Operational Definitions for Year 2000 Objectives:

Priority Area 14, Maternal and Infant Health

Katherine E. Heck and Richard J. Klein

Introduction

Healthy People 2000, with its Midcourse Revisions,

presents 319 objectives to improve the health of Americans

by the year 2000 (1,2). Because these objectives are

national, not solely Federal, the achievement of these

objectives is dependent in part on the ability of health

agencies at all levels of government to assess objective

progress. To permit comparison of local and State health

data with national data and that of other States and localities,

Healthy People 2000 objective 22.3 targets the development,

dissemination, and use of collection methods that improve

comparability among data collected by all levels of

government. The objective states:

Develop and disseminate among Federal, State, and

local agencies procedures for collecting comparable data

for each of the year 2000 national health objectives and

incorporate these into Public Health Service data

collection systems.

Achieving this objective entails determining and

defining the information needed to measure progress toward

each national health objective. The purpose of this Statistical

Note is to provide definitions and data collection

specifications for objectives in Priority Area 14: Maternal

and Infant Health, one of 22 priority areas of Healthy People

2000. In this publication the text (appendix A) and

operational definitions of the objectives are presented,

important data issues are discussed, and references are cited

for expanded discussions of the data systems (appendix B)

that provide data for the national objectives. When

appropriate, the text of questionnaire items used to measure

the objectives is also provided.

Table 1 is a data comparability worktable with objective

definitions, data sources and issues. This table presents the

short text of each objective, the measure, the operational

definition (numerator and denominator where applicable),

national data source, and a brief description of data issues.

The data issues for each objective are discussed in greater

detail below.

Objective 14.1: Infant mortality

Infant mortality is a period rate measured as the number

of infant deaths (deaths before one year of age) occurring

during a year per 1,000 live births occurring in the same

year. Three data sets within the National Vital Statistics

System (NVSS, which encompasses mortality, natality, and

linked birth and infant death files) contribute to the

calculation of infant mortality rates. Infant mortality for the

total population (14.1, 14.1d, 14.1g), whites, and blacks

(14.1a, 14.1e, 14.1h) is computed by dividing the number of

infant deaths during a given year from the mortality file by

the number of live births during the same year from the

natality file and multiplying by 1,000.

Because of inconsistencies in reporting of race and

Hispanic-origin data between birth and death certificates (3),

the cohort-linked birth/infant death data are used to calculate

infant mortality rates for Hispanic-origin groups and for race

Number 14

December 1997

From the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

CENTERS FOR DISEASE CONTROL

AND PREVENTION
2
3
4
5
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groups other than white and black (14.1b, 14.1c, 14.1f,

14.1i, 14.1j). The linked birth/infant death file matches the

death certificate to the corresponding birth certificate for

each infant who dies in the United States. With this data set,

race/ethnic-specific infant mortality rates can be calculated

using the more accurate race and Hispanic-origin data from

the birth certificate. However, because some infant deaths

cannot be matched to their corresponding birth certificates,

infant mortality rates from the linked file tend to

underestimate the actual rates by 2 to 3 percent (4). Data for

Puerto Rican subobjectives are based on States reporting

Hispanic origin on the birth certificate. The number of States

reporting Hispanic origin on the birth certificate increased

from 23 States and the District of Columbia in 1984 to all

States and the District of Columbia in 1993.

Baseline and subsequent data for 1983–91 for these

special population subobjectives (14.1b, 14.1c, 14.1f, 14.1i,

14.1j) were generated from linked files produced on a birth

cohort basis (that is, all deaths in the first year of life to

members of a particular birth cohort, regardless of year of

death). Beginning with 1995 data, linked files are being

produced on a period basis. For example, all infant deaths

occurring in 1995 were matched to their corresponding birth

certificate (whether the birth occurred in 1995 or 1994), and

this group of deaths is used to calculate the rate. The

denominator of the period linked file is the births for the

period (such as all births occurring in 1995). To adjust for

unlinked records, the Division of Vital Statistics provides

weights for the deaths from the period linked file to an

independent total. Linked file data will not be produced for

1992–94.

Infant mortality is divided into neonatal and

postneonatal mortality, according to when the infant dies;

those dying in the first 28 days of life are regarded as

neonatal, and those dying after 28 days but before their first

birthday are regarded as postneonatal. The causes of death

tend to differ between these groups; for example, birth

trauma is a more common cause neonatally, while SIDS

(Sudden Infant Death Syndrome) is more common

postneonatally. The neonatal mortality rate is calculated by

dividing the number of neonatal deaths by the number of

live births times 1,000; the postneonatal mortality rate

divides the number of postneonatal deaths by the number of

live births times 1,000. The same denominator (the number

of live births) is used for infant mortality, neonatal mortality,

and postneonatal mortality rates and, therefore, the neonatal

and postneonatal rates sum to the total infant mortality rate.

Objective 14.2: Fetal mortality

Fetal mortality is sometimes called stillbirth. Fetal

deaths, defined according to World Health Organization

guidelines, are those in which the fetus never draws a breath

or shows other evidence of life; if the infant lives for any

length of time it is classified as a live birth and an infant

death. States are required to report fetal deaths if they occur

in the 20th week of pregnancy or later, or if they weigh at

least 350 grams (4). Some States report earlier fetal deaths,

but most official data (including the data used to measure

this objective) are calculated using only deaths at 20 or more

weeks. The week of pregnancy is dated from the first day of

the last menstrual period. Fetal deaths may be underreported

(4,5). The data source is the NVSS, using fetal death reports;

the fetal death rate used to track this objective is calculated

as the number of fetal deaths per 1,000 live births plus fetal

deaths. Fetal deaths to blacks are tracked as a special

population subgroup (14.2a).

Objective 14.3: Maternal mortality

Maternal mortality is measured as the rate of maternal

deaths per 100,000 live births. To be included in this

definition, a death must occur during pregnancy or within 42

days of termination of pregnancy, and must result from

obstetric causes (ICD–9 codes 630 through 676). The data

source for maternal mortality is the NVSS, using death

certificate data for the numerator.

Maternal mortality rates are computed on the basis of

the number of live births. The maternal mortality rate

indicates the likelihood of a pregnant woman dying of

maternal causes. The number of live births used in the

denominator is an approximation of the population of all

pregnant women who are at risk of a maternal death.

Caution should be used when comparing these rates

with maternal mortality rates from other reports. NCHS uses

the definition of maternal mortality and related coding

conventions recommended in the International Classification

of Diseases, Ninth Revision (ICD–9), by the World Health

Organization. Other definitions may use a different time

interval from pregnancy to death and may be more inclusive

with regard to the cause of death. ICD–10, which will be

implemented for mortality in the U.S. effective with 1999

data, uses the same definition of maternal mortality as

ICD–9, but has provision for including late maternal deaths

(more than 42 days but less than one year after termination

of pregnancy, and for obstetric-related deaths occurring a

year or more after the termination of pregnancy) and

pregnancy-related deaths irrespective of the cause of

death (6).

Maternal mortality to black mothers is tracked as a

special population subgroup (14.3a).

Objective 14.4: Fetal Alcohol Syndrome

This objective measures the number of infants affected

with fetal alcohol syndrome per 1,000 live births. Fetal

alcohol syndrome (FAS) may not be immediately

recognizable in the infant at birth, and as a result the

magnitude of this problem is difficult to estimate. The

Centers for Disease Control and Prevention (CDC) currently

uses a variety of data sources to measure FAS. The Birth

Defects Monitoring Program (BDMP) was the source for

published Healthy People 2000 data through 1993. However,

the BDMP system of voluntary reporting by hospitals was

unreliable and the system no longer exists. Hospital

discharge data, using infants with the ICD–9 code of 760.71,

may be used, but this method necessarily results in an

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undercount, as not all FAS-affected babies are correctly

diagnosed while in the hospital in order to receive this

discharge code. CDC is sponsoring pilot programs in two

States, Colorado and New Mexico (see reference 7 for a

description of the Colorado project), to improve the tracking

of FAS. However, accurate national estimates of FAS rates

are unlikely to be available soon. Objectives 14.4a and 14.4b

track American Indians/Alaska Natives and blacks as special

populations.

Objective 14.5: Low birthweight and very

low birthweight

Low and very low birthweight are measured by the

percent of infants who are below a specified weight at birth,

2500 grams for low birthweight and 1500 grams for very

low birthweight. This information is recorded on the birth

certificate and thus the data are available through the NVSS.

The data are considered to be very reliable. Very few births,

about 0.1 percent in 1994, do not have weight recorded on

the birth certificate. These missing records are subtracted

from both numerator and denominator before calculating the

percent. Data for subobjectives targeting Puerto Rican live

births (14.5c-d) are based on States reporting Hispanic origin

on the birth certificate. The number of States reporting

Hispanic origin on the birth certificate increased from 23

States and the District of Columbia in 1987 to all 50 States

and the District of Columbia in 1993. Subobjectives 14.5a-b

track low and very low birthweight rates for black infants.

Objective 14.6: Weight gain in pregnancy

The Institute of Medicine (IOM) has made

recommendations regarding the proper amount of weight to

gain during pregnancy (8). This guideline varies according to

the woman’s body mass index (a measure of weight for

height) before pregnancy. Body mass index (BMI) is

measured as the person’s weight in kilograms divided by the

square of their height in meters. According to IOM

guidelines, women in the thinnest group, those with a BMI

of less than 19.8, should gain 12.5 to 18 kilograms. Those

with a BMI of 19.8 to 26.0 should gain 11.5 to 16

kilograms. Those with a BMI of 26.1 to 29.0 should gain 7

to 11.5 kilograms. Women with a BMI of over 29.0 should

gain at least 6.8 kilograms.

The baseline estimate for Healthy People 2000 came

from the National Natality Survey, fielded in 1980. The

National Maternal and Infant Health Survey (NMIHS) was

used for the 1988 estimate. The NMIHS has not been

repeated; consequently, updates are not available.

Objective 14.7: Severe complications of

pregnancy

This objective tracks the percent of pregnancies that

have severe complications requiring hospitalization, such as

ectopic pregnancy, pre-eclampsia, or birth trauma.

Hospitalizations with ICD–9 codes 630 through 676

(excluding 635 and 650, legal abortion and uncomplicated

delivery) from the National Hospital Discharge Survey

(NHDS) are divided by the total number of deliveries

(ICD–9 procedure code V27). The rate for this objective has

been declining and the target appears to have been met in

1993. However, hospitalization patterns have changed over

the past several years, resulting in declining rates of

hospitalization. Because the objective is measured by

hospitalization rates, this change in the use of health services

may influence the measurement of objective 14.7. The

declines observed in severe pregnancy complications thus

may reflect a true improvement in obstetric health, a

decrease in the likelihood of being hospitalized for a given

condition, or some combination of the two. Black mothers

are tracked as a special population (14.7a).

Objective 14.8: Cesarean delivery

The estimates used to monitor this objective are the

percent of deliveries that are cesarean (C-section), the

percent of primary (first-time) cesarean deliveries (14.8a),

and the percent of repeat cesarean deliveries among women

who had a previous cesarean delivery (14.8b). The total

C-section rate is computed by dividing the total number of

cesarean deliveries (ICD–9 code 74, omitting 74.3 and

74.91) by the total number of deliveries (ICD–9 code V27).

The primary C-section rate is computed by dividing the

number of first cesareans (ICD–9 code 74, omitting 74.3 and

74.91, for women with no ICD–9 code 654.2 (uterine scar)

on record) by the number of deliveries to women with no

previous cesarean section deliveries (ICD–9 code V27 less

women with ICD–9 code 654.2 on record). The repeat

C-section rate, which is the complement of the Vaginal Birth

After Cesarean (VBAC) rate, is calculated by dividing the

number of women with a repeat cesarean section (ICD–9

code 74, omitting 74.3 and 74.91, for women with ICD–9

code 654.2 on record) by the total number of deliveries

(ICD–9 code V27) for women with a uterine scar (ICD–9

code 654.2).

The data used to track this objective are based on

deliveries (births as well as fetal deaths) recorded in hospital

records from the NHDS. Information on cesarean delivery

for live births only is also available from the NVSS (birth

certificate) data using the question on method of delivery

which asks for vaginal, VBAC, primary, and repeat

C-sections. The two sources of data yield close, but not

identical, estimates of the cesarean delivery rate.

Objective 14.9: Breastfeeding

This objective measures breastfeeding at two ages of the

infant, the percent of all mothers who breastfed their infant

during the early postpartum period (measured as

breastfeeding in the hospital following delivery), and the

percent of all mothers (including those who did not

breastfeed in the hospital) who were breastfeeding 6 months

following delivery. The data source for this objective is the

Ross Mothers Survey (RMS) mailed to approximately

725,000 mothers annually, performed by Abbott

Laboratories. The RMS is based on lists of new mothers

8
representing over 80 percent of U.S. births; however, these

lists, which Abbott acquires from a marketing company, may

not be representative of all women giving birth in the U.S.

About 50 percent of women respond to the mail survey,

though there are seasonal variations (for example, rates are

lower in December), so the response rate may also influence

the representativeness of this survey. The survey asks

whether the woman was breastfeeding in the hospital and

also asks about breastfeeding during several time periods

until the infant is 6 months of age. The definition of

breastfeeding includes exclusive breastfeeding or

breastfeeding supplemented by bottle-feeding of formula or

cow’s milk. The questions asked are shown in figure 1.

Note: Time periods asked are: in the hospital; 1 week of

age; 1 month of age; 2 months of age; 3 months of age; 4

months of age; 5 months of age; 6 months of age; yesterday.

The ‘‘in the hospital’’ and ‘‘6 months of age’’ values are

used to track the Healthy People 2000 objective.

Figure 1. Ross Mothers Survey breastfeeding questions

As best you can remember, would you please check the milk your

baby was fed at the following ages:

In the hospital 6 months of age

h Breast milk — —

h Cow’s milk (whole, 2%, skim, etc.) — —

h Similac (low iron or with iron) — —

h Similac Neocare — —

h Isomil — —

h Isomil DF — —

h Alimentum — —

h Enfamil (low iron or with iron) — —

h Lactofree — —

h Nutrami gen — —

h Prosobee — —

h Carnation Alsoy — —

h Carnation Follow-Up — —

h Carnation Follow-Up Soy — —

h Carnation Good Start — —

h Gerber (low iron or with iron)

formula — —

h Gerber soy formula — —

h SMA (low iron or with iron) — —

h Nursoy — —

h Bonamil — —

h Next Step — —

h Next Step Soy — —

h Other (please specify)

SOURCE: Ross Mothers Survey, Abbott Laboratories.

Because the RMS does not make estimates for

American Indians and Alaska Natives (AI/AN), the

subobjective measuring breastfeeding rates among AI/AN

(14.9d) is tracked by the Pediatric Nutrition Surveillance

System (PNSS). This system, in operation since 1978,

attempts to monitor the prevalence of nutrition-related

problems and other risk factors related to infant mortality

and low birthweight, among high-risk prenatal populations.

Estimates from the PNSS are affected by variability in

participation, as well as the sampling frame, a convenience

sample of participants in WIC, food stamps, and other such

programs; 18 States as well as the District of Columbia and

American Samoa participated in PNSS in 1990. This sample

may not fully represent the AI/AN population.

Subobjectives 14.9a (mothers with annual family

incomes of less than $10,000), 14.9b (black mothers), and

14.9c (Hispanic mothers) are tracked with data from the

Ross Mothers Survey.

Breastfeeding data are also available from several

NCHS surveys, including the National Health and Nutrition

Examination Survey (NHANES), the National Survey of

Family Growth (NSFG), the NMIHS, and periodic

supplements of the National Health Interview Survey

(NHIS), and may be used to estimate the prevalence of

breastfeeding. However, unlike the annual RMS, these

surveys are fielded only periodically. Breastfeeding rates

derived from the NCHS surveys are very similar to those

produced by the Ross Mothers Survey.

This objective also appears as objective 2.11 in the

Healthy People 2000 Nutrition priority area.

Objective 14.10: Abstinence from tobacco,

alcohol, cocaine, and marijuana during

pregnancy

The goal of this objective is to increase abstinence

during pregnancy from four substances: tobacco, alcohol,

cocaine, and marijuana. The objective is measured by the

proportion of women who do not use a given substance

during pregnancy. However, accurate surveillance of this

problem is difficult as women may be reluctant to divulge

their use of substances, particularly illegal ones, during

pregnancy.

The baseline data for the tobacco component of this

objective were drawn from the 1985 NHIS. For the 1988

figures, the NMIHS was used to provide an update for

tobacco and baseline estimates for alcohol, cocaine, and

marijuana. Since 1989, annual updates on abstinence from

tobacco are available from birth certificate data, and the

NHIS was also used in 1990 and 1991. For 1993, data on all

four substances were provided by the National Institute on

Drug Abuse’s National Pregnancy and Health Survey

(NPHS) (9). No plans currently exist to replicate the NPHS

or the NMIHS. Therefore, there are no data sources currently

identified for updates to the alcohol, cocaine, and marijuana

components of this objective.

Objective 14.11: Prenatal care use in the first

trimester of pregnancy

This objective measures the percentage of women

receiving prenatal care during the first trimester (three

months) of pregnancy. Information on prenatal care is

derived from the item on the birth certificate that asks for

month of pregnancy that prenatal care began. The number of

births with missing values is subtracted from the

denominator population before calculating the percentage.

Data for the Hispanic subobjective (14.11c) are based on

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States reporting Hispanic origin on the birth certificate. The

number of States reporting Hispanic origin on the birth

certificate increased from 23 States and the District of

Columbia in 1987 to all 50 States and the District of

Columbia in 1993. Subobjectives 14.11a and 14.11b track

the use of early prenatal care by black and American

Indian/Alaska Native mothers.

Objective 14.12: Preconception care and

counseling by primary care providers

Objective 14.12 measures the proportion of primary care

providers who routinely provide age-appropriate

preconception care and counseling to their patients who need

the intervention. This objective is actually a set of measures

calculated separately for each type of provider and for each

type of service.

The Primary Care Provider Surveys, conducted by the

Department of Health and Human Services Office of Disease

Prevention and Health Promotion, are a set of national

surveys of family physicians, pediatricians, nurse

practitioners, obstetricians/gynecologists, and internists

belonging to professional organizations. They include

questions regarding preconception care and providers’

counseling practices. However, results from the surveys may

not be entirely reliable for several reasons. Response rates

varied considerably by type of provider, from 50–80 percent.

This measurement was constructed based on the two

questions shown in figure 2. The data measure the percent of

each different type of primary care provider who answered

that 81–100 percent of their patients routinely receive

information about family planning or preconception care,

and the percent who said that 81–100 percent of their

patients who need counseling for family planning receive it.

The measure for those receiving preconception care was not

asked separately as a specific question.

This objective also appears as objective 5.12 in the

Healthy People 2000 Family Planning priority area.

Objective 14.13: Screening for fetal

abnormalities

This objective is tracked by the percent of pregnant

women whose blood is screened for alphafetoprotein (AFP).

A high value of AFP may indicate that the fetus has a neural

tube defect or other health problem. The data source for this

objective is the Foundation for Blood Research, located in

Maine, which conducts a national survey of screening

laboratories to gather this information. Laboratories surveyed

represent 63 percent of U.S. births. The testing rates,

however, vary by region. For the Healthy People 2000

measure, the number of screening tests is weighted up to a

U.S. total and divided by the total number of live births in

the U.S.

Objective 14.14: Risk-appropriate care among

infants and pregnant women

High-risk pregnancies and births should receive special

interventions; this standard of medical care forms the basis

of objective 14.14. The objective was originally planned to

be measured by the proportion of very low birthweight

infants born in tertiary level III hospitals (that is, a hospital

with a Neonatal Intensive Care Unit). However, no data

source has been found that can adequately measure this

objective.

Objective 14.15: Newborn screening and

follow-up

This objective seeks to increase the percent of newborns

who are screened for genetic disorders; the two disorders

tracked are sickle cell anemia and galactosemia. Also

measured is the proportion of infants screened with a

positive result who receive treatment. The Council of

Regional Networks for Genetic Services (CORN) at Emory

University tracks information on infant screening for genetic

disorders. CORN gathers information from State health

departments on the proportion of infants screened and the

proportion who received a diagnosis. For the baseline (1987)

measure, ten States and the District of Columbia reported

sickle cell screening: AZ, CO, DC, GA, LA, MI, NY, NC,

TX, WA, and WY. Thirty-five States and DC reported

galactosemia at baseline: AL, AK, AZ, AR, CA, CO, CT,

DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, ME, MA, MI,

MN, MT, NV, NJ, NM, NY, NC, OH, OR, RI, TX, UT, VT,

WV, and WI. Beginning in 1990, every State and the District

of Columbia reported both sickle cell and galactosemia

screening.

The percent screened is tallied as the number of infants

screened divided by the number of live births in the States

reporting this information. Infants who test positive are then

tracked until they begin receiving a doctor’s care. The

proportion who receive treatment is the percent of infants

who had a clinically confirmed diagnosis of those who

Figure 2. Primary Care Provider Surveys preconception care and

counseling questions

For each of the following, the provider was asked to estimate [the]

percentage of [their] patients routinely receiving this service. 0–20%;

21–40%; 41–60%; 61–80%; 81–100%; NA.

h Please [provide the] best estimate [of] the percentage of your current

patients . . . who routinely receive each service.

Definition of ‘‘routinely’’: For the purpose of this survey, ‘‘routinely’’

means the receipt of services at regular intervals. Patients who receive

a service only once in many years, in general, should not be included

in your responses, because they are not provided with this service

‘‘routinely.’’

h Please answer the following questions about patients’ receipt of

counseling/treatment services in terms of the percentage of your patients

who need the intervention, not the percentage of your total patient population. For example, only 20% of your total patient population may receive

counseling about smoking; however, this 20% may represent 85% of your

patients who smoke. Therefore, the proper answer would be 80–100%

(based on 85%).

Type of service:

Counseling about family planning

SOURCE: Primary Care Provider Surveys, Office of the Assistant Secretary for Health, Office

of Disease Prevention and Health Promotion.

10
initially tested positive. CORN makes the assumption that if

a diagnosis was confirmed, then therapy was instituted. The

phone number for CORN is (404) 727–1475.

Objective 14.16: Primary care for babies

18 months and under

The U.S. Clinical Preventive Services Task Force made

recommendations for primary care among individuals in

several different age groups (10). This set of

recommendations is the prescribed set of primary care

services that this objective should measure. No data source

has been found that encompasses all aspects of this list of

recommendations, shown in figure 3. Thus, baseline data

have not been produced for this objective.

Figure 3. U.S. Clinical Preventive Services Task Force recommendations for primary care for babies 18 months and under

h Screening: height and weight, blood pressure, hemoglobinopathy screen at

birth, phenylalanine level at birth, T4 and/or TSH (at birth) for thyroid

h Counseling parents: injury prevention, child safety car seats, smoke

detector, flame retardant sleepwear, hot water heater temperature <120–130

degrees F, window/stair guards, pool fence, safe storage of drugs, toxic

substances, firearms, matches, syrup of ipecac, poison control phone

number, effects of passive smoking, anti-tobacco message, advice about

baby bottle tooth decay, cardiopulmonary resuscitation (CPR) training,

breastfeeding, iron-enriched formula and foods

h Immunizations: Diphtheria-tetanus-pertussis (DTP), oral poliovirus,

measles-mumps-rubella (MMR), H. influenzae type b (Hib) conjugate,

Hepatitis B, varicella

h Chemoprophylaxis: Ocular prophylaxis at birth

h Special populations:

– Preterm or low birth weight: hemoglobin/hematocrit

– Infant of a mother at risk for HIV: HIV testing

– Low income, immigrants: Hemoglobin/hematocrit

– TB contacts: PPD

– Native American/Alaska Native: Hemoglobin/hematocrit, Hepatitis A

vaccine, pneumococcal vaccine

– Travelers to developing countries: Hepatitis A vaccine

– Increased individual or community lead exposure: blood lead level

– Inadequate water fluoridation: daily fluoride supplement

– Family history of skin cancer, nevi, fair skin, eyes, hair: avoid

excess/midday sun, use protective clothing

SOURCE: U.S. Clinical Preventive Services Task Force.

Objective 14.17: Spina bifida and other neural

tube defects

Neural tube defects (NTDs) are readily noticed at the

birth of a child; they include spina bifida and anencephaly.

This objective is measured by the number of NTD-affected

births per 10,000 live births. Surveillance systems for birth

defects are not available nationally; although birth defect

data are available on birth certificates, they are generally not

well reported. The Birth Defects Monitoring Program, which

entailed voluntary surveillance by hospitals, was used for

Healthy People 2000 data through 1993, when the program

was discontinued. Since then, some States have been

performing their own surveillance; currently about 20 States

are able to measure the incidence of NTDs. CDC is working

with States to improve the surveillance of this health

problem.

Healthy People 2000 measures this objective by tracking

births. However, because 30 40 percent of NTD-affected

pregnancies are terminated, it is possible to create an

adjusted prevalence of NTDs by adding NTD-affected

terminated pregnancies and births, and dividing them by the

total number of live births.

References

1. U.S. Department of Health and Human Services. Healthy

people 2000: National health promotion and disease prevention

objectives. Washington: Public Health Service. 1990.

2. U.S. Department of Health and Human Services. Healthy

people 2000 midcourse review and 1995 revisions.

Washington: Public Health Service. 1995.

3. Frost F, Shy KK. Racial differences between linked birth and

infant death records in Washington State. Am J Public Health

70:974–6. 1980.

4. National Center for Health Statistics. Vital statistics of the

United States, 1992, vol II, mortality, part A. Washington,

D.C.: Public Health Service. 1996.

5. Goldhaber MK. Fetal death ratios in a prospective study

compared to State fetal death certificate reporting. Am J Public

Health 79:1268–70. 1989.

6. World Health Organization. ICD–10: International Statistical

Classification of Diseases and Related Health Problems, Tenth

Revision. Geneva: WHO. 1992.

7. Miller LA, Shaik T, Stanton C, et al. Surveillance for fetal

alcohol syndrome in Colorado. Public Health Reports

110:690–7. 1995.

8. Committee on Nutritional Status During Pregnancy and

Lactation, Institute of Medicine, National Academy of

Sciences. Nutrition during pregnancy: Part I: Weight gain, Part

II: Nutrient supplements. National Academy Press. 1990.

9. National Institute on Drug Abuse. National Pregnancy and

Health Survey. Drug use among women delivering live births:

1992. Rockville, MD: U.S. Department of Health and Human

Services. 1996.

10. U.S. Preventive Services Task Force. Guide to clinical

preventive services, 2nd ed. Baltimore: Williams & Wilkins.

1996.

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APPENDIX A:

Maternal and Infant Health Objectives

14.1: Reduce the infant mortality rate to no more than 7

per 1,000 live births.

NOTE: Infant mortality is deaths of infants under 1 year;

neonatal mortality is deaths of infants under 28 days; and

postneonatal mortality is deaths of infants aged 28 days up

to 1 year.

14.1a: Reduce the infant mortality rate among blacks to

no more than 11 per 1,000 live births.

14.1b: Reduce the infant mortality rate among

American Indians and Alaska Natives to no more than

8.5 per 1,000 live births.

14.1c: Reduce the infant mortality rate among Puerto

Ricans to no more than 8 per 1,000 live births.

14.1d: Reduce the neonatal mortality rate to no more

than 4.5 per 1,000 live births.

14.1e: Reduce the neonatal mortality rate among blacks

to no more than 7 per 1,000 live births.

14.1f: Reduce the neonatal mortality rate among Puerto

Ricans to no more than 5.2 per 1,000 live births.

14.1g: Reduce the postneonatal mortality rate to no

more than 2.5 per 1,000 live births.

14.1h: Reduce the postneonatal mortality rate among

blacks to no more than 4 per 1,000 live births.

14.1i: Reduce the postneonatal mortality rate among

American Indians and Alaska Natives to no more than 4

per 1,000 live births.

14.1j: Reduce the postneonatal mortality rate among

Puerto Ricans to no more than 2.8 per 1,000 live births.

14.2: Reduce the fetal death rate (20 or more weeks of

gestation) to no more than 5 per 1,000 live births plus

fetal deaths.

14.2a: Reduce the fetal death rate (20 or more weeks of

gestation) among blacks to no more than 7.5 per 1,000

live births plus fetal deaths.

14.3: Reduce the maternal mortality rate to no more

than 3.3 per 100,000 live births.

14.3a: Reduce the maternal mortality rate among black

women to no more than 5 per 100,000 live births.

14.4: Reduce the incidence of fetal alcohol syndrome to

no more than 0.12 per 1,000 live births.

14.4a: Reduce the incidence of fetal alcohol syndrome

among American Indians and Alaska Natives to no more

than 2 per 1,000 live births.

14.4b: Reduce the incidence of fetal alcohol syndrome

among blacks to no more than 0.4 per 1,000 live births.

14.5: Reduce low birthweight to an incidence of no more

than 5 percent of live births and very low birthweight to

no more 1 percent of live births.

NOTE: Low birthweight is weight at birth of less than 2,500

grams; very low birth weight is weight at birth of less than

1,500 grams.

14.5a: Reduce low birthweight among blacks to an

incidence of no more than 9 percent of live births.

14.5b: Reduce very low birthweight among blacks to

no more 2 percent of live births.

14.5c: Reduce low birthweight among Puerto Ricans to

an incidence of no more than 6 percent of live births.

14.5d: Reduce very low birthweight among Puerto

Ricans to no more 1 percent of live births.

14.6: Increase to at least 85 percent the proportion of

mothers who achieve the minimum recommended weight

gain during their pregnancies.

NOTE: Recommended weight gain is pregnancy weight gain

recommended in the 1990 National Academy of Science’s

report, Nutrition During Pregnancy.

14.7: Reduce severe complications of pregnancy to no

more than 15 per 100 deliveries.

NOTE: Severe complications of pregnancy is measured

using hospitalizations due to pregnancy-related

complications.

14.7a: Reduce severe complications of pregnancy

among blacks to no more than 16 per 100 deliveries.

14.8: Reduce the cesarean delivery rate to no more than

15 per 100 deliveries.

14.8a: Reduce the primary (first time) cesarean delivery

rate to no more than 12 per 100 deliveries.

14.8b: Reduce the repeat cesarean delivery rate to no

more than 65 per 100 deliveries among women who had

a previous cesarean delivery.

12
14.9*: Increase to at least 75 percent the proportion of

mothers who breastfeed their babies in the early

postpartum period and to at least 50 percent the

proportion who continue breastfeeding until their babies

are 5 to 6 months old.

Duplicate objective: 2.11

14.9a*: Increase to at least 75 percent the proportion of

low-income mothers who breastfeed their babies in the

early postpartum period and to at least 50 percent the

proportion who continue breastfeeding until their babies

are 5 to 6 months old.

Duplicate objective: 2.11a

14.9b*: Increase to at least 75 percent the proportion of

black mothers who breastfeed their babies in the early

postpartum period and to at least 50 percent the

proportion who continue breastfeeding until their babies

are 5 to 6 months old.

Duplicate objective: 2.11b

14.9c*: Increase to at least 75 percent the proportion of

Hispanic mothers who breastfeed their babies in the

early postpartum period and to at least 50 percent the

proportion who continue breastfeeding until their babies

are 5 to 6 months old.

Duplicate objective: 2.11c

14.9d*: Increase to at least 75 percent the proportion of

American Indian and Alaska Native mothers who

breastfeed their babies in the early postpartum period

and to at least 50 percent the proportion who continue

breastfeeding until their babies are 5 to 6 months old.

Duplicate objective: 2.11d

14.10: Increase abstinence from tobacco use by pregnant

women to at least 90 percent, increase abstinence from

alcohol by pregnant women to at least 90 percentand

increase abstinence from cocaine and marijuana to

100 percent.

14.11: Increase to at least 90 percent the proportion of

all pregnant women who receive prenatal care in the first

trimester of pregnancy.

14.11a: Increase to at least 90 percent the proportion of

pregnant black women who receive prenatal care in the

first trimester of pregnancy.

14.11b: Increase to at least 90 percent the proportion of

pregnant American Indian and Alaska Native women

who receive prenatal care in the first trimester of

pregnancy.

14.11c: Increase to at least 90 percent the proportion of

pregnant Hispanic women who receive prenatal care in

the first trimester of pregnancy.

14.12*: Increase to at least 60 percent the proportion of

primary care providers who provide age-appropriate

preconception care and counseling.

Duplicate objective: 5.10

14.13: Increase to at least 90 percent the proportion of

women enrolled in prenatal care who are offered

screening and counseling on prenatal detection of fetal

abnormalities.

14.14: Increase to at least 90 percent the proportion of

pregnant women and infants who receive

risk-appropriate care.

14.15: Increase to at least 95 percent the proportion of

newborns screened by State-sponsored programs for

genetic disorders and other disabling conditions and to

90 percent the proportion of newborns testing positive for

disease who receive appropriate treatment.

14.16: Increase to at least 90 percent the proportion of

babies aged 18 months and younger who receive

recommended primary care services at the appropriate

intervals.

14.17: Reduce the incidence of spina bifida and other

neural tube defects to 3 per 10,000 live births.

*Duplicate objective.

13
APPENDIX B:

Bibliography for major Healthy People 2000 data systems

General:

+ Kovar MG. Data Systems of the National Center for

Health Statistics. Vital Health Stat 1(23). 1989.

+ National Center for Health Statistics. Health, United

States, 1995. Hyattsville, Maryland: Public Health

Service. 1996. Appendix I.

National Health and Nutrition Examination

Survey (including HHANES):

+ McDowell A, et al. Plan and operation of the second

National Health and Nutrition Examination Survey,

1976–80. National Center for Health Statistics. Vital

Health Stat 1(15). 1981

+ Maurer KR. Plan and operation of the Hispanic Health

and Nutrition Examination Survey, 1982–84. Vital Health

Stat 1(19). 1985.

+ Plan and operation of the third National Health and

Nutrition Examination Survey, 1988–94. National Center

for Health Statistics. Vital Health Stat 1(32). 1994.

+ Ezzati TM, et al. Sample design: Third National Health

and Nutrition Examination Survey. National Center for

Health Statistics. Vital Health Stat 2(113). 1992.

National Survey of Family Growth:

+ Waksberg J, Sperry S, Judkins D, Smith V. National

Survey of Family Growth, Cycle IV, evaluation of linked

design. National Center for Health Statistics. Vital Health

Stat 2(117). 1993.

+ Judkins DR, Mosher WD, Botman S. National Survey of

Family Growth: Design, estimation, and inference.

National Center for Health Statistics. Vital Health Stat

2(109). 1991.

+ Waksberg J and Northrup DR. Integration of sample

design for the National Survey of Family Growth, cycle

4, with the National Health Interview Survey. Vital Health

Stat 2(96). 1985.

National Health Interview Survey:

+ Massey JT, Moore TF, Parsons VL, Tadros W. Design and

estimation for the National Health Interview Survey,

1985–94. National Center for Health Statistics. Vital

Health Stat 2(110). 1989.

+ Questionnaires from the National Health Interview

Survey, 1985–89. National Center for Health Statistics.

Vital Health Stat 1(31). 1993.

+ National Center for Health Statistics. Current estimates

from the National Health Interview Survey. National

Center for Health Statistics. Vital Health Stat 10.

Published annually.

National Hospital Discharge Survey:

+ Simmons WR and Schnack GA. Development of the

design of the NCHS Hospital Discharge Survey. Vital

Health Stat 2(39). 1970.

+ Haupt BJ and Kozak LJ. Estimates from two survey

designs: National Hospital Discharge Survey. National

Center for Health Statistics. Vital Health Stat 13(111). 1992.

+ National Center for Health Statistics. Detailed diagnoses

and procedures, National Hospital Discharge Survey.

National Center for Health Statistics. Vital Health Stat 13.

Published annually.

National Vital Statistics System:

+ National Center for Health Statistics. Vital Statistics of the

United States. Volume I. Natality; and Volume II.

Mortality. Hyattsville, Maryland: National Center for

Health Statistics. Published annually.

+ National Center for Health Statistics. Advanced report of

final natality statistics; and Advanced report of final

mortality statistics. MVSR, suppl. Hyattsville,

Maryland: National Center for Health Statistics. Published

annually.

National Notifiable Disease Surveillance

System:

+ Centers for Disease Control and Prevention. Summary of

notifiable diseases, United States. Morbidity and Mortality

Weekly Report. Published annually.

Youth Risk Behavior Survey:

+ Kann L, Kolbe LJ, Collins JL (eds.). Measuring the health

behavior of adolescents: The Youth Risk Behavior

Surveillance System and recent reports on high-risk

adolescents. Public Health Reports 108 (Suppl 1):1–67. 1993

School Health Policies and Programs Study:

+ Errecart MT, Ross JG, Robb W, et al. The School Health

Policies and Programs Study (SHPPS): Methodology. J of

School Health 8(65):295–301. 1995.

14
Published issues of Healthy People 2000 Statistical Notes

Number Title Date of Issue

1 Health Status Indicators for the Year 2000 Fall 1991

2 Infant Mortality Winter 1991

3 Health Status Indicators: Definitions and National Data Spring 1992

4 Issues Related to Monitoring the Year 2000 Objectives Summer 1993

5 Revisions to Healthy People 2000 Baselines July 1993

6 Direct Standardization (Age-Adjusted Death Rates) March 1995

7 Years of Healthy Life April 1995

8 Evaluating Public Health Data Systems: A Practical Approach June 1995

9 Monitoring Air Quality in Healthy People 2000 September 1995

10 Health Status Indicators: Differentials by Race and Hispanic Origin September 1995

11 Operational Definitions for Year 2000 Objectives: Priority Area 20, Immunization and

Infectious Diseases

February 1997

12 Operational Definitions for Year 2000 Objectives: Priority Area 13, Oral Health May 1997

13 Healthy People 2000 Midcourse Revisions: A Compendium August 1997

15
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