The State of Infant Health: Is There Trouble Ahead?

By Jennifer L. Howse, Ph.D. and Michael C. Caldwell, M.D., M.P.H.

The infant mortality rate (IMR) is a summary measure of the health and well-being of a nation. Do you believe America's infants are better off today than they were in 1990? If so, take a closer look at the data in this 2004 Edition of America's Health: State Health Rankings, because the results are mixed. While we have made some strides, we have also taken steps back. The latest IMR for the United States shows the first increase in more than 40 years (Kochanek, 2004). The current IMR of seven infant deaths per 1,000 live births is moving in the wrong direction - away from the Healthy People 2010 objective of 4.5 infant deaths per 1,000 live births (Kochanek et al, 2004). This ranks the United States 28th internationally (NCHS, 2003). Clearly, we still have more work to do for our communities, our families and our children.

There is certainly good news over the past decade. Significant progress has been made in the overall reduction of key risk factors related to infant health, reflecting improvements in both the provision of clinical services and successful public health promotion and education efforts. For example, there has been a welcome overall reduction in the prevalence of smoking, including among pregnant women. Public health agencies in collaboration with community partners have been instrumental in achieving this decline through smoking cessation programs, as well as policies and laws related to smoke-free public environments. In addition, more women are receiving adequate prenatal care, and the gap in the receipt of these services by race/ethnicity is decreasing. Again, local public health agencies have contributed markedly by enrolling eligible women and children into Medicaid and State Children's Health Insurance Programs. Through these programs, more high-risk women now have access to adequate prenatal care, and more children have health insurance coverage.

But despite these improvements, much work remains. In 2003, 12.6 million women of childbearing age and 9.1 million children under age 19 were uninsured (U.S. Census Bureau, 2004a). According to the Institute of Medicine, uninsured women receive fewer prenatal services and report greater difficulty in obtaining needed care than women with insurance (IOM, 2002). Similarly, health insurance status is the single most important influence in determining whether health care is accessible to children when they need it (IOM, 1998). One third of uninsured children have no usual source of medical care-nearly 10 times the rate of those with private coverage (NCHS, 2003). Coupled with increasing rates of child poverty, the future trend looks even more negative for our nation's children (U.S. Census Bureau, 2004b).

Largely responsible for the higher rate of IMR in the United States is the excess contribution of prematurity. Prematurity is the leading cause of neonatal mortality and the leading cause of infant mortality among black infants (Mathews et al, 2003). Babies born early and small are more likely to suffer health complications. Premature birth today is a common, costly and serious problem.

Today, there are nearly 500,000 babies born preterm in the United States, which is more than 12 percent of live births (NCHS, 2003). Rates have increased in all states over the last decade. Fourteen states and the District of Columbia had preterm rates of 13 percent or more, well over the national average of 12.1 percent. These states include: Alabama, Delaware, Florida, Hawaii, Kentucky, Louisiana, Mississippi, Missouri, Nevada, North Carolina, South Carolina, Tennessee, Texas and West Virginia (March of Dimes, 2003a).

Early and fragile births are not only a leading contributor to mortality but also a major cause of disability, chronic health problems and hospitalization. Annual hospital charges for infants born with any diagnosis of prematurity/low birthweight totaled $13.6 billion-nearly half of all hospital charges for infants in 2001 (March of Dimes, 2003b). Prematurity data are contrary to the optimistic views of the general public, which tend to be informed largely by "miracle baby survival stories" in the media.

Why are so many babies born premature? What can we do to address this major health concern? Risk factors for prematurity include: history of preterm birth, maternal age, multifetal pregnancy, stress, infection, smoking and obesity. Many of the causes are still unknown and require continued research.

The duration, severity and consequences of rising rates of preterm birth warrant the need for an immediate and comprehensive public health response. Toward this end, the March of Dimes has rallied national partners-the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Association of Women's Health, Obstetric and Neonatal Nurses-launching a National Prematurity Campaign. The overriding goal of this campaign is to reverse the rising trend of prematurity and to actually decrease the number of babies born too small and too soon. Campaign resources are being targeted to five areas:

1. Raising public awareness about the serious consequences of prematurity.
2. Educating pregnant women about the warning signs and symptoms of preterm labor, and providing service to families affected by prematurity.
3. Supporting health care practitioners in better risk detection.
4. Stimulating more public and private investment in research and clinical translation.
5. Advocating for increased access to health care for women of childbearing age and children.

Action and a sustained commitment from agencies across the United States will be needed to get results measured by an actual reduction in rates of preterm birth.

The challenge for the future is the reduction of these adverse birth outcomes at both state and national levels. This challenge will occur on several fronts:

• Addressing persistent disparities, particularly by racial/ethnic groups;
• Addressing the preventable causes of preterm birth;
• Increasing access to a range of services including prepregnancy and prenatal care; and
• Improving community health conditions, as well as new breakthroughs in obstetric and neonatal medicine.

As the public health infrastructure continues to experience increased burden, with fewer resources to deal with a growing number of responsibilities, protecting our needed and traditional programs and services is also important to improve the health of mothers and infants. We need a robust public health system to successfully promote healthier communities.

It is also important to reflect on past successes in promoting national public health campaigns aimed at improving children's health, such as immunization, anti-smoking, the Back to Sleep campaign and the
Folic Acid campaign. These successes would not be possible without the local community dialogue, leadership, partnerships and commitments that are so vital to improving outcomes on the ground, i.e., all health is local. Local efforts complement our national and state efforts and are key to any long-term success. The March of Dimes and the National Association of County & City Health Officials (NACCHO) invite your support to join together in a collective mission to achieve the goal of healthy children in healthy communities, starting at the moment of birth. For more information on the National Prematurity Campaign, visit the March of Dimes Web site- www.marchofdimes.com. Let's get to work.

References

Institute of Medicine. 1998. America's Children: Health Insurance and Access to Care. National Academy Press, Washington, D.C.

Institute of Medicine. 2002. Health Insurance Is a Family Matter. National Academy Press, Washington, D.C.

Kochanek K.D., Smith B.L. Deaths Preliminary Data for 2002. National vital statistics reports; Volume 52, Number 13. National Center for Health Statistics, Hyattsville, Md. 2004.

March of Dimes Perinatal Data Center. Unpublished analyses using the 2001 National Center for Health Statistics Natality file: 2003a. Retrieved from www.marchofdimes.com/peristats.

March of Dimes Perinatal Data Center. Unpublished analyses using the 2001 Agency for Healthcare Research and Quality, Nationwide Inpatient Sample: 2003b. Retrieved from www.marchofdimes.com/peristats.

Mathews T.J., Menacker F., MacDorman M.F. Infant mortality statistics from the 2001 period linked birth/infant death data set. National vital statistics reports; Volume 52, Number 2. National Center for Health Statistics, Hyattsville, Md. 2003.

National Center for Health Statistics. Health, United States, 2003. Hyattsville, Md. 2003.

United States Census Bureau. Data prepared for the March of Dimes using the March 2004 Current Population Survey: 2004a.

United States Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2003, Current Population Reports, Washington, D.C. 2004b.