Improving Birth Outcomes - Position Statement

I. ASTHO Supports State and Territorial Efforts Designed to Improve Birth Outcomes

The Association of State and Territorial Health Officials (ASTHO) supports state and territorial health agencies in their work to improve birth outcomes through policy and comprehensive system-wide changes. Improving birth outcomes will improve the health of mothers and their children across their lifespans. Health officials can leverage public health, social services, and primary care to improve quality and reduce costs to the healthcare system and families.

II. ASTHO Recommends

• Developing comprehensive and systematic approaches to improve birth outcomes by prioritizing prevention policies across disciplines, enabling and facilitating access to care, and improving state public health infrastructure, with an emphasis on reducing health disparities.
• Using the executive leadership of state health officials to develop strategic partnerships at the local, tribal, state, and national levels that leverage public, private, and nonprofit organizations to develop cross-cutting programs, influence policy development, and provide consistent messaging.
• Supporting state and territorial health agency leaders in seamlessly providing a continuum of services to families by improving collaboration, coordination, and funding across public health, social, and medical programs. This includes programs such as Title V Maternal and Child Health (MCH) grants; Women, Infants, and Children (WIC) grants; Title X Family Planning grants; home visitation programs; and Medicaid, as well as many public health and medical programs, including such programs as services to children with special healthcare needs, HIV, injury and violence prevention, oral health, chronic disease, early learning, and behavioral health.
• Addressing health disparities by incorporating approaches that modify or influence social determinants of health, such as changing the environments in which families live or improving the ability of families to thrive in their environments. This includes mobilizing community health and wellness resources, identifying individuals and communities of greatest need, and using proven practices to engage, inform, and deliver needed health services.
• Developing, reviewing, and enhancing regional care systems, especially neonatal intensive care units (NICUs) and perinatal care, for high-risk pregnancies and deliveries in collaboration with healthcare provider organizations, hospitals, and payers.
• Facilitating strategies to promote preconception health, intrapartum care, healthcare, and reproductive life planning within existing family planning, healthcare, educational, and public health settings.
• Enhancing prenatal care interventions for women with Medicaid coverage who are at high risk for preterm birth.
• Reducing non-medically-indicated elective inductions and Cesarean sections prior to 39 weeks gestation by working closely with patients, providers, hospitals, private insurers, and Medicaid to make 39 weeks of gestation the standard of care.
• Working closely with insurers and healthcare providers to ensure smoking cessation programs are part of the care provided, including all appropriate screening, assessment, counseling, and treatment services.
• Working closely with the public, new mothers and their families, caretakers, and healthcare providers to implement infant safe sleep education campaigns.
• Strategic planning among stakeholders and partners, including private and public insurers, to identify resource needs and opportunities to obtain federal, state, and private funding to serve all high‐risk families.
• Funding and supporting rigorous quality improvement and program evaluation practices through optimal use of health data from the local, state, regional, and national levels to demonstrate MCH program effectiveness.
• Continuous evaluation using public health surveillance systems to track progress in populations, communities, and states and territories. Data to track include vital statistics, hospital discharge data, electronic health records, and health surveillance systems, such as fetal infant mortality review. Birth outcome data at the state and territorial level will enable state and territorial health agencies to develop programs and policies that support improving birth outcomes and contribute to development and use of evidence-based practices.

III. Background

ASTHO’s members are responsible for ensuring the health of the residents in their states and territories. State health officials and their leadership teams are uniquely positioned to affect maternal and child health outcomes in their states and communities. Led by the state health official, these leadership teams are key components of successfully engaging partners and implementing interventions through state health agencies at the state and local levels. In October 2011, ASTHO President David Lakey (TX) declared improving birth outcomes as his President’s Challenge to all state and territorial health officials.
There are multiple strategies for improving birth outcomes and maternal health. A priority area of focus is on preventing preterm births. Preterm birth is the leading cause of neonatal death. Preterm births also increase the chance of disabilities and developmental delays among infants who survive. Infants born before 34 weeks gestation are more likely to die or experience lifelong morbidity. Preterm births often result in less healthy babies than full-term infants. Most preterm infants are low birth weight, which places the infant at greater risk of developing adult chronic conditions, such as diabetes and heart disease. In the United States, the preterm birth rate has increased more than 30 percent in the last 20 years, costing billions of dollars each year. The medical, educational, and lost productivity costs associated with preterm birth were more than $26 billion in 2005, equaling $51,600 per infant born preterm.
Non-medically-indicated or elective labor inductions and C-sections have increased. One study of a hospital system found that 44 percent of deliveries were scheduled C-sections, with 71 percent of those being elective. Deliveries between 37 and 38 weeks account for 17.5 percent of live births in the United States. Babies delivered between 37 and 39 weeks have higher risks of complications than babies born at 39 and 40 weeks. Some complications include increased neonatal intensive care (NICU) admissions, the need for ventilator support, and difficulty breastfeeding.
The U.S. infant mortality rate of 6.14 deaths before age 1 per 1,000 live births is the lowest in U.S. history but is still higher than the Healthy People 2020 target of 6.0 deaths per 1,000 live births. Although the United States is experiencing a decrease in infant mortality, the causes are not fully understood. Infant mortality rates in individual states range from 4.7 to 10.0 deaths per 1,000 births. One of the most important factors contributing to infant mortality is the preterm birth rate in the United States. Other risk factors include birth defects and congenital anomalies, the sleeping position and location of infants, maternal smoking and secondhand smoke exposure, and overheating.
There are significant racial and ethnic inequities, at all economic levels, in preterm birth and infant mortality rates. In 2007, 18.3 percent of infants born to African American mothers were preterm, much higher than for Asian/Pacific Islanders (10.9%), Caucasians (11.5%), Latinos (12.3%), and American Indian/Alaskan Native women (13.9%). Preterm birth rates for infants born to African American mothers are higher in each preterm group, and, overall, African Americans experience an infant mortality rate more than twice the national average.

Approval History

Access Policy Committee Review and Approval on February 22, 2012.
Board Review and Approval on March 15, 2012.
Policy Expires on March 2014.
ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position statements are not voted on by the full ASTHO membership.

Related ASTHO Documents

• 21st Century Health System Position Statement (2008)
• Home Visiting Position Statement (2010)
• Obesity Prevention and Control Position Statement (2008)
• Prevention Policy Statement (2008)
• Newborn Screening Position Statement (2010)
• Reproductive Health Services Position Statement (2009)
• Tobacco Use Prevention and Control Position Statement (2010)

Notes

1. Healthy Babies Are Worth the Wait: Preventing Preterm Births Through Community-Based Interventions: An Implementation Manual. March of Dimes. 2009.
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3. Martin JA, Kirmeyer S, Osterman M, Shepherd RA. “Born a bit too early: Recent trends in late preterm births.” Hyattsville, MD: National Center for Health Statistics. 2009. NCHS data brief, no 24.
4. Board on Health Sciences Policy, Behrman RE, Butler AS (eds). Preterm Birth: Causes, Consequences, and Prevention. Committee on Understanding Premature Birth and Assuring Healthy Outcomes. National Academies Press. 2006. Available from: http://books.nap.edu/catalog.php?record_id=11622.
5. Clark S, Miller D, Belford M, Dildy G, Frye D, Meyers J. “Neonatal and maternal outcomes associated with elective term delivery.” American Journal of Obstetrics and Gynecology. 2009. 200:156.e1-.e4.
6. Davidoff MJ, Dias T, Damus K, Russell R, Bettegowda VR, Dolan S, et al. “Changes in the gestational age distribution among U.S. singleton births: impact on rates of late preterm birth, 1992 to 2002.” Semin Perinatol. 2006. 30(1):8-15.
7. March of Dimes. Get Ready for Labor: Why at Least 39 Weeks Is Best for Your Baby. Available from: http://marchofdimes.com/pregnancy/getready_atleast39weeks.html. Accessed February 5, 2012.
8. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). March of Dimes. 2010. Available from: http://www.cdph.ca.gov/programs/mcah/Documents/MCAH-EliminationOfNon-MedicallyIndicatedDeliveries.pdf. Accessed April 26, 2012.
9. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary Data for 2010. Hyattsville, MD: National Center for Health Statistics. 2012. National Vital Statistics Reports; vol 60 no 4. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. Accessed April 26, 2012.
10. Healthy People 2020. Maternal, Infant, and Child Health. Available from: www.healthypeople.gov. Accessed February 5, 2012.
11. America’s Health Rankings. United States Infant Mortality 2011. United Health Foundation. Available from: http://www.americashealthrankings.org/ALL/IMR/2011. Accessed January 17, 2012.
12. “Sudden, Unexplained Infant Deaths.” In Shapiro C. Sudden, Unexplained Infant Death Investigation: A Systematic Training Program for the Professional Infant Death Investigation Specialist. Department of Health and Human Services. 2007. Available from: http://www.cdc.gov/sids/trainingmaterial.htm. Accessed April 26, 2012.
13. Martin JA. “Preterm Births: United States, 2007.” CDC Health Disparities and Inequalities Report — United States, 2011; Supplement vol 60. Hyattsville, MD: National Center for Health Statistics. 2011. Available from: http://www.cdc.gov/mmwr/pdf/other/su6001.pdf.
14. MacDorman MF, Mathews TJ. Recent Trends in Infant Mortality in the United States. Hyattsville, MD: National Center for Health Statistics. 2008. NCHS data brief, no 9. Available from: http://www.cdc.gov/nchs/data/databriefs/db09.pdf. Accessed April 26, 2012.