Introduction

Since the turn of the century, the United States has made great advances
in improving infant health, as indicated by the infant mortality rate. From
an infant mortality rate of more than 100 deaths per 1,000 live births in the
early 19OOs, infant mortality declined steadily until the 1950s. After almost
ten years of relatively little change from the mid-1950s to the mid-1960s, the
marked decline in infant mortality resumed, to a rate of 13.0 deaths per
1,000 live births in 1979.

While recognizing this significant achievement, Surgeon General Julius
B. Richmond has said: "If we are to accelerate or even continue the prog-
ress we have made in improving maternal and infant health in this Nation,
we must have a firm knowledge base drawn from science and sound profes-
sional practice, assess our commitment of current health resources and serv-
ices directed at improving pregnancy outcome, and develop the social
strategies needed to target our efforts, especially toward those who remain
unserved and underserved."

To contribute to the achievement of these goals, as well as furthering the
over-all disease prevention and health promotion objectives set by the
Department of Health and Human Services for the 199Os, Dr. Richmond
convened the first Surgeon General's Workshop on Maternal and Infant
Health, December 14-17, 1980, in Reston, Va. The Workshop brought
together 72 health and social services professionals, economic experts, con-
sumer representatives and State, Federal and local government officials for
intensive discussions of the subject.

The principal objective of the Workshop was to survey and analyze the
state-of-the-art and to develop policy recommendations for a national
social strategy that would help assure the continuation of past progress in
reducing infant mortality and morbidity and improving pregnancy outcome
in the United States, with particular attention to populations at greatest
risk. The Workshop participants reviewed national objectives for maternal
and infant health, explored the development of alternative indices for
maternal and infant health status and addressed the unresolved problems
that raise barriers to further reduction of infant mortality and morbidity.

The Workshop was asked to build on the work of the Child Health In-
itiative of the Secretary of Health and Human Services, the Surgeon Gen-
eral's Reports on Health Promotion and Disease Prevention, Healthy Peo-
ple, and Promoting Health and Preventing Disease: Objectives for the Na-
tion, and the Report of the Select Panel for the Promotion of Child Health.

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The Workshop focused on three basic themes: improvement of service
delivery to the underserved; expansion of health promotion and prevention
services; and knowledge development. The participants were divided into
three discussion groups to consider Urban Issues, Rural Issues and Issues of
Knowledge Development and Application. Their assignments were two-
fold:
A. To review and assess the current status of:
   . The state-of-the-art of knowledge concerning health services and
   treatment interventions that affect maternal and infant health.
   . The present systems, approaches and services available to improve
   maternal and infant health.
  . The deficiencies in current services and knowledge related to im-
  proving maternal and infant health.
   . Allocation of resources for maternal and infant health.
B. To develop social strategies to:
   . Target, improve and expand services to maintain the improvement
  of maternal and infant health, especially for populations at risk of
   adverse outcomes.
   . Expand health promotion and prevention services for maternal and
   infant health.
  . Develop and apply knowledge needed to continue to improve
   maternal and infant health.
In considering these strategies, the participants were asked to include and
identify the roles and responsibilities of government, public and private
agencies and organizations, private health care providers, and the public at
large for the development of partnerships and coalitions in meeting iden-
tified needs.
After separately discussing the issues, the three participant groups com-
bined to consider the various findings and recommendations in a total con-
text and refine them for presentation to the Surgeon General.
Presenting the findings and recommendations of the Workshop to the
Surgeon General, Workshop Chairman Ezra C. Davidson, M.D., sum-
marized the deliberations that concentrated on social strategies that will be
needed to continue to reduce infant mortality in the United States and to
assure that no groups are left out of future progress as further reductions
are achieved.
One of the main messages growing out of the Workshop was that services
and public education should insure that care to pregnant women begin in
the first three months of pregnancy and continue through the early life of
the infant.


Recommendations and Findings

INTRODUCTION

In a democratic society, public support is essential to political decisions
favorable to any policy and program initiatives. In the area of maternal and
infant health, with its complex medical, social and economic implications,
several elements are necessary to the achievement of favorable decisions and
goals.

First, there must be an effort to maintain the problems of infant and
maternal health high on the national agenda.

Second, there is a need to form strong coalitions of leaders and interest
groups in the public and private sectors who support the cause of healthy
mothers and infants and are willing to work toward advancing that objec-
tive.

Third, an informed citizenry is a source of strength in working to achieve
national objectives.

These three principles require placing relevant information before leaders
in the administrative and legislative branches of government, members of
the involved professions, public interest groups and the public at large.
Available data and other information can be mobilized to attract the atten-
tion of many sectors of society and to mold a strong constituency for mater-
nal and child health and well-being. Themes to recognize in supporting the
cause of maternal and child health include:

. Problems in maternal and infant health are social problems, in addition
to being those of individuals and families, and, therefore, are legitimate and
significant domains for public policy.

. The effect of resources allocated to these problems, and the programs
these resources helped to mount, are among the very few in health and
human services that can be measured in solid and quantitative ways. Data
demonstrate spectacular relations between national investments and results
obtained. They also indicate a strong measure of efficiency and effec-
tiveness in the use of resources.
. Controlling a problem is different from liquidating it. Health problems
related to infants and mothers are controllable and great strides have been
made. However, the levels of control already attained can be reduced if
vigilance is lowered or resources and efforts are cut back.
. There remain wide variations in rates of mortality and morbidity among
different sectors of the population, some of the rates being unacceptably
high.

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. Support for policies and programs related to infant and maternal care is
rooted in basic human decency and certainly in prevailing American values.
It is important, however, to make the point that there are many economic
benefits that flow from the proposed policies and programs. Information
can be compiled about the reduction in rates of hospitalization and long-
term institutionalization, about reductions in the need for other costly serv-
ices, and the economic returns from adults whose health was spared from
serious problems through these programs. It would also be useful to gather
and disseminate information about the relationship between infant mor-
bidity and handicaps; subsequent abuse and neglect; and potential for
crime, delinquency and other deviance.
The goals of policies in this area, the nature and organization of proposed
programs, and information concerning infant and maternal health care
should constitute the subject of public debate in national, regional and local
forums encouraged by concerned agencies and interest groups.
The pluralism of American society is most likely to be reflected in
pluralistic solutions. And, it is through debate at the various levels that pro-
grams can be evolved to meet general standards of quality and effectiveness
while being tailored to unique local needs and environments.
It is with these concepts and principles in mind that the Workshop
presents the following recommendations and findings which are not com-
prehensive, but point out high priority areas:

Recommendation 1

There should be a national initiative to assure prenatal evaluation and
counseling in the first trimester of pregnancy for all pregnant women.
a. There should be a linkage of pregnancy diagnosis to opportunities to
receive this care.

b. There should be no fiscal, categorical or administrative barriers to
receipt of this prenatal evaluation.
c. The counseling should include information on the risks of smoking,
consumption of alcohol and other drugs, and environmental hazards.

Recommendation 2

The Surgeon General's Workshop endorses the standards of prenatal and
infant care, including psychosocial support and family planning services,
proposed by the Select Panel for the Promotion of Child Health (See Ap-
pendix B).

Recommendation 3

Maternal and Child Health (MCH) care should take place within a
regionalized system which focuses on primary providers and has service,
education and quality assurance or evaluation components. This system
should function under the direction of a regional council which works with
MCH resource centers and other providers. Each MCH area should have a
designated MCH center to serve as an educational, consultative and care
resource to the region.
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All MCH programs should have a strong mental health component which
includes capacities for:

a. Identification and recognition of the special cultural and other in-
dividual differences in family functioning and prenatal and early child
care patterns to guarantee appropriate service availability and effec-
tiveness.
b. Provide expert consultation including where appropriate, diagnosis
and preventive intervention planning to meet the needs of families where
for a variety of reasons traditional clinical services are not available or are
ineffective.
c. To make available appropriate expertise for integrated health, mental
health, and special education services during the time of rapid central
nervous system growth in the early years of life.

Rationale

There is evidence that regional perinatal programs are able significantly
to improve pregnancy outcome with a comprehensive system functioning at
all levels of health care delivery. The regional concept can be broadened to
include all MCH activity. The focus of most MCH activity should be where
primary care is given. Programs which function to centralize care at tertiary
centers do not maximize outcome.

In addition to service, the ideal system must have sophisticated educa-
tional activities to improve and maintain professional skills and research or
outcome evaluation to provide an objective basis for improvement and
change. Systems with an objective data base are necessary for the efficient
use of human and financial resources, and they allow targeting of specific
problems.

The lack of appropriate effective MCH services are often related to an in-
ability to understand and/or meet the special needs of at risk populations,
especially the underserved.

Implementation

The lead agency for the implementation of a regionalized system should
be the State health department. This agency, because of its responsibility to
the entire State, should identify the appropriate regional structure. Regions
must be logical and follow patient service patterns and not be bound by
political jurisdictional boundaries (States, counties and health service agen-
ties) .

The State health department should create a statewide MCH council and
regional councils when more than one region is designated. The councils
should have memberships of health professionals and representation from a
broad spectrum of organizations with an established interest in MCH and
consumers.

Regional MCH resource centers should be designated by the councils for
each region. These centers, often located at universities, would contract
with the State to provide personnel, skills and leadership to meet the goals

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and objectives established by the council. These centers must work in con-
cert with the entire region. Specific activities of the resource centers should
include: speciality and subspeciality medical services, including consultation
and patient transportation, education, data collection and evaluation.

Much of the basic framework and maintenance of the regionalization ef-
fort can be accomplished through improved utilization of existing
resources, such as Social Security Act Titles V, X, XIX, XX; WIC; and
State matching funds, State education funds and private sector support.

Recommendation 4

To improve maternal and infant health, adequate financial support
should be available to provide services, especially to the underserved and
adolescents. Public programs and private insurance should provide com-
prehensive coverage for all pregnant women and infants, through such con-
siderations as:

a. Revision of Title XIX State matching formula should be considered to
address criteria such as low-income population, available State tax base
funds, number of mothers and children in need, number of mothers and
children served by public programs and hospital reimbursement policies.
b. Studying of revision of the Title V formula should be undertaken with
consideration of links to need (e.g., number and rate of live births, infant
mortality, low birthweight rate, adolescent pregnancies, adjusted income,
level of education and performance criteria) as factors in the formula.
c. Increasing State legislature funding for perinatal services.
d. Finding ways to provide for the special needs of pregnant women and
their children who do not have U.S. residential status.
e. Taking immediate remedial,action before the above long-term changes
are effected, to meet the financial crisis currently existing in urban inpa-
tient and ambulatory care institutions for underserved populations.
f. Initiating policy changes that would permit service dollars to follow
patients across political jurisdiction boundaries.

Recommendation 5

Expand mechanisms to pay for prenatal care, delivery and ongoing child
health care for the uninsured.

Expansion of public financing programs.

Over seven million children and pregnant women are poor but ineligible
for coverage under the Medicaid program. Many live in urban and rural
areas but remain uncovered because they fail to meet restrictive eligibility
criteria. For example:
. Many low-income women and children live in two-parent families, yet
only 33 States cover children in intact families.
. A high proportion of pregnant women and children are poor but do not
meet very strict State income requirements.
. Most States fail to cover women for their first pregnancy.

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As a first step designed to address the most pressing coverage needs of the
uninsured poor, we recommend that Federal/State health financing pro-
grams be required to cover all poor children and pregnant women regardless
of family composition. This will assure that those most in need will not be
denied access to vital pregnancy-related or child health services because of
inability to pay for care.
Expansion of private insurance

Most Americans receive insurance coverage through the workplace. Yet a
high proportion of urban and rural residents are without such protection
because they tend to be employed in small firms, farming or self employed
where there are no insurance benefits. Those residents who do receive in-
surance protection through employers are far more likely to have only
minimal benefit coverage. We recommend that groups be formed to work
with State legislatures to assure that all States require all insurers to include
a minimal set of pregnancy-related and infant care benefits in all plans in-
cluding:
. prenatal care
o all labor, delivery and postpartum care
. all medical care needed by infants in the first year of life and all preven-
tive services up to age 5.
. making efforts to educate and mobilize interested parties (employers,
employees, unions, legislatures) to assure that employer health insurance
packages include comprehensive care for women and children.
These recommendations do not preclude other innovative approaches
(e.g. "completion") but the basic necessity of ensuring universal coverage
of services for mothers and infants cannot be compromised.
Recommendation 6

There must be support for extension of existing Federal, State and local
programs to provide ambulatory prenatal care to areas without adequate
resources.

Rationale

a. It is recognized that ambulatory prenatal services are woefully lacking
in rural America in general. This may be the result of the lack of
opportunity for a pregnant woman to enter the health care system
because of the absence of trained personnel to provide these services.
b. The patient may not be able to pay for the services that are needed for
optimal prenatal care. Many private providers are requiring payment in
advance of services to be rendered.

c. Without adequate quantity and quality of prenatal services, early
assessment or high risk identification may not be done in time to identify
the type of specific care that may be needed.
Implementation

a. Require the provisions of prenatal care in all NHSC programs (free-
standing and RHIs).

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b. Require that CHCs provide ambulatory care for prenatal patients.
Both a. and b. must be a system of referral for delivery and for return
follow-up care.
c. Make it mandatory that prenatal services are a priority where local
health departments receive Title V funds and that Title V agencies pro-
vide prenatal services if no other appropriate means are available.
d. Provide support for existing nurse midwifery and/or nurse practi-
tioner programs; and accredited PA and Child Health Associate Pro-
grams.
e. Encourage the development of prepaid insurance programs, i.e.
HMOs.

f. Concentration of efforts so that third party companies will be made to
cover certain ambulatory services, i.e. outpatient sterilization, laboratory
services, genetic counseling.
g. Create a regional perinatal council that may assist in recruitment and
continuing education of the providers in rural areas.
h. Support the development of transportation systems for women to
receive prenatal care as well as well-baby care for their infants.
i. Revise the definition of manpower for underserved areas to include
areas where there may be a physician, but the physicians will not provide
prenatal care and will not deliver babies.
j. Revise the GMENAC recommendations on the future need for train-
ing obstetricians and gynecologists in the light of the newly emerging in-
formation that many family practitioners in small rural areas are refusing
to provide prenatal care and to deliver babies.

Recommendation 7

To improve nutrition the following recommendations are made in accord
with those of the Select Panel:

. The Nation must be educated by all appropriate sectors of society-the
health system, schools, the media, private industry and government-about
health promoting and risk reducing diets.
. Employers and health care providers should take steps to encourage
breast feeding and support mothers who choose to breast feed and are able
to do so.

. Policies of both the public and private health care sectors should ensure
that nutrition services become an integral part of health services for mothers
and children.

Recommendation 8

The trend towards physicians in rural areas discontinuing the provision of
maternity services should be moderated and if possible reversed.

Rationale

a. This trend is generally detrimental to the desired outcomes for
mothers and infants.

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b. The Workgroup believes that all women should have accessibility to
maternity services appropriate to their individual risk status as near to
their homes as possible.
c. Maternity services delivered in community hospitals as appropriate
under (b) will be generally more personal, convenient and less expensive.

Implementation

The Office for Maternal and Child Health should call a joint conference
to include the American Academy of Family Physicians, American College
of Obstetricians and Gynecologists, American Academy of Pediatrics,
American Hospital Association, American Osteopathic Association,
American Medical Association and other appropriate private and public
agencies to examine this issue and make appropriate recommendations for
correcting this problem.

Recommendation 9

Federal Food Programs (WIC, Food Stamp, Food Commodity and
School Lunch) shall be introduced or extended to provide low income preg-
nant and postpartum women and infants with nutritious food and provide
cultural and ethnic food choices.

Rationale

Nutrition has not been adequately recognized as an integral part of ma-
ternal/infant health services. Good nutrition is essential to the development
and maintenance of optimum health. In addition, good nutrition reduces
the frequency of such problems as anemia, toxemia, low birth weight, and
nutritional deficiencies.

implementation

Federal: The USDA should change the regulations of the Federal food pro-
grams to allow alternative ethnic and cultural foods-especially for Indo-
chinese, Korean, Vietnamese and other minority groups whose needs have
not been previously addressed.

Slate: Each State should see to it that low income pregnant and postpartum
women and infants should receive food from one or more of the Federal
food programs.

. Pregnant women should be given priority
. Within three years low income women and infants in all geographic areas
of the State should have access to WIC services
. These services should be coordinated with maternal and child health pro-
grams.

Each State should see that the food programs offer education regarding
maternal and infant health and family food budgeting and preparation.
Local: School Lunch Programs should be introduced or expanded to pro-
vide a free lunch for students who are low income expectant mothers.

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Recommendation 10

The following data systems should be developed to improve management
of perinatal programs:
a. Birth-death record linkages.
b. Uniform patient data base.

Recommendation 11

The Surgeon General should promote a single standard definition of
maternal mortality, perinatal mortality and other measures of mortality rel-
evant to maternal and infant health and work with State registrars and
health officers to assure that standard measures are adopted in each State.

Recommendation 12

To improve maternal and infant health, the Secretary of HHS should
convene a task force to explore approaches to developing effective quality
assurance programs in public and private ambulatory care settings encom-
passing all members of the professional care team.
Recommendation 13

The Surgeon General should bring together the relevant parties, such as,
public health, nursing, medicine, nutrition and other health professionals,
to plan for the training of maternal and child health professionals. Service
models for maternal and child health should be created as a basis for train-
ing and delivery of services. Elements of this training that the Workshop
considers important include the following:
. Use of health teams.

. Utilization of mid-level practitioners.
. Emphasis on growth and development, psychosocial factors and nutri-
tion.

. Emphasis on training in public policy and public administration.
(The above are in accord with the recommendations of the Select Panel.)

Recommendation 14

An organized program of education in systems development and com-
munity resource development pertaining to regionalized maternal and child
health care should be provided for staff at State Health Department
Perinatal Centers and university perinatal staff.
Rationale

There is enthusiasm for this concept in some rural areas which lack per-
sons with expertise in developing such services. Providing training to ap-
propriate persons would facilitate planning and implementation of region-
alized perinatal services.
Implementation

Approach the Office for Maternal and Child Health, and private founda-
tions for initial funding of such services.

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Recommendation 15

We strongly recommend that in rural areas, maternal and infant services
be strengthened through utilization of indigenous workers (Resource
Parents).

Rationale

The traditional health care system has not been completely successful in
promoting and enrolling women into early prenatal care. In addition it has
been difficult to sustain mothers and infants in the system through the
perinatal cycle (21 months) for a variety of reasons.

Indigenous workers have been successfully used in numerous health pro-
grams to extend accessibility, acceptability and continuity of care.

Indigenous workers (Resource Parents) could:

. Identify pregnant women who are not in a system of care
. Facilitate entry into the health care system and other community agency
resources as needed

. Serve as interpreters for language and/or cultural values between patient
and care provider
. Provide support so that mothers and infants will continue in the health
care system for the prescribed course of care.

Qualifications

Resident of target area and respected member of target population, pref-
erably a parent, who has demonstrated leadership, and has interest and abil-
ity to convey concepts and skills to parents.

Functions and Training

Job description, initial training, continuing education and consultation
should be developed through the Area Resource Center jointly with the pri-
mary care and mental health providers and members of the local commu-
nity. The curriculum may be based on guidelines from already established
training programs, but should be designed to meet specific community
needs.

Identification and Recruitmeni

The primary care provider may request selected agencies to assist in the
identification and recruitment of Resource Parents, who may be volunteers
or may be funded through the following sources: CETA, Title XX,
Agricultural Extension, public agencies, project grants, local community
funding such as service clubs, voluntary health services or church groups.

Recommendation 16

The Workshop supports the continued implementation of the Public
Health Service genetic diseases program and encourages further regionaliza-
tion and extension of the program to uncovered areas. Infants with abnor-
malities identified through mandated neonatal screening programs should
be assured of follow-up and treatment.

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Recommendation 17

Adolescents represent a special population with problems of sexuality,
pregnancy and parenting. There should be special programs to meet the
needs of this population, to include health, education, social, nutritional
and other support services.

Recommendation 18

Each State should develop a plan to make prenatal and parenting edu-
cation available to all families during pregnancy and to those families with
preschool infants.

Rationale

Many families in urban and rural areas have no, or limited, access to
prenatal and parenting information.

Implementation

The Office for Maternal and Child Health should work with State health
departments to develop plans in cooperation with State and local prenatal
and parenting education groups, and health providers to utilize present pro-
grams when available and create new programs where not available.

Recommendation 19

The Workshop supports the organizational changes recommended by the
Select Panel to reduce fragmentation and improve administration of mater-
nal and child health programs on the Federal level and the State level, in-
cluding:

. Every State should review its options for consolidation of program effort
related to maternal and child health and attempt to place authority over all
relevant funding streams in an appropriate division in the State health unit.
. Creation of a Maternal and Child Health Advisory Council in each State.
. Establishment of a Maternal and Child Health Administration as an
agency of the Public Health Service, which would include, at a minimum,
the Title V MCH program, the Adolescent Pregnancy Program and Title X
Family Planning.
. Creation in legislation of a National Commission on Maternal and Child
Health.

Recommendation 20

The Workshop recognizes that there are a large number of people who
are currently denied access to adequate maternal and infant care which in-
terferes with improving pregnancy outcome and improving infant health.
The Surgeon General and the Secretary of HHS should take strong
measures to remove these barriers where they exist within programs pro-
viding maternal and child health training or services, such as:
. Racial, age and residential status discrimination.
. Insensitivity of providers.

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, Lack of respect for patients.

. Refusal to place services in areas where the clients are located.

. Lack of recognition of clients as equal partners in efforts to provide serv-
ices to the needy population.

Recommendation 21

Research should be continued to find more information concerning the.
initiation of labor.

Rationale

The knowledge already gained in this field holds great promise for attack-
ing the high rate of pre-term births since the large portion of neonatal
deaths comes the pre-term births.

Recommendation 22

A research program on pregnancy, birth and the infant should be sup-
ported to help increase the understanding of the problems of pregnancy,
embryonic and fetal development, the birth process, lactation, and neonatal
development.

Rationale

A research program in this area can and will contribute knowledge on
methods to assess and determine fetal distress and immaturity, as well as
knowledge concerning the transmission of genetic material and techniques
for intrauterine diagnosis.

Implementation

Additional research opportunities should be pursued to tind out:
a. What changes occur in uterine, placental, and fetal circulatory pat-
terns following maternal exercise, stress, alcohol consumption, or smok-
ing;
b. Effects on fetal development of chronic oxygen deprivation;
c. Fetal adaptation to less than optimal intrauterine environments;
d. Maternal and fetal roles in the onset of human labor;
e. Management techniques for high risk pregnancies; and
f. Neonatal disorders that compromise successful adaptation to ex-
trauterine life.

Recommendation 23

A research program to study the causes of Sudden Infant Death Syn-
drome and to identify the risk factors that predispose an infant to SIDS
should be carried forward.

Rationale

Efforts have already contributed toward understanding the relationship
between chronic hypoxia and SIDS as well as the realization that SIDS vic-
tims are not as healthy as once believed.

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Implementation
Two major groups of studies should be undertaken which include: an epi-
demiological study of SIDS risk factors and an expansion of basic studies
on the causes of SIDS.

Recommendation 24
A research program should be carried forward on congenital defects
which would support studies on inborn structural, functional, and bio-
chemical defects found in the fetus and the newborn.

Rationale
Research in the past led to the rubella virus vaccines as well as techniques
to detect congenital defects in utero.
Implementation
Studies should be carried forward to determine what genetic and cultural
factors may regulate or interfere with normal development; how maternal,
paternal and fetal exposure to potential teratogenic drugs and agents may
be causes of newborn congenital malformations; and how genetic environ-
mental factors interact to contribute to congenital defects.

Recommendation 25
A nutrition research program should be carried forward to gain more
knowledge on infant feeding patterns, the development of dietary patterns
and tastes, and the role of social and cultural factors in human nutrition.
Rationale
We have increased our understanding of nutrient requirements during
pregnancy and infancy, the control of glucose metabolism in pregnant dia-
betic women, and the contribution of nutrients to hyaline membrane
disease.
Implementation
We should continue and expand studies to:
a. Determine the nutritional status and requirements of pregnant women
and the fetus;
b. Increase knowledge about nutritional management for premature in-
fants;
c. Find the precursors and determinants of childhood obesity; and
d. Find out more about the role of breast milk in prevention of infection
in the infant.

Recommendation 26
Develop an index of morbidity including indicies of assessing and
measuring the well-being of populations of infants and families.
Rationale
Such an index would provide us at Federal, State and local levels with a
sensitive tool to measure continued progress.

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Recommendation 27

Facilitate the establishment of a State and/or subarea perinatal sur-
veillance system along with the training of persons (perinatal epi-
demiologists) who would collect, analyze and distribute on a timely basis,
perinatal information.

Rationale

The vital statistics system of the United States is the one certain data
resource for developing trend information on birth weight and neonatal and
postneonatal mortality for all areas. Some States have greatly enhanced the
use of the system by linking birth and death records to increase our
knowledge about risk factors which helps focus programs more closely on
high risk sectors of the population.

Implementation

As linked birth and death record data become available, increased atten-
tion should be given to the production, analysis and dissemination of the
data that are useful for policy and planning agencies. Fetal death statistics
which vary from area to area require that new attention be given to improv-
ing the data base in all parts of the country for fetal mortality, particularly
at gestation ages of 20 weeks or more. The National Center for Health
Statistics should place these recommendations high on the agenda of its
relationships with State health statistics agencies.

The Birth Defect Surveillance activities of CDC should be continued and
expanded to broaden the search for causes of birth defects and to monitor
the causes of infant pediatric morbidities.
CDC should expand the Epidemiologic Intelligence Service specifically to
increase epidemiologic capacity in State perinatal and Maternal Child
Health departments as it has done in State infection control units in State
Health Departments.

Recommendation 28

Institute and/or continue population based longitudinal surveillance of
significant childhood morbidities to help understand the magnitude and the
correlation of these morbidities as the population matures.

Rationale

These represent major methods for better understanding risk factors and
assessments of interventions for which new investments are needed. These
studies are essential to understanding morbidity in children.

Recommendation 29

Establish community oriented, university based health services research
centers responsible for collecting, analyzing, and disseminating data as well
as training investigative perinatal health professionals.


Recommendation 30

Institute studies in health services, behavioral, and social research
specifically looking at the characteristics of populations which do not re-
ceive prenatal as well as child care services. These studies should follow sub-
sequent developmental patterns including infant and family patterns from
the prenatal stage through the early years of life. They should also examine
the characteristics of the present health care system which impede the
delivery of such services as well as the patterns of care which provide effec-
tive services.

Rationale

Considerable new knowledge is needed to improve health services for
mothers and infants especially for underserved segments of society. To im-
prove health outcomes as much as possible, we need a better understanding
of the precise events that affect pregnant women and infants and the range
and variation in subsequent developmental patterns in the infants and their
families.

Also, there is the need for more information about the nature and utiliza-
tion of the interventions health professionals use to meet such risks and how
to improve clinical service approaches and outcomes. The problem is com-
plex considering the extended period from anticipation of pregnancy to the
development of the fetus and the newborn through infancy.

Implementation

Significant investigations are needed to:
a. Determine the characteristics of populations not receiving prenatal
and well-child care services and their subsequent developmental patterns
and the characteristics of the supposed health care delivery system serving
those populations and the ingredients of a more effective health care
system.
b. Determine the differences in pregnancy outcomes between well served
and unserved or underserved groups.
c. Study the organizational aspects for health services for mothers and
infants including: the layout of services, the relationship of infant and
maternal health care to other services, interprofessional relationships be-
tween professionals and other members of the staffs and develop the
clinical science of intervention for the population at risk for poor out-
comes.

Recommendation 31

Evaluate the effects of pluralistic service delivery approaches on maternal
and infant health problems which have a multitude of causes.

Recommendation 32

Evaluate and monitor the consequences of diminishing and/or realloca-
tion of resources currently supporting maternal and infant health services.

16


Recommendation 33

The Workshop urges the Surgeon General to use the influence of his of-
fice to develop a strategy of public information and education to promote
the recognition of the great value to the nation of healthy pregnant women
and infants.

17


Excerpts From Keynote Addresses

OPENING REMARKS, DECEMBER 14-
JULIUS B. RICHMOND, M.D.
Surgeon General and Assistant Secretary for Health, U.S. Department of
Health and Human Services

In recent years, we have made considerable progress in the reduction of
infant mortality. Chances that a child will be born alive and will live to his
or her first birthday are better now than at any time in our history. Between
1965 and the present, infant mortality rates dropped almost 50 percent to
the present rate of fewer than 13 deaths for each 1,000 live births.

Although this progress is dramatic and encouraging, the mortality rates
for black infants-twice the rate for whites-is unacceptable in our society.
And it is disturbing that the gap in the rates between white and black is not
narrowing.

In the light of progress we have made, and in view of the glaring gaps, it
was felt there should be a review of where we have been and where we are
going in order to make improvements and to sustain and, even, accelerate
progress. It is time to take an inventory and for that reason this Workshop
was organized to bring to bear expertise and competence on the subject of
parental and infant health, which underscores the role of both mother and
father in the assurance of good infant health.

There are inequities within the general progress we have made in pro-
moting infant and child health. For example, low income populations today
are seeing providers of care as frequently as the more affluent. The problem
is they are not necessarily getting the right kind of services, not receiving
preventive services and, usually, services characterized by lack of continu-
ity.

We need now to develop strategies that will enable us to cope with these
and other problems in effective ways.

I think that we are very fortunate in this country that these efforts to im-
prove maternal and infant health do not come from one source exclusively;
not exclusively or even predominantly a Federal effort. Much health care is
provided in this nation through the private sector and bringing together pri-
vate and public actions becomes important as we pursue this effort.

Last year, the Surgeon General's Report on Prevention set as a national
goal the reduction of infant mortality to a rate of nine per 1,000 live births
by 1990. But we must recognize that the present rate of 13 per 1,000 is low
enough to plateau once again. Then, the issues become much more complex

18


and difficult to assess and resolve. I am sure this group recognizes the seri-
ousness of that problem and will provide valuable guidance as to how to
proceed to continue to improve maternal and infant health for all parts of
our society.

The shaping of public policy in a pluralistic society is a complex process.
Three major factors interact in the development of improved programs.

The first is clearly a sound knowledge base from which we can generate
improved programs. Certainly, through research and professional experi-
ence, we have a much richer knowledge base than we had several decades
ago. It must continue to grow, but the knowledge base isn't always applied
fully or evenly.

Therefore, we must turn our attention to the need for two additional
dimensions: political will-or commitment of appropriate and adequate re-
sources, and a social strategy to harness the knowledge base and the polit-
ical will. Clearly, the commitment of resources is not enough unless we have
the overall social strategy through which we will be able to exercise that will.

As to the timing of this Workshop, I suggest the agenda we are consider-
ing is an important one for our nation and I do not believe any administra-
tion will be refractory to considering the issues that will come out of this
Workshop and the recommendations you will be generating. Those recom-
mendations will need to go into the public domain and I believe they will be
considered seriously by all decision makers in the public and private sectors.
Recommendations from this Workshop will be important for all of those
with responsibilities for the health and welfare of our population.

The health and welfare of our children is of particular importance. There
is a special urgency because children have only one childhood that they pass
through and, if they don't get the benefits of all that our society has for
them, it becomes very difficult to go back and make restitution.
The Chilean poet Gabriela Mistral summed it up in these words: "The
child cannot wait. Many things we need can wait, but he cannot. . .To him
we cannot say `tomorrow,' his name is `today.' "
It is in that spirit that we meet. Your work will be important over time.
I am calling upon you to assist in developing the social strategy devoted to
improving maternal and infant health in this nation. The strategy involves
not only the Federal government, but also State and local governments,
private voluntary and for-profit organizations, and academic institutions
and foundations, all working together toward the common good.

ADDRESS, DECEMBER 15-
PATRICIA ROBERTS HARRIS
Secretary of Health and Human Services
The fundamental issues which face this country will remain the same no
matter who holds the reins of power and, traditionally, we have functioned
within a broadly defined consensus about what we seek to accomplish in
order to make this a "more perfect union."

                                             19


In the area of health and human services, our shared concern about the
well-being of our fellow citizens insures that we will face a number of issues,
but today I want to focus on one issue about which all of us share con-
cern-the health and well-being of mothers and children.
Every one of us-from President to private citizen-bears a special
responsibility for the fate of the Nation's children. Children are at one and
the same time our most valuable and our most vulnerable human resource.
Their future is, in a very real sense, our future; and each generation owes to
the next an investment in the health and well-being of children.
We need not approach the issue of child health today as a crisis. On
balance, the statistical information indicates quite the contrary-that the
health of our children has never been better. The infant mortality rate is at
its lowest point in the nation's history; infectious diseases have been re-
duced dramatically; parents today have a better chance of raising healthy
children into adulthood than at any point in world history.
We can be proud of those accomplishments. At the same time, a closer
look indicates that not all the vital signs are good.
The most disturbing sign of trouble is that Americans do not share
equally in this improved health status. Black infants, for instance, have a
mortality rate which is nearly double that of whites. Furthermore, among
children aged one to four, minority children die at a rate 70 percent greater
than white children; and non-white children die from disease and birth
defects at rates 25 percent higher than whites.
Poor children-a disproportionate number of whom are minorities-
inherit ill health along with their poverty; and ill health at such an early age
can become a lifetime affliction.
The health of American children might be better than ever before, but the
health of some American children and the health of countless other children
beyond our borders is far worse than any of us can, or should, accept. I did
not come here today, however, to wring my hands about such conditions.
Those of you in this audience appreciate both our successes and the enor-
mous challenge which lies ahead. And so, for us, the question is: "Where
do we go from here?"
In my judgment two obstacles lie before us-one, a largely technological
and managerial challenge and the other a test of our moral commitment. On
the one hand we must have the tools to do the job and, on the other, the will
to get it done.
In our evolving understanding of the full meaning of the words "equal
opportunity," we must now recognize that adequate health care is a prereq-
uisite to equal opportunity in this society. Health care must be a right for all
our people and adequate health care for infants and children, those who are
just beginning life, is clearly essential.
This, then, is my message to you today. As involved as you are every day,
in the delivery of services, in research, and in the better management of pro-
grams, you and this country cannot afford to lose sight of the other obstacle

20


which stands between us and better health for our children. In addition to
those specific roles which must be played in securing maternal and child
health, you must become advocates of a cause; this country needs your help
in making certain that all your fellow citizens understand as you do how
much remains to be done if all children of this planet are to have a chance
for decent health.

We can bring about change. We may complain about shrinking
resources, but the task can be accomplished if we manage those resources
well and if we remain committed to the cause.
With help from millions of caring people in every walk of life, we can
save children from the ravages of disease and poverty, and we must. For if
we do not save the children, we shall have lost everything.

DECEMBER 16: THE INVISIBLE CHILDREN-
GEORGE I. LYTHCOTT, M.D.

Administrator, Health Services Administration, Department of Health and
Human Services

When we compare our progress in recent years with that of many other
industrialized Nations, we find that we are not performing as well as we
might in maternal and infant care. We rank 14th among the Nations in in-
fant mortality. Our percentage of infants born with a low birthweight-
percent -is not as good as Nations like Sweden, with 4 percent, or urban
China, which was said to have had a prematurity rate of 2.5 percent during
the 1970s.

At least in this context, then, the issue before us here is why have be done
so poorly in comparative terms? And how can we improve our record?

My answer to the first question is: We have neglected the fundamentals of
maternal and child health. That neglect is manifestly evident among the
poor and most minorities. I call the young of these Americans our "invisi-
ble children." Tucked away in urban slums, rural backwaters and Indian
reservations, they are all but invisible to most of America. They are hungry,
ill-clothed and living in hostile environments. These children need a full
measure of primary health care if they are to make it safely to adulthood.

The terrible irony of it all is that we have all but mastered the difficult,
the complex and the heretofore considered impossible, but have overlooked
the fundamental and the basic. Our health care system is a bit like a ballet
virtuoso who can perform feats requiring the utmost agility, onstage, only
to stumble headlong over a curtain rope, offstage.

Consider these facts: some 3.3 million rural poor families in America
have no running water in their homes; another 7.2 million have to use "well
water" which fails to meet drinking standards; and 6.5 million more use
community water systems which also fail to meet standards. The answer lies
less in advancing our already sophisticated medical science and technology
and more in paying closer attention to the needs of those invisible mothers
and children living in forgotten squalor.

21


It is the nature of these problems which lie at the very heart of this work-
shop's agenda. And it is the solution to these problems that will do the most
to help us achieve those three goals for 1990 that Dr. Richmond spelled out
in Healthy People last year: reduce infant mortality by 35 percent; reduce
deaths among children one to 14 by 20 percent; and reduce deaths among
adolescents and young adults by 20 percent.

Ambitious as these goals sound, they are achievable. Given the resources,
the imagination and the commitment, we can reach those targets. Commit-
ting the resources is a decision that the Nation as a whole must make and the
mood of Congress will be critical here. But imagination and commitment
are ingredients well within the grasp of the health care community itself.

We must continue developing ideas that bring the programs of maternal
and child health into a cohesive, productive relationship with one another.
To achieve this does not necessarily require acts of law, but it does, indeed,
require acts of imagination. The 34 improved pregnancy outcome projects
scattered around the Nation are an example of this. These projects seek to
make pregnancy and childbirth safer events for high-risk mothers living in
poverty. They take dead aim at those invisible children and mothers. When
federal support funds for these projects come to an end, the structures of
collaboration they have brought into being will stay in place-bringing
together the people and the resources of the State, the community, the
hospital and the university medical center.

Ideas like this are helping to erode the petty rivalries and turf problems
that I believe he at the root of our so-called categorical health dilemma. Ex-
citing experiments in integrated service are afoot now which shatter the
myth that unbreathable walls exist between us. The laws which govern our
categorical health programs were never meant to divide our enterprise, but
were intended to fix responsibility and accountability. I submit that we can
have the latter without sacrificing the former, if we keep our eye on what
matters.

A critical reassessment of the economic and programmatic direction of.
our financing system is central and essential for all of us concerned about
the health of mothers and children. We must redirect the billions of dollars
of public and private reimbursements to provide incentives for keeping
mothers and children well, and not merely paying for their care after they
are sick.

We must plan for the future-select strategies that hold the promise of
returning more to the Nation than their cost. Few areas of health offer more
potential for realizing that aim than the health of children. We must begin
making the case that our children are not only valuable in their own right,
but respresent the Nation's primary investment in its future.
We have it within our technical grasp to complete the agenda in maternal
and child health in the next ten years. Whether we shall do so depends in
great part on the will, the vision and the imagination of experts like you.

22


An International Perspective
Norman Kretchmer, M.D., Director, National Institute of Child Health
and Human Development
Robert E. Greenberg, M.D., Chairman, Department of Pediatrics,
University of New Mexico School of Medicine
(These two scientists presented impressions of their recent 18-day visit to
the Republic of China under a scientific study agreement between that Na-
tion and the United States. The ten areas of study include child health and
nutrition and human genetics. During the visit, urban and rural areas were
observed.)

Kretchmer
One overriding impression of the Chinese situation regarding child
health, nutrition and human genetics was the policy set by the government:
"One child is the best, and two the most." Our hosts sought information
from us from a technological viewpoint regarding human genetics and
antenatal and postnatal diagnosis and postnatal care and nutrition in an ef-
fort to produce a perfect child.
One professor of obstetrics said the idea was: "`Since we are dealing with
one child, that child is a treasure and, consequently, that child must be
perfect ,"  The Chinese are looking to the Americans to provide
technological know-how to help them achieve that level throughout the Na-
tion.
Prematurity rates were surprising: 6-10 percent in urban areas and 2-3
percent in rural areas, compared to the United States rate of 4-5 percent at
the very best and 12-14 percent at worst.
The Nation is seriously deficient in research and medical education; the
cultural revolution which took place some years ago put China back two
generations in research.

Greenberg
We noted a sharp contrast in the implementation of a system of
care-rural and urban-and a coalescence of therapeutic and preventive ef-
forts, opposed to frequent separation that characterizes the American situa-
tion.
There are some 50 minority groups in China, but they represent only a
small portion of the population so the people are generally of a quite com-
mon genetic stock. One is offered the research opportunity of investigating
general genetic uniformity, compared to the disparity in the United States.
From our viewpoint, the reduced incidence of low birthweight infants
that seems to characterize many areas of China is absolutely incredible. This
represents an important area for investigation. If true, a marked reduction
of low birthweight infants can be effected in the absence of technology and
even secondary resources. 1 hope one of the outcomes of this Workshop will
be the recognition of the importance of cross-cultural research efforts to
determine low birthweight infant statistics.

                                            23


A DOMESTIC VIEW: FEDERAL MATERNAL AND
INFANT HEALTH SERVICES PROGRAMS

Gilbert S. Omenn, M.D.
Program Associate Director, Human Resources, Office of Management
and Budget
Much progress can be documented by using the infant mortality rate as
an indicator and a proxy for other health objectives. The infant mortality
rate fell 44 percent in the United States between 1965 and 1978, dropping
from 24.7 to 13.8 infant deaths per 1,000 live births. Masked in this signifi-
cant overall decline, however, are substantial racial and geographic varia-
tions:
. In 1978, the nation's infant mortality rate for blacks was 23.1. In con-
trast, for Indians it was 13.7 and for whites 12.0. (No separate rate for His-
panics is currently available.) The rate for black thus was roughly twice the
rate for white.
. In 1978, Statewide infant mortality rates ranged from 10.4 to 27.3. State
rates for blacks ranged from 11 .O to 35.2, while the rates for whites ranged
from 9.9 to 14.9.
For the five-year period 1971-75, county infant mortality rates ranged
from 1.9 to 63.1. Nearly one-third of our 3,100 counties had rates in excess
of 20.0.
My staff and I recently began an in-depth review of major programs
which have as an explicit major goal the improvement of the health of
mothers and children. It includes the Supplemental Feeding Program for
Women, Infants and Children (WIC) in the Department of Agriculture and
the Maternal and Child Health, Family Planning, Community Health Cen-
ter and Head Start programs in HHS. It has been fascinating and gratifying
to hear the budgets for these important, large federal programs justified by
good results in terms of health status measures. In FY 1980, these five pro-
grams spent more than $1 billion on health and related services for more
than 10 million American mothers and children. Many of the services pro-
vided through these programs are also funded by Medicaid. Thus, the total
Federal funding channeled through these programs is substantially in excess
of $1 billion.
Several recent efforts can be cited as examples of effective maternal and
infant health program coordination.
In predominantly rural areas of Alabama, an Improved Pregnancy Out-
come project was organized to combine funds from maternal and child
health, family planning, National Health Service Corps, Appalachian Re-
gional Commission and State programs. Regional health consulting and ad-
vocacy teams were established, county-based plans were developed for local
maternal and child health services, and commitments are being negotiated
between state and county health officials regarding the quantity and quality
of services. Major improvements have been made in the analysis of vital sta-

24


tistics and in improving the data available on individual use of health serv-
ices. The initiative has been most effective in reducing the State infant mor-
tality rate-down from 20 in 1976 to below 14 in 1979. Maternal and fetal
mortality rates have also decreased. Not all indices have improved, how-
ever, the incidences of teenage pregnancies and illegimate births have in-
creased.
Again, in a rural area, north-central Florida, MHC, WIC and Title X
Family Planning, Title XIX Medicaid and Title XX social services resources
have been combined under the cooperative direction of the State and county
health departments and the University of Florida Medical School. Teams
dispatched from central project offices in Gainesville to different rural loca-
tions each day have helped reduce operating costs by centralized account-
ing, recordkeeping, external reporting and other administrative activities.
They have been most effective in reducing repeat teenage pregnancies from
40 percent in 1977 to 5 percent in 1979. Other positive health achievements
between 1977 and 1979 include a decrease in cesarean sections to 3 percent
and decreases in the rates of fetal mortality and Tow weight births.
Other examples of effective State and local program coordination are
found in South Carolina, Cincinnati, Denver and Portland. I trust that
many of you in this Workshop will provide detailed information on these
and other successful coordinating efforts. We need to encourage and
strengthen these initiatives and develop effective methods of replicating
them.
Resources from Federal health programs should go disproportionately, I
believe, to those areas of greatest need with the best plans for addressing
those needs successfully and efficiently with both public and private re-
sources. Targeting can be based upon clear, quantified objectives for im-
provements in health status and health outcomes for defined population
groups in specific geographic and political units. Local and State officials
should be encouraged to tie together the resources available from the related
Federal programs in a plan that offers the best chances in particular settings
to achieve these objectives.
Despite the focus of Federal programs on improving maternal and child
health, none allocates funds to States primarily on the basis of measures
which directly reflect poor health status. WIC allocations are based primar-
ily on each State's proportion of poor children under age five. The State's
relative infant mortality rate is used in the formula, but it receives much less
than equal weight. In addition, adjustments are made in the allocations so
that States are able to maintain program levels from year to year. The WIC
formula is not established by law, but at the discretion of the Secretary of
Agriculture. Given the 1990 goals and WIG's health objectives, I recom-
mend that we examine the desirability and feasibility of making formula
changes which would more closely target WIC funds to States with the
greatest health needs.
In the MCH program, almost half of the total program funds, by law, are
allocated on the basis of the State's proportion of live births. Additional

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