In 2009, 12.2% of babies born in the United States were preterm—that is, more than 500 000 babies.1 In 2008, the infant mortality rate stood at 4.29 per 1000 live births.2 While both of these statistics are trending ever so slightly in the right direction, there is more that can be done. The health case alone is compelling: every child born in the United States deserves the best chance possible to start life with a healthy beginning. Add to that a just-as-compelling economic case—an Institute of Medicine report says that preterm birth and the associated complications have an economic cost of at least $26.2 billion3—it is clear that we as a society must do all that we can to accelerate the downward trends.
That is why I chose to challenge my state and territorial health official colleagues to take steps to improve infant mortality and morbidity in their states. Each year the incoming president of the Association of State and Territorial Health Officials (ASTHO) issues a challenge, and as ASTHO president in 2012, I issued the Healthy Babies President's Challenge, with 3 primary aims:
- Focus on improving birth outcomes as state health officials and state leadership teams work with state partners on health and community system changes.
- Create a unified message that builds on the best practices from around the nation and the efforts from Health and Human Services regions IV and VI (south and southeastern states, from New Mexico and Oklahoma to Kentucky and North Carolina), which can be adopted by states, US territories, and the District of Columbia.
- Develop clear measurements to evaluate targeted outreach, progress, and return on investment.
State and territorial health officials have the capability to have a tremendous positive impact in the area of maternal and child health. But do not mistake capability for ease. As with any endeavor, there are challenges. That is why I am proud and humble to report that health officials in 48 states and Washington, District of Columbia, have signed a pledge to work to reduce preterm birth and infant mortality in their states.
This is no small feat, and ASTHO has not worked alone in this endeavor. One of the inspirations for the Healthy Babies President's Challenge was the regional work that took place in regions IV and VI, which had the highest infant mortality and morbidity rates in the country. In the spring of 2010, representatives from these states met and committed to work together toward improvement in this area. By the end of the year, the Health Resources and Services Administration (HRSA) pledged support for this effort. With HRSA's help, regions IV and VI have convened several meetings where state teams featuring leaders across several areas of state government have met to share ideas and develop strategies for their states. A collaborative innovation network (CoIN) has emerged, and HRSA plans to use it as a model to roll out to the rest of the country.
Other partners have also been instrumental in this outreach. ASTHO partnered with the March of Dimes, which used its vast influence and prestige to encourage states to sign the Healthy Babies President's Challenge pledge and promised resources to states that did. The Association of Maternal and Child Health Programs has long been a leader in this area and deserves recognition for its daily contributions. HRSA's Healthy Start has been working to eliminate health disparities in child and maternal health for 2 decades; the Center for Medicare & Medicaid Services and other agencies recently launched the Strong Start program to “reduce the risk of significant complications and long-term health problems for both expectant mothers and newborns,” and the Centers for Disease Control and Prevention listed maternal and child health as priorities in both Healthy People 2010 and Healthy People 2020.
More important than challenges and pledges, however, are results. Those of us involved in public health know it can take years, even decades, to measure the impact of the strategies and programs we initiate. For example, one goal we established for the Healthy Babies President's Challenge in collaboration with the March of Dimes is to reduce preterm births by 8% by 2014, using 2009 as the baseline year—a 5-year time horizon. That is why it is especially gratifying to see the encouraging early results we are seeing.
In Texas, we developed the Healthy Texas Babies initiative, which included several proposals that were passed by the state legislature in 2011. One key part is a new Medicaid requirement where doctors must provide a medical reason why an induction or cesarean delivery is necessary before 39 weeks' gestation for the procedure to be covered—and each case is reviewed. As a result of our overall effort, we think we will reach or surpass our goal of reducing Medicaid expenditures by $7.2 million in 2 years. Combined with other local and statewide initiatives, we are well on our way to meeting the goal of reducing preterm birth by 8% and, importantly, reducing the health disparity gap that exists in maternal and child health outcomes.
Kentucky initiated its Healthy Babies Are Worth the Wait program in partnership with the March of Dimes in 2007. It targeted 3 sites, with several different intervention and community partnership programs, from prenatal health programs for expectant mothers to health care provider education to toolkits for community leaders. The results were dramatic. By 2010, the 3 sites experienced a 15.6% reduction in preterm births. Control sites without the interventions, selected because they shared similar characteristics with the test sites, experienced a 4.2% reduction.
Another example is Oklahoma's Every Week Counts project. A primary feature of their effort was a campaign to get the state's 59 birthing hospitals to voluntarily commit to a hard stop of no induced or caesarean deliveries before 39 weeks' gestation unless medically necessary. Eventually, 52 hospitals agreed, covering 95% of all births. The rates of inductions or scheduled caesarean deliveries before 39 weeks have plummeted throughout the latter half of 2011 and into 2012. The rate of inductions with a documented medical reason has fallen 26%, and the rate without a documented reason has tumbled 65%. These results need continued monitoring, but Oklahoma is seeing a noticeable reduction in the number of infants that need time in neonatal intensive care units.
My ASTHO President's Challenge spans 2012, but the healthy babies challenge must continue. We are seeing rapid progress and gaining momentum in our efforts. Building on this success we expect to continue to improve birth outcomes. Successful programs are being shared around the country through state health officials. For example, ASTHO has developed a resource (available at: www.astho.org/healthybabies) where state health agencies, local health agencies, and community and nongovernmental groups can learn about the strategies being implemented.
I encourage the entire public health enterprise—federal, state, and local governments; universities and researchers; and nongovernmental organizations—to continue the Healthy Babies President's Challenge. Here are 4 suggested areas of focus:
- Implement state policy change to eliminate elective inductions and caesarean deliveries prior to 39 weeks' gestation. Mechanisms can include hospital policies, payment/Medicaid policies, and individual and provider education.
- Improve access to care, including 17-Hydroxyprogesterone for all women of reproductive age as clinically indicated.
- Develop and implement a regional campaign to address the following aspects of women's health:
- Life course health—preconception/pregnancy/interconception;
- Smoking cessation, especially for pregnant women;
- Chronic conditions—obesity and diabetes; and
- Influenza immunizations for pregnant women.
- Safe sleep—individual education and community interventions to ensure families with newborns provide a safe sleeping environment for their infants.
Implementing these healthy babies strategies will save scarce health care dollars. More important, these efforts can save lives and prevent disabilities. People deserve a chance to reach their full potential. Let us make sure that all infants have the best chance for a strong and healthy start in life.
1. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final data for 2009. National vital statistics reports; vol 60 no 1. Hyattsville, MD: National Center for Health Statistics. 2011.
2. National Center for Health Statistics (US). Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville (MD): National Center for Health Statistics (US); 2012 May. Mortality. Available from: http://www.ncbi.nlm.nih.gov/books/NBK98772/
3. Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press, 2007.