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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
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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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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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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.
Representative terms from entire chapter:
prenatal care
