some may decline, and others may show no change. Although this makes overall assessments more complicated, it can be useful to highlight problems and gains in specific areas.

The committee focused on access problems that it believed, if corrected, were most likely to lead to improved health outcomes across the age spectrum. It identified indicators that could be used to measure changes in the degree of access to specific types of personal health care (defined as the one-on-one interaction of provider and patient). The committee's deliberations resulted in a list of 15 indicators that were grouped into several distinct categories. These categories define a set of national objectives (see above) for the personal health care system; each set of indicators provides a means for assessing progress toward a specific objective.

THE COMMITTEE'S INDICATORS AND PROGRESS TOWARD ACCESS OBJECTIVES

Objective 1: Promoting Successful Birth Outcomes

Numerous studies have shown links between the early initiation, amount, and content of prenatal care and birth outcomes. Outcomes that indicate problems in access include infant mortality, low birthweight, and incidence of congenital syphilis.

For all races slightly less than 70 percent of all women received adequate prenatal care in each year from 1986 to 1988. The percentage of women receiving early care increased steadily during the 1970s (from 67.9 percent for all races in 1970 to 75.9 percent in 1979) but remained static between 1980 and 1988. There is a striking difference between whites and blacks in receiving adequate prenatal care (73.5 and 50.7 percent, respectively) (Figure 1).

The U.S. infant mortality rate dropped 7 percentage points between 1989 and 1990, a significantly greater decline than occurred during previous years of the decade when the average annual decline was less than 3 percentage points. The average rate of decline during the 1980s was well below the annual average of 4.7 percentage points. However, the greatest portion of the decrease during the past two decades was in neonatal deaths, which probably reflects improvements in medical technology rather than better prenatal care. With respect to low birthweight, some decline in rates occurred during the 1970s, but no improvement was apparent during the 1980s.

Each case of congenital syphilis indicates either a lack of any prenatal care (even one prenatal care visit should alert a health care provider to the need for treatment) or a lack of adequate care (a prenatal visit at which an infected mother is not diagnosed is inadequate). Treatment of syphilis at least 30 days prior to delivery should prevent infection in the infant.



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