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CHAPTER 4 An Overview of Promising Interventions A major conclusion that can be drawn from the data presented in Chapters 1 through 3 (Part I ~ of this report is that reducing the incidence of low birthweight holds great promise for improving the outcome of pregnancy and reducing infant mortality over the next decade. In Part II, summarized in this brief chapter, the committee explores various approaches to preventing low birthweight, based on current information and exper fence. The committee reviewed many possible strategies, evaluating in particular interventions that could reduce the major low birthweight risk factors summarized in Chapter 2. The inquiry has been limited to interventions in the general domain of health services--an appropriate focus given the composition of the committee and its charge. The committee did not, for example, assess the relationship to pregnancy outcome of the majority of social welfare and income redistribution programs, although it is apparent that a variety of approaches well outside the purview of health services have much to contribute to reducing low birthweight. For example, the income maintenance experiment in Gary, Indiana, suggested a positive relationship between income supplementation and pregnancy outcome.) A1SO, research has suggested a link between high-quality early childhood education for economically disadvantaged children and lower pregnancy rates in the teenage years for the "graduates. of such programs--a significant finding because of the increased low birthweight risk among adolescent mothers.2 Reducing poverty and improving education could do much to decrease low birthweight, given the strong associations among birthweight socioeconomic status, and education (Chapter 3), but such perspectives are not explored in this report. The committee's review of health-related strategies has led to the conclusion that, despite many unanswered questions regarding the causes of and risks associated with low birthweight, policymakers and health professionals know enough at present to intervene more vigorously to reduce the incidence of low birthweight in infants. Methods already available have demonstrated their value in reducing low birthweight. These and a few new measures, detailed in following chapters, merit additional support and investment. No single approach will solve the low bir thweight problem. Instead, several types of programs should be 115

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116 undertaken simultaneously. These range from specific medical procedures to broad scale public health and educational approaches. Promising Strategies Activities that have been shown to reduce low birthweight or that have the potential for doing so can be grouped into five major areas. These clusters are: 1. Reducing r isks associated with low birthweight in the interval before pregnancy by means of risk identification, counseling, and risk reduction; enlarging the content of general health education related to reproduction; and expanding and improving the provision of family planning services (Chapter 5~. 2. Increasing the accessibility of early and regular high-quality prenatal care services to all women. Achieving this goal entails understanding the reasons why some women still obtain little or no prenatal care, and systematically removing major barriers (Chapter 7~. 3. Strengthening and expanding the content of prenatal care for all women, and increasing the flexibility of such services to meet the varied needs of individual women. For women identified as being at elevated risk of delivering a low birthweight infant, certain components of care should be emphasized to lessen defined risks and to detect preterm labor or intrauterine growth retardation as early as possible to allow treatment of these conditions where feasible reshaper 8~. 4. Mounting a long-term, extensive public information program to convey a few well-chosen messages aimed at preventing low birthweight (Chapter 9~. S. Conducting a multifaceted program of research on low birthweight. Topics on which research is needed span many of the sciences--basic biomedical research, epidemiology, social and behavioral sciences, and health services research and evaluation. The committee attaches great importance to this last strategy. AS noted in earlier chapters, much remains to be learned about the etiology of low birthweight and the risks associated with it. In subsequent chapters, numerous research topics are highlighted, including issues in the content of prenatal care, how best to encourage high-risk, hard-to-reach women to enroll early in prenatal care, and how to decrease such behavioral risks as smoking during pregnancy. These and other research issues are noted throughout the report and are not confined to a single chapter. Due to a lack of adequate data, the committee was not able to calculate the precise impact of the recommended interventions on the incidence of low birthweight, although both chapters 3 and 6 suggest the potential effects on the low birthweight rate of providing prenatal care to all pregnant women beginning in the first trimester. The

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117 committee believes, however, that if the interventions described in this report were implemented, it is reasonable to project that the nation would be able to meet the goal set by the Surgeon General for 1990: that low birthweight babies should constitute no more than 5 percent of all live births and that no county or racial/ethnic subpopulation should have a rate of low birthweight that exceeds 9 percent of all live births. 3 The committee was not able to calculate the costs or cost- effectiveness of the recommended interventions because of problems in the quality and uniformity of available cost data, difficulties in delineating the specific services to be offered, and uncertainties about the def initial of target populations. For example, estimates of the costs of measures that should be implemented in the per iod before pregnancy to reduce the r isks associated with low birthweight are not available. Information does exist on the cost-effect~veness of family planning, but it does not include calculations of the economic impact of projected changes in the low birthweight rate resulting from family planning practices, and the committee did not undertake such an analysis. Lack of adequate data also prevented the committee from estimating the additional public expenditures that would be required to finance the recommended public information program and research efforts. With regard to extending the availability of prenatal care, however, the committee found that a straightforward, common sense analysis could be performed regarding some of the financial implications involved in the provision of prenatal services to pregnant women (Chapter 103. The committee defined a target population of high-risk women (women with less than a high school education and on welfare) who often do not begin prenatal care in the first trimester of pregnancy. The current low birthweight rate in this group is about 11.5 percent. The committee estimated the increased expenditures that would be required to provide routine prenatal care to all members of the target population from the first trimester to the time of delivery. These expenditures were compared to savings that could be anticipated through a decreased incidence of low birthweight resulting front the improved utilization of prenatal care by the target population. The savings were estimated for a single year only and consisted of initial hospitalization costs, rehospitalization costs, and ambulatory care costs associated with general morbidity. The many assumptions that shaped these calculations are detailed in the chapter. The analysis showed that if the i mproved use of prenatal care reduced the rate of low birthweight in the target population from 11.5 percent to only 10 .76 percent, the ~ ncreased expenditures for prenatal services would be approximately equal to a so ngle year of cost savings in direct medical care expenditures for low bi~thweight infants in the target population. It the rate were reducer to Y percent (tne upper limit of the Surgeon General's goal described above), every additional dollar spent for prenatal care within the target group would save $3.38 In the costs of care for low birthweight infants because there would be fewer low birthweight infants requir ing expensive medical care.

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118 National Direction for a National Problem Moving ahead in the directions advocated in this report will re- quire that the issue of low birthweight become more widely understood and recognized as an important national problem. For too long this issue has been the concern only of those interested in maternal and child health. Low birthweight and its consequences merit the atten- tion of Congress, state governments, professional groups, business and labor organizations, church and women's groups, schools, and the media. Each should become involved in addressing the problem of low birthweight. The federal government, particularly the executive branch, is uniquely positioned to play a leadership role in stimulating necessary discussion and action. Its visibility and resources are great, and the public is attentive to its pr for ities . The committee urges that the Depar tment of Health and Human Services define and pursue a variety of activities designed to focus attention on low birthweight--its importance, its causes and associated r isks, and pathways for its Prevention. Such leadership must include an increased commitment of resources to the low birthwe~ght problem through approaches such as those outl ined in th is report. Coupled with broad scale discussion in the private and public sectors, such federal leadership will increase the nation's awareness of the low birthweight challenge and help create the capacity to reduce its ~ incidence. References and Notes 1. Kehrer B and Wolin C: Impact of income maintenance on low birthweight: Evidence from the Gary experiment. J. Hum. Resourc. 14:434-462, 1979. Weikart DP: The cost effectiveness of high quality early childhood education programs. Testimony prepared for the Select Committee on Children, Youth and Families. Washington, D.C.: U.S. House of Representatives, June 30, 1983. Public Health Service: Promoting Health/Preventing Disease: Objectives for the Nation, pp. 17-18. Washington, D.C.: U.S. Government Pr inting Off ice, Fall 1980.