fortified foods or supplements or a
combination of the two, in addition to consuming folate-rich foods, such
as orange juice, green vegetables, and beans.[^85]

Most grain products (including enriched flour, breads, breakfast
cereals, rice, and pasta) now are fortified with folic acid. However,
the amount of folic acid that some segments of the reproductive-aged
population might receive through their diet may not adequately meet the
PHS recommendation of 400 micrograms daily. Thus, women capable of
becoming pregnant need to review their dietary options, eat a diet that
includes folate-rich foods, and target consumption of folic
acid-fortified food as well as take a folic acid-containing supplement.

### Prenatal Substance Exposure

16-17. Increase abstinence from alcohol, cigarettes, and illicit drugs
among pregnant women.

Target and baseline:

+----------+-------------------------------+--------------+------------+
| O        | Increase in Reported          | 1996--97\    | 2010\      |
| bjective | Abstinence\                   | Baseline     | Target     |
|          | in Past Month From            | (unless      |            |
|          | Substances\                   | noted)       |            |
|          | by Pregnant Women\*           |              |            |
+----------+-------------------------------+--------------+------------+
|          |                               | ###          |            |
|          |                               | #### Percent |            |
+----------+-------------------------------+--------------+------------+
| **1      | Alcohol                       | 86           | 94         |
| 6-17a.** |                               |              |            |
+----------+-------------------------------+--------------+------------+
| **1      | Binge drinking                | 99           | 100        |
| 6-17b.** |                               |              |            |
+----------+-------------------------------+--------------+------------+
| **1      | Cigarette smoking^†^          | 87 (1998)    | 99         |
| 6-17c.** |                               |              |            |
+----------+-------------------------------+--------------+------------+
| **1      | Illicit drugs                 | 98           | 100        |
| 6-17d.** |                               |              |            |
+----------+-------------------------------+--------------+------------+

\*Pregnant women aged 15 to 44 years.

^†^Smoking during pregnancy for all women giving birth in 1998 in 46
States, the District of Columbia, and New York City.

**Target setting method:** Better than the best for 16-17a and 16-17c;
complete elimination for 16-17b and 16-17d.

**Data sources:** National Household Survey on Drug Abuse, SAMHSA for
16-17a, 16-17b, and 16-17d; National Vital Statistics System, CDC, NCHS
for 16-17c.

Note: The table below may continue to the following page.

+---------------------------+---------+-----------+---------+--------+
| **Pregnant Women Aged 15\ | **1     | *         | **1     | **16   |
| to 44 Years, 1996--97     | 6-17a.\ | *16-17b.\ | 6-17c.\ | -17d.\ |
| (unless noted)**          | Alcohol | No Binge  | No      | No     |
|                           | Abst    | D         | Ci      | Drugs, |
|                           | inence, | rinking,\ | garette | Past   |
|                           | Past    | Past      | S       | M      |
|                           | Month** | Month**   | moking, | onth** |
|                           |         |           | 1       |        |
|                           |         |           | 998\*** |        |
+===========================+=========+===========+=========+========+
|                           | Percent |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > **TOTAL**               | 86      | 99        | 87      | 98     |
+---------------------------+---------+-----------+---------+--------+
| **Race and ethnicity**    |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > American Indian or      | DNA     | DNA       | 80      | DNA    |
| > Alaska Native           |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Asian or Pacific        | DNA     | DNA       | 97      | DNA    |
| > Islander                |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Asian                   | DNC     | DNC       | 98      | DNC    |
+---------------------------+---------+-----------+---------+--------+
| > Native Hawaiian and     | DNC     | DNC       | 84      | DNC    |
| > other Pacific Islander  |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Black or African        | DNA     | DNA       | 91      | DNA    |
| > American                |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > White                   | DNA     | DNA       | 86      | DNA    |
+---------------------------+---------+-----------+---------+--------+
|                           |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Hispanic or Latino      | 93      | 99        | 96      | 99     |
+---------------------------+---------+-----------+---------+--------+
| > Not Hispanic or Latino  | DNA     | DNA       | 86      | DNA    |
+---------------------------+---------+-----------+---------+--------+
| > Black or African        | 83      | 99        | 90      | 95     |
| > American                |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > White                   | 85      | 99        | 84      | 98     |
+---------------------------+---------+-----------+---------+--------+
| **Education level** (aged |         |           |         |        |
| 18 to 44 years)           |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Less than high school   | 79      | 99        | 78      | 92     |
+---------------------------+---------+-----------+---------+--------+
| > High school graduate    | 91      | 99        | 83      | 100    |
+---------------------------+---------+-----------+---------+--------+
| > At least some college   | DNA     | 98        | 94      | DNA    |
+---------------------------+---------+-----------+---------+--------+
| > College graduate        | DNA     | DNA       | DNA     | DNA    |
+---------------------------+---------+-----------+---------+--------+
| **Disability status**     |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Persons with            | DNC     | DNC       | DNC     | DNC    |
| > disabilities            |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+
| > Persons without         | DNC     | DNC       | DNC     | DNC    |
| > disabilities            |         |           |         |        |
+---------------------------+---------+-----------+---------+--------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Smoking during pregnancy for all women giving birth in 1998 in 46
States, the District of Columbia, and New York City.

Note: The table above may have continued from the previous page.

A range of effects, including spontaneous abortion, LBW, and preterm
delivery, have been associated with prenatal use of licit and illicit
drugs, including alcohol, tobacco, cocaine, and marijuana.[^86]**^,^**
[^87]**^,^**
[^88]**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
As discussed above, tobacco is associated with LBW and spontaneous
abortion.Error: Reference source not found Heavy alcohol use is
associated with FAS,Error: Reference source not found and even moderate
alcohol use has demonstrated effects on preterm delivery.Error:
Reference source not found The use of cocaine during pregnancy is
associated with premature birth and impaired fetal growth.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
In addition, women who use cocaine are at especially high risk of
infectious diseases, including hepatitis B and HIV. Exposure to
marijuana in utero may be associated with LBW, preterm birth, and
neurobehavioral functioning. However, isolating the effects of marijuana
use on newborns is difficult because users of the drug often use alcohol
and tobacco as well.Error: Reference source not found

Self-reported use of illicit drugs, such as cocaine and marijuana, is
quite rare, with 98 percent of pregnant women reporting abstaining from
these drugs. Rates of abstinence from harmful substances during
pregnancy appear to be declining slowly. The use of alcohol during
pregnancy, despite the established health risk, exemplifies this trend.
In 1996--97, 86 percent of pregnant women abstained from alcohol use, an
increase of 9 percent from the 1988 baseline. Rates of frequent drinking
(at least seven drinks per week or at least five drinks on any occasion
in the past month) among pregnant women have begun to decline, with only
1.3 percent of pregnant women reporting recent binge drinking in
1996--97, compared to 2.9 percent in 1994--95.[^89] Unintentional
alcohol exposure is particularly likely to occur early in pregnancy,
before a woman knows she is pregnant. In addition to the objectives
presented here, objectives in Focus Area 26. Substance Abuse, address
alcohol consumption among women of reproductive age and tobacco use by
pregnant women.

16-18. (Developmental) Reduce the occurrence of fetal alcohol syndrome
(FAS).

**Potential data source:** Fetal Alcohol Syndrome Network (FASNet), CDC,
NCEH.

FAS is one of the leading preventable causes of mental retardation and a
leading cause of birth defects, including growth deficiency and
microcephaly. Affected children also are likely to show infantile
irritability, poor coordination, hypotonia, and attention
deficit/hyperactivity disorder.Error: Reference source not found**^,^**
[^90] The diagnosis of FAS is based on three criteria: prenatal or
postnatal growth retardation or both, central nervous system impairment,
and characteristic facial malformations. Abnormalities of other organs
and systems, however, have been noted in combination with these
characteristics.[^91] Estimates of the cases of FAS vary from 0.2 to 1.0
per 1,000 live births. [^92]**^,^** [^93]**^,^** [^94] In addition to
FAS, studies have documented more subtle growth and neurodevelopmental
deficits among children whose mothers drank alcohol during pregnancy.
Alcohol-related birth defects and alcohol-related neurodevelopmental
disorders are thought to occur three to four times more often than
diagnosed cases of FAS.Error: Reference source not found Because of
these lifelong effects, and because a safe level of alcohol consumption
during pregnancy has not been identified, the American Academy of
Pediatrics and the American College of Obstetricians and Gynecologists
recommend that women who are pregnant or are planning a pregnancy
abstain from the use of alcohol.[^95]**^,^** [^96]

Despite broad agreement on the importance of FAS, consistent diagnosis
of the syndrome at birth has been difficult to achieve. Thus, accurately
estimating the number or proportion of infants affected by FAS is
challenging for a number of reasons: the difficulty of evaluating an
infant's central nervous system, lack of training among clinicians,
inconsistent diagnostic criteria, clinicians' tendency to avoid
associating their patients with the stigma of alcohol problems, and
failures of mothers to report alcohol intake during gestation.Error:
Reference source not found

### Breastfeeding, Newborn Screening, and Service Systems

16-19. Increase the proportion of mothers who breastfeed their babies.

Target and baseline:

+---------+-------------------------------+-------------+-------------+
| Ob      | Increase in Mothers Who       | 1998        | 2010 Target |
| jective | Breastfeed                    | Baseline    |             |
+---------+-------------------------------+-------------+-------------+
|         |                               | ####        |             |
|         |                               | ### Percent |             |
+---------+-------------------------------+-------------+-------------+
| **16    | In early postpartum period    | 64          | 75          |
| -19a.** |                               |             |             |
+---------+-------------------------------+-------------+-------------+
| **16    | At 6 months                   | 29          | 50          |
| -19b.** |                               |             |             |
+---------+-------------------------------+-------------+-------------+
| **16    | At 1 year                     | 16          | 25          |
| -19c.** |                               |             |             |
+---------+-------------------------------+-------------+-------------+

**Target setting method:** Better than the best.

**Data source:** Mothers' Survey, Abbott Laboratories, Inc., Ross
Products\
Division.

Note: The table below may continue to the following page.

+--------------------------------+------------+------------+-----------+
| **Mothers, 1998**              | **B        |            |           |
|                                | reastfed** |            |           |
+================================+============+============+===========+
|                                | **16-19a.\ | **16-19b.\ | *         |
|                                | Early\     | 6 Months** | *16-19c.\ |
|                                | Po         |            | 1 Year**  |
|                                | stpartum** |            |           |
+--------------------------------+------------+------------+-----------+
|                                | Percent    |            |           |
+--------------------------------+------------+------------+-----------+
| > **TOTAL**                    | 64         | 29         | 16        |
+--------------------------------+------------+------------+-----------+
| **Race and ethnicity**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > American Indian or Alaska    | DNC        | DNC        | DNC       |
| > Native                       |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Asian or Pacific Islander    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Asian                        | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Native Hawaiian and other\   | DNC        | DNC        | DNC       |
| > Pacific Islander             |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 45         | 19         | 9         |
+--------------------------------+------------+------------+-----------+
| > White                        | 68         | 31         | 17        |
+--------------------------------+------------+------------+-----------+
|                                |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Hispanic or Latino           | 66         | 28         | 19        |
+--------------------------------+------------+------------+-----------+
| > Not Hispanic or Latino       | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > White                        | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| **Education level**            |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Less than high school        | 48         | 23         | 17        |
+--------------------------------+------------+------------+-----------+
| > High school graduate         | 55         | 21         | 12        |
+--------------------------------+------------+------------+-----------+
| > At least some college        | 55         | 21         | 12        |
+--------------------------------+------------+------------+-----------+
| > College graduate             | 78         | 40         | 22        |
+--------------------------------+------------+------------+-----------+
| **Disability status**          |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Persons with disabilities    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Persons without disabilities | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Breast milk is widely acknowledged to be the most complete form of
nutrition for infants, with a range of benefits for infants' health,
growth, immunity, and development. The benefits of breastfeeding include
decreased new cases or severity of diarrhea,Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
respiratory infections,Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** and ear
infections,Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
among others, and reduced cost to the family.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** In addition,
breastfeeding has been shown to improve maternal health, with
demonstrated effects, including reduction in postpartum bleeding,Error:
Reference source not found earlier return to prepregnancy weight,Error:
Reference source not found reduced risk of premenopausal breast
cancer,Error: Reference source not found and reduced risk of
osteoporosis,Error: Reference source not found continuing long after the
postpartum period. In general, the American Academy of Pediatrics
considers breastfeeding to be "the ideal method of feeding and nurturing
infants."Error: Reference source not found

Universal breastfeeding is not recommended in the United States. Women
who use illicit drugs, who have active, untreated tuberculosis, or who
test positive for HIV, as well as those who use certain prescribed
drugs, should not breastfeed.Error: Reference source not found**^,^**
[^97] In general, however, increasing the rate of breastfeeding,
particularly among low-income and certain racial and ethnic populations
less likely to begin breastfeeding in the hospital or to sustain it
throughout the infant's first year, is an important public health goal.

Rates of breastfeeding are highest among college-educated women and
women aged 35 years and older. The lowest rates of breastfeeding are
found among those whose infants are at highest risk of poor health and
development: those aged 21 years and under and those with low
educational levels. However, many of these groups have shown the
greatest increase in breastfeeding rates since 1989. Rates of
breastfeeding among African American women during the postpartum period
increased 65 percent, and rates of African American women breastfeeding
at 6 months grew 81 percent between 1988 and 1997. Breastfeeding rates
among women aged 20 years and under at both periods also increased
substantially, as did those among women with a grade-school
education.Error: Reference source not found While these improvements are
encouraging, education of new mothers and their partners; education of
health providers; changes in routine maternity ward practices; social
support, including support from employers; and greater media portrayal
of breastfeeding as the normal method of infant feeding are needed to
increase breastfeeding rates among those at highest risk.

16-20. (Developmental) Ensure appropriate newborn bloodspot screening,
followup testing, and referral to services.

**16-20a.** Ensure that all newborns are screened at birth for
conditions mandated by their State-sponsored newborn screening programs,
for example, phenylketonuria and hemoglobinopathies.

**16-20b.** Ensure that followup diagnostic testing for screening
positives is performed within an appropriate time period.

**16-20c.** Ensure that infants with diagnosed disorders are enrolled in
appropriate service interventions within an appropriate time period.

**Potential data source:** Title V Performance Measures, HRSA, MCHB,
National Newborn Screening and Genetic Resource Center.

Newborn screening (NBS) programs began in the early 1960s with the
development of a screening test for phenylketonuria (PKU) and a system
for blood sample collection on filter paper and transportation of that
sample. Since then, all States and some territories of the United States
have included NBS as part of their preventive public health system. NBS
programs in the United States were the first population-based screening
programs for genetic conditions and signaled the integration of genetic
testing into public health programs. The mass screening of 4 million
infants per year in the United States has been heralded as a successful
program that is cost effective and reduces illness, disability, and
death associated with inherited conditions. The universal acceptance of
newborn screening for specified conditions since 1960 attests to the
undeniable benefits that flow from testing and appropriate treatment and
intervention.

The array of screening tests performed by each State varies and is
changing constantly. All State programs now include screening for PKU
and congenital hypothyroidism. More than 40 programs screen for sickle
cell disease, and almost all screen for galactosemia. Others include
congenital adrenal hyperplasia, homocystinuria, maple syrup urine
disease, biotinidase deficiency, and tyrosinemia. A few States also
include cystic fibrosis, additional metabolic disorders, and some other
conditions such as congenital infections. Virtually all States treat or
refer for treatment those with a confirmed diagnosis. However, some
disorders are more uniformly screened for than others, and followup
testing and early initiation of preventive treatment are uneven. For
example, screening for PKU and congenital hypothyroidism is virtually
universal, although reporting is not.[^98]**^,^** [^99] Screening and
followup for galactosemia, sickle cell disease, and other
hemoglobinopathies have been less consistent.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Sickle cell disease
can lead to severe illness and early death, and galactosemia leads to an
increased risk of death from overwhelming infection in early infancy,
failure to thrive, vomiting, liver disease, and mental retardation in
untreated survivors.[^100] Therefore, it is vital that screening be
universally available, that screening be of the highest quality, that
diagnostic testing be provided for those newborns who screen positive,
and that followup treatment be offered to children with diagnosed
disorders.[^101]**^,^** [^102]**^,^** [^103]

16-21. (Developmental) Reduce hospitalization for life-threatening
sepsis among children aged 4 years and under with\
sickling hemoglobinopathies.

**Potential data source:** National Hospital Discharge Survey (NHDS),
CDC, NCHS.

Significant illness, disability, and death are associated with sickle
cell disease because of increased susceptibility to severe bacterial
infections---meningitis, pneumonia, and septicemia---all major causes of
death among children with the disorder.[^104]**^,^** [^105]**^,^**
[^106] Life-threatening episodes of sepsis from pneumococcus and other
organisms are well-recognized complications of sickle cell disease in
children. The efficacy of daily oral penicillin prophylaxis in
preventing infection among young children with sickle cell disease has
been demonstrated.Error: Reference source not found Sepsis rates have
been shown to be clearly improved by prophylactic therapy in the U.S.
penicillin trial, but concerns about actual use of penicillin in large
populations and about penicillin-resistant organisms necessitate
continued monitoring of sepsis rates in large populations.

16-22. (Developmental) Increase the proportion of children with special
health care needs who have access to a medical home.

**Potential data source:** Title V Reporting System, HRSA, MCHB.

Historically, services for children with special health care needs have
been difficult for families to access and for providers to coordinate.
Families must navigate a variety of organizations and providers and
often face geographic and financial barriers to care. Primary care
providers in the community are not always comfortable providing care to
children with complex needs, nor do they have time to coordinate the
variety of resources families need. A lack of knowledge---of
comprehensive needs and corresponding community-based resources and of
payment mechanisms---presents a challenge for both families and
providers. Poor communication between families and providers and
cross-cultural misunderstandings are additional concerns for both
families and providers.

Care for children with special health care needs should be provided and
coordinated through a "medical home" that is accessible,
family-centered, continuous, comprehensive, coordinated, compassionate,
and culturally competent and linguistically appropriate. Physicians and
parents share responsibility for ensuring that children and their
families have access to all the medical and nonmedical services needed
to help them achieve their maximum potential. The attributes of such a
medical home are defined below:

-   Accessible care is care that is provided in the child's community,
    in which all insurance, including Medicaid, is accepted and changes
    in insurance status are accommodated.

-   Family-centered care recognizes that the family is the principal
    caregiver and the center of strength and support for children.
    Family-centered services share unbiased and complete information
    with families on an ongoing basis.

-   Continuous care assures that the same primary pediatric health care
    professionals are available from infancy through adolescence and
    provide assistance with transitions (to home, school, and adult
    services).

-   Comprehensive health care is available 24 hours a day, 7 days a
    week, and addresses preventive, primary, and tertiary needs.

-   Coordinated care links families to support, educational, and
    community-based services, and information is centralized.

-   Compassionate caregivers express concern for the well-being of the
    child and family.

-   Culturally appropriate and linguistically competent care recognizes,
    values, and respects the family's cultural background.[^107]**^,^**
    [^108]**^,^** [^109]**^,^** [^110]**^,^** [^111]

16-23. Increase the proportion of Territories and States that have
service systems for children with special health care needs.

**Target:** 100 percent.

**Baseline:** 15.7 percent of Territories and States met Title V for
service systems for children with special health care needs in FY 1997.

**Target setting method:** Total coverage.

**Data source:** Title V Block Grant Application Form 13, HRSA, MCHB.

Children with special health care needs and their families often require
a range of services.[^112] Health services, for example, include health
education and health promotion; preventive and primary care, including
routine screening for impairments of vision, hearing, speech, and
language, and assessment of physical and psychosocial milestones;
specialized diagnostic and therapeutic services; and habilitation and
rehabilitation services. Early intervention services are necessary as
well, as are educational, vocational, and mental health services and
support services for children and their families. Enabling services,
such as transportation and child care, are necessary to ensure access to
care. Transition services are needed to assist in the progression from
adolescent health care to adult services and from school to work.

Families continuously face the challenge of obtaining and coordinating
the primary and special services their children require. Differing
eligibility criteria, duplication and gaps in services, inflexible
funding sources, and poor coordination among service sectors are some of
the barriers consistently reported. Many of these issues can be resolved
only through the concerted effort of a system of services---the broad
array of public and private entities serving children and families in
the Nation's communities. These service systems should ensure access to
a source of insurance for primary and specialty care and enabling
services, an identified medical home, and care coordination. Families
and their care professionals should participate in the design and
implementation of these service systems.[^113] This collaborative
partnership will strengthen the ability of families to care for their
children with special needs and will enable children with complex
conditions to live at home with their families.

## Related Objectives From Other Focus Areas 

1\. Access to Quality Health Services

1-1. Persons with health insurance

1-2. Health insurance coverage for clinical preventive services

1-4. Source of ongoing care

1-5. Usual primary care provider

1-6. Difficulties or delays in obtaining needed health care

1-9. Hospitalization for ambulatory-care-sensitive conditions

1-12. Single toll-free number for poison control centers

1-13. Trauma care systems

1-14. Special needs of children

5\. Diabetes

5-8. Gestational diabetes

6\. Disability and Secondary Conditions

6-2. Feelings and depression among children with disabilities

6-7. Congregate care of children and adults with disabilities

6-9. Inclusion of children and youth with disabilities in regular
education\
programs

7\. Educational and Community-Based Programs

7-1. High school completion

7-2. School health education

7-4. School nurse-to-student ratio

8\. Environmental Health

8-11. Elevated blood lead levels in children

8-20. School policies to protect against environmental hazards

8-22. Lead-based paint testing

9\. Family Planning

9-2. Birth spacing

9-7. Adolescent pregnancy

9-8. Abstinence before age 15 years

9-9. Abstinence among adolescents aged 15 to 17 years

9-10. Pregnancy prevention and sexually transmitted disease (STD)
protection

9-11. Pregnancy prevention education

13\. HIV

13-17. Perinatally acquired HIV infection

14\. Immunization and Infectious Diseases

14-1. Vaccine-preventable diseases

14-2. Hepatitis B in infants and young children

14-18. Antibiotics prescribed for ear infections

14-19. Antibiotics prescribed for common cold

14-22. Universally recommended vaccination of children aged 19 through
35 months of age

14-23. Vaccination coverage for children in day care, kindergarten, and
first grade

14-24. Fully immunized young children and adolescents

14-25. Providers who measure childhood vaccination coverage levels

14-26. Children participating in population-based immunization
registries

14-27. Vaccination coverage among adolescents

14-30. Adverse events from vaccinations

14-31. Active surveillance for vaccine safety

15\. Injury and Violence Prevention

15-1. Nonfatal head injuries

15-2. Nonfatal spinal cord injuries

15-3. Firearm-related deaths

15-4. Proper firearm storage in homes

15-5. Nonfatal firearm-related injuries

15-7. Nonfatal poisonings

15-8. Deaths from poisoning

15-9. Deaths from suffocation

15-10. Emergency department surveillance systems

15-11. Hospital discharge surveillance systems

15-12. Emergency department visits

15-19. Safety belts

15-20. Child restraints

15-23. Bicycle helmet use

15-24. Bicycle helmet laws

15-31. Injury protection in school sports

15-33. Maltreatment and maltreatment fatalities of children

15-38. Physical fighting among adolescents

15-39. Weapon carrying by adolescents on school property

18\. Mental Health and Mental Disorders

18-2. Adolescent suicide attempts

18-5. Eating disorder relapses

18-7. Treatment for children with mental health problems

18-8. Juvenile justice facility screening

19\. Nutrition and Overweight

19-3. Overweight or obesity in children and adolescents

19-4. Growth retardation in children

19-12. Iron deficiency in young children and in females of childbearing
age

19-13. Anemia in low-income pregnant females

19-14. Iron deficiency in pregnant females

19-15. Meals and snacks at school

21\. Oral Health

21-1. Dental caries experience

21-2. Untreated dental decay

21-8. Dental sealants

21-9. Community water fluoridation

21-10. Use of oral health care system

21-13. School-based health centers with oral health component

21-14. Health centers with oral health service components

21-15. Referral for cleft lip or palate

21-16. Oral and craniofacial State-based surveillance system

22\. Physical Activity and Fitness

22-6. Moderate physical activity in adolescents

22-7. Vigorous physical activity in adolescents

22-8. Physical education requirement in schools

22-9. Daily physical education in schools

22-10. Physical activity in physical education class

22-11. Television viewing

22-12. School physical activity facilities

24\. Respiratory Diseases

24-1. Deaths from asthma

24-2. Hospitalizations for asthma

24-3. Hospital emergency department visits for asthma

24-5. School or work days lost

25\. Sexually Transmitted Diseases

25-9. Congenital syphilis

25-10. Neonatal STDs

25-11. Responsible adolescent sexual behavior

25-12. Responsible sexual behavior messages on television

25-14. Screening in youth detention facilities and jails

25-17. Screening of pregnant women

26\. Substance Abuse

26-6. Adolescents riding with a driver who has been drinking

26-9. Substance-free youth

26-10. Adolescent and adult use of illicit substances

26-14. Steroid use among adolescents

26-15. Inhalant use among adolescents

26-16. Peer disapproval of substance abuse

26-17. Perception of risk associated with substance abuse

27\. Tobacco Use

27-2. Adolescent tobacco use

27-3. Initiation of tobacco use

27-4. Age at first use of tobacco

27-6. Smoking cessation during pregnancy

27-7. Smoking cessation by adolescents

27-11. Smoke-free and tobacco-free schools

27-14. Enforcement of illegal tobacco sales to minors laws

27-15. Retail license suspension for sales to minors

27-17. Adolescent disapproval of smoking

28\. Vision and Hearing

28-2. Vision screening for children

28-4. Impairment in children and adolescents

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Anencephalus:** Congenital absence of all or a major part of the
brain.

**Birth defect:** An abnormality in structure, function, or body
metabolism that is present at birth, such as cleft lip or palate,
phenylketonuria, or sickle cell disease.

**Breastfeeding:** Exclusive use of human milk or use of human milk with
a supplemental bottle of formula. "Exclusive breastfeeding" refers to
the use of only human milk, supplemented by solid food when appropriate
but not supplemented by formula.

**Children with special health care needs:** Children who have or are at
risk for a chronic physical, developmental, behavioral, or emotional
condition and who also require health care and related services of a
type or amount beyond that required by children generally.

**Congenital anomaly:** See birth defect.

**Developmental disabilities:** A broad spectrum of impairments
characterized by developmental delay or limitation or both in personal
activity, such as mental retardation, cerebral palsy, epilepsy, hearing
and other communication disorders, and vision impairment. The more
severe developmental disabilities require special interdisciplinary
care.

**Eclampsia/Preeclampsia:** A condition that occurs in the second half
of pregnancy, characterized by hypertension, edema, and proteinuria.
When convulsions and coma are associated, it is called eclampsia.

**Ectopic pregnancy:** A gestation elsewhere than in the uterus, often
occurring in the fallopian tube. An ectopic pregnancy cannot develop
normally and causes fainting, abdominal pain, and vaginal bleeding.

**Fetal alcohol syndrome (FAS):** A cluster of structural and functional
abnormalities found in infants and children as a result of alcohol
consumption by the mother during pregnancy and characterized by growth
retardation, facial malformations, and central nervous system
dysfunction.

**Fetal death:** The death of a fetus in utero after 20 weeks or more of
gestation. The fetal death rate is the number of fetal deaths in a
population divided by the total number of live births and fetal deaths
in the same population during the same time period.

**Genetic disorders:** The group of health conditions that result
primarily from alterations in a gene or combination of genes.

**Gestational trophoblastic disease:** A type of cancer associated with
pregnancy in which a grape-like mole develops in the womb.

**Hydrocephalus:** A condition marked by dilation of the cerebral
ventricles accompanied by cerebrospinal fluid within the skull.

**Hypotonia:** A condition of diminished tone of the skeletal muscles,
with diminished resistance of muscles to passive stretching.

**Infant death:** Death of an infant less than 1 year old. Neonatal
death is the death of an infant less than 28 days after birth;
postneonatal death is the death of an infant between 28 days and 1 year
after birth.

**Infant mortality rate:** The number of deaths of infants less than 1
year old (obtained from death certificates) per 1,000 live births in a
population (obtained from birth certificates).

**Intrapartum period:** Period extending from the onset of labor through
the completion of delivery.

**Intrauterine growth retardation (IUGR):** The failure of a fetus to
maintain its expected growth potential at any stage of gestation.
Infants with IUGR may be born at full term but are smaller than
expected.

**Level III hospital:** A facility for high-risk deliveries and neonates
that can provide care to very small infants, including mechanical
ventilation and neonatal surgery and special care for transferred
patients and for which a full-time neonatologist serves as the director.

**Live birth:** The complete expulsion or extraction from its mother of
an infant, irrespective of the duration of pregnancy, which after such
separation, breathes or shows any other evidence of life, such as the
beating of the heart, pulsation of the umbilical cord, or definite
movement of voluntary muscles, whether or not the umbilical cord has
been cut or the placenta is attached. Each infant from such a birth is
considered live born.

**Low birth weight (LBW):** Weight at birth of less than 2,500 grams
(about 5.5 pounds).

**Maternal death:** Death of a woman while pregnant or within 42 days of
the end of pregnancy, irrespective of the duration or site of the
pregnancy, from any cause related to or aggravated by the pregnancy or
its management but not from accidental or incidental causes.

**Maternal mortality rate:** (also referred to as the maternal mortality
ratio) Represents the number of maternal deaths for every 100,000 live
births.

**Medical home:** Medical care for infants and children that is
accessible, continuous, comprehensive, family-centered, coordinated, and
compassionate.

**Neonatal period:** The first 28 days of life.

**Neural tube defects (NTDs):** A set of birth defects that result from
failure of the neural tube to close in utero. Two of the most common
NTDs are anencephaly (absence of the majority of the brain) and spina
bifida (incomplete development of the back and spine).

**Occurrence:** As the term is used in this chapter, occurrence is the
incidence of new cases among live births per year that are caused
primarily by prenatal factors. In the spina bifida and other neural tube
defects objective, identification is in the first year of life, and
occurrence is reported as the number of cases per 10,000 live births per
year. In the fetal alcohol syndrome objective, some children who have
the condition at birth are not identified until age 4 or 5 years;
occurrence is reported as a number per 10,000 live births. In the
developmental disabilities objective, children with specified conditions
such as mental retardation are not always identified until about age 7
or 8 years even though the conditions are usually caused by prenatal
events; occurrence in these objectives is reported as a number per
10,000 children aged 8 years.

**Perinatal death:** Includes fetal deaths after 28 weeks of gestation
and infant deaths within the first 7 days of birth.

**Postneonatal period:** The period from an infant's 29th day of life
until the first birthday.

**Postpartum period:** The 6-week period immediately following birth.

**Preeclampsia:** (see eclampsia).

**Prenatal care:** Pregnancy-related health care services provided to a
woman between conception and delivery. The American College of
Obstetricians and Gynecologists recommends at least 13 prenatal visits
in a normal 9-month pregnancy: one each month for the first 28 weeks of
pregnancy, one every 2 weeks until 36 weeks, and then weekly until
birth.

**Preterm birth:** Birth occurring before 37 weeks of pregnancy.

**Renal agenesis:** Associated with duplicated vagina and uterus.

**Sudden infant death syndrome (SIDS):** Sudden, unexplained death of an
infant from an unknown cause.

**Surfactant:** A surface-active agent that prevents the lungs from
filling with water by capillary action.

**Synthetic surfactant:** An artificial substance that prevents a
newborn's lungs from filling with water.

**Teratogenic:** Causing malformations of an embryo or fetus.

**Very low birth weight (VLBW):** Weight at birth of less than 1,500
grams (about 3.3 pounds).

## References

[^1]: National Center for Health Statistics (NCHS). *Health, United
    States, 1999.* Hyattsville, MD: U.S. Department of Health and Human
    Services, 1999.

[^2]: Ventura, S.J.; Anderson, R.N.; Martin, J.A.; et al. Births and
    deaths: Preliminary data for 1997. *National Vital Statistics
    Report* 47(4):1-42, 1999.

[^3]: Hoyert, D.L. Medical and life-style risk factors affecting fetal
    mortality, 1989--90. *Vital and Health Statistics 20 Data National
    Vital Statistics System* 31:1-32, 1996.

[^4]: Ventura, S.J.; Martin, J.A.; Curtin, S.C.; et al. Births: Final
    data for 1997. *National Vital Statistics Report* 48(3), 2000.

[^5]: Lewit, E.M.; Baker, L.S.; Hope, C.; et al. The direct cost of low
    birth weight. *Future Child* 5(1):35-56, 1995.

[^6]: Camas, O.R.; Cheung, L.W.Y.; and Lieberman, E. The role of
    lifestyle in preventing low birth weight. *Future Child*
    5(1):121-138, 1995.

[^7]: Stratton, K.; Howe, C.; Battaglia, F.; eds. *Fetal Alcohol
    Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment.*
    Washington, DC: National Academy Press, 1996.

[^8]: Chasnoff, I.J.; Burns, W.J.; Schnoll, S.H.; et al. Cocaine use in
    pregnancy. *New England Journal of Medicine* 313:666-669, 1985.

[^9]: Centers for Disease Control and Prevention (CDC). Medical-care
    expenditures attributable to cigarette smoking during
    pregnancy---United States, 1995. *Morbidity and Mortality Weekly
    Report* 46(44):1048-1050, 1997.

[^10]: American Academy of Pediatrics (AAP), Work Group on
    Breastfeeding. Breastfeeding and the use of human milk. *Pediatrics*
    100(6):1035-1039, 1997.

[^11]: AAP, Committee on Pediatric AIDS. Human milk, breastfeeding, and
    transmission of human immunodeficiency virus in the United States.
    *Pediatrics* 96:977‑979, 1995.

[^12]: Ross Products Division, Abbott Laboratories, Inc. Mothers'
    Survey, Columbus, OH: the Company, 1999.

[^13]: Hogan, D.P.; Msall, M.E.; Rogers, M.L.; et al. Improved
    disability population estimates of functional limitation among
    children aged 5-17. *Maternal and Child Health Journal*
    1(4):203-216, 1997.

[^14]: LaPlante, M.P., and Carlson, D. Disability in the United States:
    Prevalence and causes, 1992. *Disability Statistics Report*.
    Washington, DC: U.S. Department of Education, 1996.

[^15]: Czeik, A.E., and Dudas, J. Prevention of the first occurrence of
    neural tube defects by periconceptional vitamin supplementation.
    *New England Journal of Medicine* 327:1832-1835, 1992.

[^16]: Hoyert, D.L.; Kockanck, K.D.; and Murph, S.L. Deaths: Final data
    for 1997. *National Vital Statistics Report* 47(19), 1999.

[^17]: CDC. Ectopic pregnancy in the United States, 1990--92. *Morbidity
    and Mortality Weekly Report* 44(3):46-48, 1995.

[^18]: NCHS. *Healthy People 2000 Review, 1997*. Hyattsville, MD: Public
    Health Service, 1997, 131-132.

[^19]: CDC. Differences in maternal mortality among black and white
    women, United States. *Morbidity and Mortality Weekly Report*
    44(2):6-7, 13-14, 1995.

[^20]: AAP, Committee on Substance Abuse. Drug-exposed infants.
    *Pediatrics* 96(2):364-367, 1995.

[^21]: Chasnoff, I.J.; Griffith, D.R.; MacGregor, S.; et al. Temporal
    patterns of cocaine use in pregnancy: Perinatal outcome. *Journal of
    the American Medical Association* 261:1741-1744, 1989.

[^22]: Bigol, N.; Fuchs, M.; Diaz, V.; et al. Teratogenicity of cocaine
    in humans. *Journal of Pediatrics* 110:93-96, 1987.

[^23]: Rayburn, W.F.; Stanley, J.R.; and Garrett, M.E. Periconceptional
    folate intake and neural tube defects. *Journal of the American
    College of Nutrition* 15(2):121-125, 1996.

[^24]: CDC. Use of folic acid for prevention of spina bifida and other
    neural tube defects: 1983--1991. *Morbidity and Mortality Weekly
    Report* 40:513-516, 1991.

[^25]: Howie, P.W.; Forsyth, J.S.; Ogston, S.A.; et al. Protective
    effect of breast feeding against infection. *British Medical
    Journal* 300:11‑16, 1990.

[^26]: Kovar, M.G.; Serdula, M.K.; Marks, J.S.; et al. Review of the
    epidemiologic evidence for an association between infant feeding and
    infant health. *Pediatrics* 74:S615‑S638, 1984.

[^27]: Popkin, B.M.; Adair, L.; Akin, J.S.; et al. Breast‑feeding and
    diarrheal morbidity. *Pediatrics* 86:874‑882, 1990.

[^28]: Beaudry, M.; Dufour, R.; and Marcoux, S. Relation between infant
    feeding and infections during the first 6 months of life. *Journal
    of Pediatrics* 126:191‑197, 1995.

[^29]: Frank, A.L.; Taber, L.H.; Glezen, W.P.; et al. Breast‑feeding and
    respiratory virus infection. *Pediatrics* 70:239‑245, 1982.

[^30]: Wright, A.L.; Holberg, C.J.; Taussig L.M.; et al. Relationship of
    infant feeding to recurrent wheezing at age 6 years. *Archives of
    Pediatric and Adolescent Medicine* 149:758‑763, 1995.

[^31]: Saarinen, U.M. Prolonged breast feeding as prophylaxis for
    recurrent otitis media. *Acta Paediatric Scandinavica* 71:567‑571,
    1982.

[^32]: Duncan, B.; Ey, J.; Holberg, C.J.; et al. Exclusive
    breast‑feeding for at least 4 months protects against otitis media.
    *Pediatrics* 91:867‑872, 1993.

[^33]: Montgomery, D., and Splett, P. Economic benefit of breast‑feeding
    infants enrolled in WIC. *Journal of the American Dietetic
    Association* 97:379‑385, 1997.

[^34]: Tuttle, C.R., and Dewey, K.G. Potential cost savings for
    Medi‑Cal, AFDC, food stamps, and WIC programs associated with
    increasing breast‑feeding among low‑income Hmong women in
    California. *Journal of the American Dietetic Association*
    6:885‑890, 1996.

[^35]: Chua, S.; Arulkumaran, S.; Lim, I.; et al. Influence of
    breastfeeding and nipple stimulation on postpartum uterine activity.
    *British Journal of Obstetrics and Gynecology* 101:804‑805, 1994.

[^36]: Dewey, K.G.; Heinig, M.J.; and Nommsen, L.A. Maternal weight‑loss
    patterns during prolonged lactation. *American Journal of Clinical
    Nutrition* 58:162‑166, 1993.

[^37]: Newcomb, P.A.; Storer, B.E.; Longnecker, M.P.; et al. Lactation
    and a reduced risk of premenopausal breast cancer. *New England
    Journal of Medicine* 330:81‑87, 1994.

[^38]: Melton, L.J.; Bryant, S.C.; Wahner, H.W.; et al. Influence of
    breastfeeding and other reproductive factors on bone mass later in
    life. *Osteoporosis International* 3:76‑83, 1993.

[^39]: Willinger, M.; Hoffman, H.J.; and Hartford, R.B. Infant sleep
    position and risk for sudden infant death syndrome: Report of
    meeting held January 13 and 14, 1994, National Institutes of Health,
    Bethesda, MD. *Pediatrics* 93(5):814-819, 1994.

[^40]: Palta, M.; Weinstein, M.R.; McGuinness, G.; et al. A population
    study. Mortality and morbidity after availability of surfactant
    therapy. Newborn Lung Project. *Archives of Pediatric and Adolescent
    Medicine* 148(12):1295-1301, 1994.

[^41]: Schoendorf, K.C., and Kiely, J.L. Birth weight and age-specific
    analysis of the 1990 U.S. infant mortality drop. Was it surfactant?
    *Archives of Pediatric and Adolescent Medicine* 151(2):129-134,
    1997.

[^42]: NCHS, CDC. National Vital Statistics System, unpublished data,
    1999.

[^43]: Berg, C.; Atrash, H.; Koonin, L.; et al. Pregnancy-related
    mortality in the United States, 1987--1990. *Obstetrics and
    Gynecology* 88:161-167, 1996.

[^44]: CDC. Maternal mortality---United States, 1982--1996. *Morbidity
    and Mortality Weekly Report* 47(34):705-707, 1998.

[^45]: Bennet, T.A.; Kotelchuck, M.; Cox, C.E.; et al.
    Pregnancy-associated hospitalizations in the United States in 1991
    and 1992: A comprehensive view of maternal morbidity. *American
    Journal of Obstetrics and Gynecology* 178:346-356, 1998.

[^46]: Grad, R., and Hill, I.T. Financing maternal and child health care
    in the United States. In: Kotch, J.B.; Blakely, C.; Brown, S.; et
    al.; eds. *A Pound of Prevention: The Case for Universal Maternity
    Care in the U.S.* Washington, DC: American Public Health
    Association, 1992.

[^47]: American College of Obstetricians and Gynecologists (ACOG).
    *Manual of Standards in Obstetric-Gynecologic Practice.* 2nd ed.
    Chicago, IL: ACOG, 1965.

[^48]: Kotelchuck, M. An evaluation of the Kessner Adequacy of Prenatal
    Care Index and a proposed Adequacy of Prenatal Care Utilization
    Index. *American Journal of Public Health* 84:1414-1420, 1994.

[^49]: Expert Panel on the Content of Prenatal Care. *Caring for Our
    Future: The Content of Prenatal Care.* Washington, DC: Public Health
    Service, 1989.

[^50]: Charles, A.G.; Norr, K.L.; Block, C.R.; et al. Obstetric and
    psychological effects of psychoprophylactic preparation for
    childbirth. *American Journal of Obstetrics and Gynecology*
    131(1):44-52, 1978.

[^51]: Genest, M. Preparation for childbirth, evidence for efficacy. A
    review. *Journal of Obstetric, Gynecologic, and Neonatal Nursing*
    10(2):82-85, 1981.

[^52]: Powell, S.L.; Holt, V.L.; Hickok, D.E.; et al. Recent changes in
    delivery site of low-birth-weight infants in Washington: Impact on
    birth weight-specific mortality. *American Journal of Obstetrics and
    Gynecology* 173(5):1585-1592, 1995.

[^53]: Kirby, R.S. Perinatal mortality: The role of hospital of birth.
    *Journal of Perinatology* 16(1):43-49, 1996.

[^54]: Paneth, N.; Kiely, J.L.; Wallenstein, S.; et al. The choice of
    place of delivery: Effect of hospital level on mortality in all
    singleton births in New York City. *American Journal of Disabilities
    in Children* 141(1):60-64, 1987.

[^55]: McCormick, M.C., and Richardson, D.K. Access to neonatal
    intensive care. *Future Child* 5(1):162-175, 1995.

[^56]: Curtin, S.C. Rates of cesarean birth and vaginal birth after
    previous cesarean, 1991--95. *Monthly Vital Statistics Report*
    45(Suppl. 3)(11):1-12, 1997.

[^57]: Main, E.K. Reducing cesarean birth rates with data-driven quality
    improvement activities. *Pediatrics* 103:374-383, 1999.

[^58]: ACOG, Task Force on Cesarean Delivery. *Considerations in
    Evaluating the Incidence of Cesarean Delivery.* Washington DC: ACOG,
    in press

[^59]: Philip, A.G. Neonatal mortality rate: Is further improvement
    possible? *Journal of Pediatrics* 126(3):427-433, 1995.

[^60]: Hack, M.; Klein, N.K.; and Taylor, H.G. Long-term developmental
    outcomes of low birth weight infants. *Future Child* 5(1):176-196,
    1995.

[^61]: Schendel, D.E.; Stockbauer, J.W.; Hoffman, H.J.; et al. Relation
    between very low birth weight and developmental delay among
    preschool children without disabilities. *American Journal of
    Epidemiology* 146(9):740-749, 1997.

[^62]: Kramer, W.B.; Saade, G.R.; Goodrum, L.; et al. Neonatal outcome
    after active perinatal management of the very premature infant
    between 23 and 27 weeks gestation. *Journal of Perinatology*
    17(6):439-443, 1997.

[^63]: Lefebvre, F.; Glorieux, J.; and St-Laurent-Gagnon, T. Neonatal
    survival and disability rate at age 18 months for infants born
    between 23 and 28 weeks of gestation. *American Journal of
    Obstetrics and Gynecology* 174(3):833-838, 1996.

[^64]: Adams, M.M.; Sarno, A.P.; Harlass, F.E.; et al. Risk factors for
    preterm delivery in a healthy cohort. *Epidemiology* 6(5):525-532,
    1995.

[^65]: Harlow, B.L.; Frigoletto, F.D.; Cramer, D.W.; et al. Determinants
    of preterm delivery in low-risk pregnancies. The RADIUS Study Group.
    *Journal of Clinical Epidemiology* 49(4):441-448, 1996.

[^66]: Virji, S.K., and Cottington, E. Risk factors associated with
    preterm deliveries among racial groups in a national sample of
    married mothers. *American Journal of Perinatology* 8(5):347-353,
    1991.

[^67]: Lundsberg, L.S.; Bracken, M.B.; and Saftlas, A.F. Low-to-moderate
    gestational alcohol use and intrauterine growth retardation, low
    birthweight, and preterm delivery. *Annals of Epidemiology*
    7(7):498-508, 1997.

[^68]: Goldenberg, R.L. Prenatal care and pregnancy outcome. In: Kotch,
    J.B.; Blakely, C.H.; Brown, S.B.; et al.; eds. *A Pound of
    Prevention: The Case for Universal Maternity Care in the U.S.*
    Washington, DC: American Public Health Association, 1992.

[^69]: Carmichael, S.; Abrams, B.; and Selvin, S. The association of
    pattern of maternal weight gain with length of gestation and risk of
    spontaneous preterm delivery. *Paediatric Perinatology and
    Epidemiology* 11(4):392-406, 1997.

[^70]: Goldenberg, R.L.; Andrews, W.W.; Yuan, A.C.; et al. Sexually
    transmitted diseases and adverse outcomes of pregnancy. *Clinics in
    Perinatology* 24(1):23-41, 1997.

[^71]: Hillier, S.; Nugent, R.; Eschenbach, D.; et al. Association
    between bacterial vaginosis and preterm delivery of low-birth-weight
    infant. *New England Journal of Medicine* 333:1737-1742, 1995.

[^72]: Meis, P.H.; Goldenberg, R.L.; Mercer, G.; et al. The preterm
    prediction study: Significance of vaginal infections. *American
    Journal of Obstetrics and Gynecology* 173(4):1231-1235, 1995.

[^73]: Berenson, A.B.; Wieman, C.M.; Wilkinson, G.S.; et al. Perinatal
    morbidity associated with violence experienced by pregnant women.
    *American Journal of Obstetrics and Gynecology* 170(6):1760-1766,
    1994.

[^74]: Dewey, K.G.; Heinig, M.J.; and Nommsen‑Rivers, L.A. Differences
    in morbidity between breast‑fed and formula‑fed infants.
    *Pediatrics* 126:696‑702, 1995.

[^75]: Copper, R.L.; Goldenberg, R.L.; Das, A.; et al. The preterm
    prediction study: Maternal stress is associated with spontaneous
    preterm birth at less than 35 weeks gestation. National Institute of
    Child Health and Human Development Maternal--Fetal Medicine Units
    Network. *American Journal of Obstetrics and Gynecology*
    175(5):1286-1292, 1996.

[^76]: Rawlings, J.S.; Rawlings, V.B.; and Read, J.A. Prevalence of low
    birth weight and preterm delivery in relation to the interval
    between pregnancies among white and black women. *New England
    Journal of Medicine* 332(2):69-74, 1995.

[^77]: Orr, S.T.; James, S.A.; Miller, C.A.; et al. Psychosocial
    stressors and low birthweight in an urban population. *American
    Journal of Preventive Medicine* 12(6):459-466, 1996.

[^78]: Institute of Medicine (IOM), National Academy of Sciences,
    Subcommittee on Nutritional Status and Weight Gain During Pregnancy.
    *Nutrition During Pregnancy*. Washington, DC: National Academy
    Press, 1990.

[^79]: Hickey, C.A.; Cliver, S.P.; McNeal, S.F.; et al. Prenatal weight
    gain patterns and birth weight among nonobese black and white women.
    *Obstetrics and Gynecolology* 88(4, Part 1):490-496, 1996.

[^80]: Siega-Riz, A.M.; Adair, L.S.; and Hobel, C.J. Institute of
    Medicine maternal weight gain recommendations and pregnancy outcome
    in a predominantly Hispanic population. *Obstetrics and Gynecology*
    84(4):565-573, 1994.

[^81]: Willinger, M.; Hoffman, H.J.; Wu, K.T.; et al. Factors associated
    with the transition to non-prone sleep positions of infants in the
    United States. The National Infant Sleep Position Study. *Journal of
    the American Medical Association* 280:329-335, 1998.

[^82]: Oyen, N.; Markestad, T.; Skjærven, R.; et al. Combined effects of
    sleeping position and prenatal risk factors in sudden infant death
    syndrome: The Nordic Epidemiological SIDS Study. *Pediatrics*
    100(4):613-621, 1997.

[^83]: Martin, R.J.; DiFiore, J.M.; Korenke, C.B.; et al. Vulnerability
    of respiratory control in healthy preterm infants placed supine.
    *Journal of Pediatrics* 127(4):609-614, 1995.

[^84]: AAP, AAP Task Force on Infant Sleep Position and SIDS. *Changing
    Concepts of Sudden Infant Death Syndrome: Implications for Infant
    Sleeping Environment and Sleep Position*. Elk Grove Village, IL:
    AAP, 2000.

[^85]: IOM, Standing Committee on Scientific Evaluation of Dietary
    Reference Intakes. *Dietary Reference Intakes for Thiamine,
    Riboflavin, Niacin, Vitamin B-6, Folate, Vitamin B-12, Pantothenic
    Acid, Biotin, and Choline*. Washington, DC: National Academy Press,
    1998.

[^86]: Zuckerman, B. Marijuana and cigarette smoking during pregnancy:
    Neonatal effects. In: Chasnoff, I., ed. *Drugs, Alcohol, Pregnancy,
    and Parenting.* Boston, MA: Kluwer Academic Publishers, 1988.

[^87]: Jones, K.L. Fetal alcohol syndrome. *Pediatric Review* 8:122-126,
    1986.

[^88]: Lundsberg, L.S.; Bracken, M.B.; and Saftlas, A.F. Low-to-moderate
    gestational alcohol use and intrauterine growth retardation, low
    birth weight, and preterm delivery. *Annals of Epidemiology*
    7(7):498-508, 1997.

[^89]: Substance Abuse and Mental Health Services Administration.
    National Household Survey on Drug Abuse, Main Findings, 1997. April
    1999, 8.

[^90]: Streissguth, A.P. The behavioral teratology of alcohol:
    Performance, behavioral, and intellectual deficits in prenatally
    exposed children. In: West, J.R., ed. *Alcohol and Brain
    Development.* New York, NY: Oxford University Press, 1986, 3-44.

[^91]: Weiner, L., and Morse, B.A. FAS: Clinical perspectives and
    prevention. In: Chasnoff, I.J., ed. *Drugs, Alcohol, Pregnancy, and
    Parenting.* Boston, MA: Kluwer Academic Publishers, 1988, 127-148.

[^92]: CDC. Update: Trends in fetal alcohol syndrome---United States,
    1979--1993. *Morbidity and Mortality Weekly Report* 44(13):245-251.

[^93]: Abel, E. L. Update on incidence of fetal alcohol syndrome.
    *Neurotoxicology and Teratology* (17)4:437-443, 1995.

[^94]: Sampson, P.D.; Streissguth, A.P.; Bookstein, F.L.; et al.
    Incidence of fetal alcohol syndrome and prevalence of
    alcohol-related neurodevelopmental disorders. *Teratology*
    56(5):317-326, 1997.

[^95]: AAP, Committee on Substance Abuse, and Committee on Children with
    Disabilities. Fetal alcohol syndrome and fetal alcohol effects.
    *Pediatrics* 1993; 91(5):1004-1006.

[^96]: ACOG. *Technical Bulletin No. 195: Substance Abuse in Pregnancy*.
    Washington, DC: ACOG, 1994.

[^97]: AAP, Committee on Drugs. The transfer of drugs and other
    chemicals into human milk. *Pediatrics* 93:137‑150, 1994.

[^98]: Council of Regional Networks for Genetic Services (CORN). Newborn
    Screening Committee, *National Newborn Screening Report---1993.*
    Atlanta, GA: CORN, 1998.

[^99]: CORN, Newborn Screening Committee. *National Newborn Screening
    Report---1993.* Atlanta, GA: CORN, 1998.

[^100]: AAP, Committee on Genetics. 1989 newborn screening fact sheets.
    *Pediatrics* 83(3):449-464, 1989.

[^101]: AAP, Committee on Genetics. Issues in newborn screening.
    *Pediatrics* 89(2):345-349, 1992.

[^102]: AAP, Section on Endocrinology, and Committee on Genetics and
    American Thyroid Committee on Public Health. Newborn screening for
    congenital hypothyroidism: Recommended guidelines. *Pediatrics*
    91(6):1203-1209, 1993.

[^103]: CORN, Newborn Screening Committee. *Guidelines for the Newborn
    Screening System: Follow-Up of Children, Diagnosis, Management, and
    Evaluation*. Atlanta, GA: CORN, 1999.

[^104]: Gaston, M.H.; Verter, J.I.; Woods, G.; et al. Prophylaxis with
    oral penicillin in children with sickle cell anemia: A randomized
    trial. *New England Journal of Medicine* 314:1593-1599, 1986.

[^105]: Davis, H.; Schoendorf, K.C.; Gergen, P.J.; et al. National
    trends in the mortality of children with sickle cell disease, 1968
    through 1992. *American Journal of Public Health* 87:1317-1322,
    1997.

[^106]: CDC. Mortality among children with sickle cell disease
    identified by newborn screening during 1990--1994---California,
    Illinois, and New York. *Morbidity and Mortality Weekly Report*
    47:169-172, 1998.

[^107]: AAP, Ad Hoc Task Force on Definition of the Medical Home. The
    medical home. *Pediatrics* 90(5):774, 1992.

[^108]: Sia, C.J., and Peter, M.I. The medical home comes of age.
    *Hawaii Medical Journal* 47(9):409-410, 1988.

[^109]: AAP, Committee on Child Health Financing. *Managed Care and
    Children With Special Health Care Needs: Creating a Medical* *Home*.
    Elk Grove Village, IL: AAP, 1998.

[^110]: AAP. *The Medical* *Home and Early Intervention: Linking
    Services for Children With Special Needs*. Elk Grove Village, IL:
    AAP, 1999.

[^111]: Brewer, Jr., E.J.; Stewart, J.; McPherson, M.; et al.
    Family-centered, community-based, coordinated care for children with
    special health care needs. *Pediatrics* 83(6):1055-1060, 1989.

[^112]: McPherson, M.; Arango, P.; Fox, H.; et al. A new definition of
    children with special health care needs. *Pediatrics*
    102(1):137-139, 1998.

[^113]: AAP, Committee on Children with Disabilities. Managed care and
    children with special health care needs: A subject review.
    *Pediatrics* 102(3):657-660, 1998.