birth outcomes. In this regard the committee supports the National Fetal and Infant Mortality Review Program established by the American College of Obstetrics and Gynecology. This program is designed to assist communities in identifying specific causes of infant and fetal mortality and the barriers that need to be addressed. Community-based studies will also help clarify how the constellation of available resources and the way they are organized affect outcomes.

Financial Barriers to Access. The committee recommends the continuation of efforts to develop a better understanding of the relationship between income and access to prenatal care. The committee was encouraged by the results of a pilot project in New York City that linked birth certificate data with Census Bureau income data by zip code. States should subscribe to the long-term objective of computerizing their birth and death records in ways that will promote small-area analyses and needs assessment—not only in terms of income but also in relation to other characteristics of local communities.

Improved Measurement of Prenatal Services. Although the committee has chosen to use the modified Kessner index as a measure of the adequacy of prenatal care, this method is not without its problems. Federal agencies and the states need to continue to develop better indices of adequate prenatal care. The federal Bureau of Maternal and Child Health, for example, has supported state efforts to develop a common outcome-oriented minimum data set and a standard definition of adequate prenatal care. Efforts should be made to develop an index that measures the timing, sensitivity, content, and quality of prenatal care and that accounts for the effects of various risk factors in determining adequacy.

Outcome Indicator: Infant Mortality

Infant mortality refers to children who die before their first birthday. Subcomponent measures of infant mortality are derived by dividing the first year after birth into two stages: neonatal (28 days old or younger) and postneonatal (between 28 days and 1 year of age). Each measure may provide potentially useful information about barriers to health care access. Dividing the first year of life into two parts allows identification of the most appropriate health interventions for specific infant age groups. Reducing neonatal mortality requires not only that steps be taken during pregnancy to increase birthweight but also that intrapartum and newborn care be improved. To achieved the latter, reorganized perinatal services have been put in place. Interventions intended to reduce postneonatal mortality must focus on improving well- and sick-child care and on intensive follow-up of high-risk infants (Centers for Disease Control, 1989b).



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