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I n f a n t m o r t a l i t y i s commonly accepted as a s e n s i t i v e indicator of a society's general l e v e l of health. I t i s r e l a t e d n o t o n l y t o the a v a i l a b i l i t y and q u a l i t y o f m e d i c a l c a r e , b u t a l s o t o broad economic and s o c i a l factors. A l t h o u g h i n f a n t m o r t a l i t y r a t e s i n the U n i t e d S t a t e s have f a l l e n significantly i n the p a s t 20 y e a r s , European experience i n d i c a t e s t h a t the o v e r a l l r a t e can be lowered f u r t h e r . A r e d u c t i o n o f 40% i s a r e a l i s t i c l o n g - t e r m g o a l . Moreover, t h e r e are major d i f f e r e n c e s i n i n f a n t m o r t a l i t y r a t e s w i t h i n the U n i t e d S t a t e s . R a c i a l , socioeconomic and geographic v a r i a n t s are o f s e r i o u s concern. I n f a n t m o r t a l i t y i s the f i r s t area o f concern t o be c o n s i d e r e d i n the Board on Medicine's study of "Contrasts i n Health Status: A Comparative Inquiry i n t o the H e a l t h Needs, B a r r i e r s and Resources o f S e l e c t e d P o p u l a t i o n Groups." T h i s h e a l t h t o p i c p r o v i d e s an i d e a l o p p o r t u n i t y t o e x p l o r e the e f f e c t s o f a t t i - tudes, b e h a v i o r and e d u c a t i o n on m a t e r n a l and i n f a n t h e a l t h ; the i n f l u e n c e o f s o c i a l s e r v i c e systems and how changes i n t h e i r o r g a n i z a t i o n might c o n t r i b u t e d i r e c t l y t o improved h e a l t h ; e f f e c t i v e a l l o c a t i o n o f m e d i c a l resources and i n - c e n t i v e s encouraging t h e i r e f f i c i e n t use; and the a c c e s s i b i l i t y , c o s t s and utili- z a t i o n o f m a t e r n a l and i n f a n t care s e r v i c e s . D e t a i l e d analyses o f i n f a n t b i r t h and death data are planned which w i l l a l l o w us t o examine the r e l a t i v e impact o f demographic, socioeconomic, b i o l o g i c and m e d i c a l care v a r i a b l e s i n d e t e r m i n i n g i n f a n t m o r t a l i t y experience. The e x p l o r a t i o n and c a r e f u l e v a l u a t i o n o f such i m p o r t a n t v a r i a b l e s w i l l a l l o w us t o c r i t i c a l l y assess the p r e s e n t o r g a n i z a t i o n and d e l i v e r y o f m a t e r n a l and i n f a n t care s e r v i c e s and t o develop alternative p r o p o s a l s f o r i m p r o v i n g these arrangements. L i t e r a t u r e reviews and analyses o f raw data w i l l be completed. The f o l l o w i n g areas have been s e l e c t e d f o r d e t a i l e d consideration: I. Programs f o r the D e l i v e r y o f M a t e r n a l and I n f a n t H e a l t h S e r v i c e s II. Economics o f M a t e r n a l and I n f a n t Care
2. III. R i s k F a c t o r s and the R e l a t i o n s h i p s o f R i s k , Care and Outcome IV, A n a l y s i s o f F a c t o r s A s s o c i a t e d w i t h Low R i s k Groups V. A n a l y s i s o f F a c t o r s A s s o c i a t e d w i t h H i g h R i s k Groups A v a i l a b l e d a t a w i l l be assessed and areas f o r f u t u r e i n v e s t i g a t i o n de- fined. These r e p o r t s w i l l be c i r c u l a t e d t o t h e C o n s u l t a n t s and s t a f f and i n p a r t w i l l form t h e summary p u b l i c a t i o n on I n f a n t and P e r i n a t a l M o r t a l i t y .
I. Programs f o r the D e l i v e r y of M a t e r n a l and I n f a n t H e a l t h S e r v i c e s Analyses o f the p r e s e n t system i n the U n i t e d S t a t e s f o r the d e l i v e r y o f m a t e r n a l and i n f a n t h e a l t h s e r v i c e s w i l l be based upon e x a m i n a t i o n o f what i s a v a i l a b l e , how these s e r v i c e s compare w i t h accepted s t a n d a r d s , how realistic the standards are and how s e r v i c e s i n the U n i t e d S t a t e s compare w i t h those in selected foreign countries. H i s t o r i c a l development o f m a t e r n a l and i n f a n t h e a l t h s e r v i c e s i n the U n i t e d S t a t e s w i l l be c o n s i d e r e d . Examination w i l l be made o f those socioeconomic, p o l i t i c a l and t e c h n o l o g i c a l f a c t o r s which have s t i m u l a t e d the l e g i s l a t i v e authori- z a t i o n , i n c r e a s e d e x p e n d i t u r e s and d r a m a t i c a l l y broadened scope of contemporary p u b l i c programs. Emphasis w i l l be g i v e n t o the f e d e r a l m a t e r n a l and infant health services. E f f o r t s o f s t a t e and l o c a l governmental agencies and those o f the p r i v a t e m e d i c a l s e c t o r w i l l a l s o be c o n s i d e r e d . T h i s summarization of h i s t o r - i c a l data w i l l p r o v i d e the f o u n d a t i o n f o r a n a l y s i s of c u r r e n t m a t e r n a l and infant h e a l t h care programs. C u r r e n t m a t e r n a l and i n f a n t h e a l t h care s e r v i c e s i n the U n i t 6 d S t a t e s w i l l be compared w i t h care standards developed by the American C o l l e g e o f O b s t e t r i c s and Gynecology and the American Academy o f P e d i a t r i c s . Organization, administra- t i o n and f i n a n c i n g o f these programs w i l l be c o n s i d e r e d . Analyses w i l l i n c l u d e a c c e s s i b i l i t y and u t i l i z a t i o n o f s e r v i c e s f o r p r e n a t a l , d e l i v e r y and postpartum m a t e r n a l c a r e , i n f a n t care and f a m i l y p l a n n i n g . Geographic d i s t r i b u t i o n o f pub- l i c and p r i v a t e m e d i c a l resources w i l l be analyzed i n r e l a t i o n t o p o p u l a t i o n d i s t r i b u t i o n and i n f a n t m o r t a l i t y r a t e s . A l t e r n a t i v e methods o f o r g a n i z i n g and f i n a n c i n g such s e r v i c e s w i l l be proposed. S o c i a l and h e a l t h s e r v i c e s systems o f s e l e c t e d f o r e i g n c o u n t r i e s w i l l a l s o be analyzed. F a c t o r s s t i m u l a t i n g c r e a t i o n o f t h e i r c u r r e n t programs w i l l be c o n s i d e r e d . Scope o f s e r v i c e s , c o s t , f i n a n c i n g and e f f e c t i v e n e s s w i l l be
4. assessed. F e a s i b i l i t y o f m o d i f y i n g procedures e f f e c t i v e i n o t h e r c o u n t r i e s f o r i n c o r p o r a t i o n i n t o American e x p e r i e n c e w i l l be examined. II. Economics o f M a t e r n a l and I n f a n t Care The e f f e c t o f Income I n e q u a l i t y and a v a i l a b i l i t y o f m e d i c a l resources w i l l be c o n s i d e r e d . C h a r a c t e r i s t i c s o f t h e poor, near poor, middle and upper c l a s s e s w i l l be s t u d i e d . Emphasis w i l l be g i v e n those c h a r a c t e r i s t i c s o f t h e poor, such as e d u c a t i o n a l a t t a i n m e n t and s i z e o f f a m i l y , w h i c h a r e o f p a r t i c u l a r relevance t o i n f a n t m o r t a l i t y . Analyses w i l l determine need f o r a separate d e f i n i t i o n of poverty i n r e l a t i o n t o health. F a c t o r s a f f e c t i n g t h e r e c e i p t o f care w i l l be c o n s i d e r e d : availability of m e d i c a l r e s o u r c e s , i n s u r a n c e coverage, p r o v i d e r c o s t and consumer p r i c e s . Secular t r e n d s w i l l be c o n s i d e r e d where p o s s i b l e . Examination w i l l be made t o determine t h e e f f i c i e n c y o f p r e s e n t systems i n a l l o c a t i n g r e s o u r c e s . Special emphasis w i l l be g i v e n t o t h e e f f i c i e n t i n t e r n a l and community use o f h o s p i t a l facilities. III. R i s k F a c t o r s and t h e R e l a t i o n s h i p o f R i s k , Care and Outcome The i n f l u e n c e o f s e l e c t e d demographic, socioeconomic and b i o l o g i c factors on i n f a n t m o r t a l i t y w i l l be reviewed. Secular t r e n d s i n a g e - s p e c i f i c m o r t a l i t y r a t e s and causes o f i n f a n t d e a t h s , u r b a n - r u r a l r a t e d i f f e r e n c e s , and t h e i n t e r - r e l a t i o n s h i p s o f m a t e r n a l age and p a r i t y , r a c e , socioeconomic status, birthweight, g e s t a t i o n a l age, d u r a t i o n o f i n t e r c o n c e p t u a l p e r i o d and p r e v i o u s o b s t e t r i c a l e x p e r i e n c e w i l l be summarized. A woman's i n f a n t m o r t a l i t y r i s k can be assessed u s i n g known demographic and s o c i a l v a r i a b l e s . M a r t i n F e l d s t e i n ("A Method o f E v a l u a t i n g P e r i n a t a l Mor- t a l i t y Risk," B r i t J Prev Soc Med 19:135-139, 1965) u t i l i z e d a m u l t i p l e r e g r e s - s i o n a n a l y s i s f o r 1958 B r i t i s h data t o e v a l u a t e t h e combined e f f e c t o f age, parity
and f a t h e r ' s o c c u p a t i o n on p e r i n a t a l m o r t a l i t y r i s k . On a s c a l e i n w h i c h 100 corresponds t o the mean n a t i o n a l p e r i n a t a l m o r t a l i t y , he c a l c u l a t e d t h a t a woman aged 38 h a v i n g h e r f o u r t h c h i l d has a r i s k o f 129.15, w h i l e a 23 year o l d h a v i n g her second c h i l d has a r i s k o f 84.11. T h i s approach t o d e v e l o p i n g a r i s k index can be expanded by i n c o r p o r a t i n g o t h e r v a r i a b l e s such as e d u c a t i o n o f mother and/or f a t h e r , m a r i t a l s t a t u s , time between successive b i r t h s and o t h e r p e r t i n e n t factors. A p o p u l a t i o n o f women can then be d i v i d e d i n t o known q u a n t i t a t i v e r i s k groups; i . e . , on F e l d s t e i n ' s s c a l e , 50, 59 t o 99, 100 t o 150, e t c . Within each r i s k group the e f f e c t o f p r e n a t a l care w i l l be r e l a t e d t o outcome by employing b o t h m o r b i d i t y and m o r t a l i t y i n d i c e s f o r mother and i n f a n t . Data recorded on the New York C i t y b i r t h c e r t i f i c a t e f o r the year 1968 i n c l u d e s a r e s e a r c h s e c t i o n and i m p o r t a n t s o c i o l o g i c d a t a . Copies o f t h e f e t a l d e a t h , l i v e b i r t h , and l i n k e d b i r t h and d e a t h r e c o r d s f o r New York C i t y f o r t h i s year w i l l enable t h e analyses d e s c r i b e d above t o be completed. Risk i n r e l a t i o n t o socioeconomic and b i o l o g i c f a c t o r s w i l l be e v a l u a t e d u s i n g such independent v a r i a b l e s as mother's e d u c a t i o n , m a r i t a l s t a t u s , p r e v i o u s c h i l d b i r t h e x p e r i e n c e , p a r i t y , age and i n t e r c o n c e p t u a l t i m e . P r e n a t a l care can a l s o be e v a l u a t e d from these data u s i n g time o f f i r s t p r e n a t a l v i s i t , t o t a l number o f p r e n a t a l v i s i t s , t e s t s performed d u r i n g p r e n a t a l p e r i o d , mode o f d e l i v e r y , k i n d o f a t t e n d a n t a t d e l i v e r y and h o s p i t a l o f d e l i v e r y . Outcome o f t h i s pregnancy can be assessed u t i l i z i n g m o r b i d i t y data such as number and k i n d o f diagnoses made d u r i n g antepartum p e r i o d , d u r a t i o n o f l a b o r , Apgar s c o r e , b i r t h w e i g h t , c o n g e n i t a l m a l f o r m a t i o n s , f e t a l and i n f a n t d e a t h . These data a r e a l l recorded on t h e r e v i s e d New York C i t y b i r t h certificate. A v a r i e t y o f d i s c r i m i n a n t f u n c t i o n techniques can be employed t o q u a n t i t a t e r i s k by b o t h socioeconomic and m e d i c a l f a c t o r s and then t o r e l a t e r i s k t o care and
outcome. The s t a t i s t i c a l methods and t h e d e t a i l s o f such analyses w i l l be de- veloped w i t h t h e h e l p o f our c o n s u l t a n t group. IV. A n a l y s i s o f F a c t o r s A s s o c i a t e d w i t h Low R i s k Group Examination o f crude i n f a n t m o r t a l i t y r a t e s among non-white r a c i a l groups r e v e a l s a f o u r - f o l d range o f v a l u e s . I n 1967, Chinese- and Japanese-Americans had crude i n f a n t m o r t a l i t y r a t e s o f 9.5 and 10.7 per 1,000 l i v e b i r t h s , w h i l e Negro and American I n d i a n r a t e s were 37.5 and 30.8 r e s p e c t i v e l y . Infant mortality r a t e s f o r Americans o f Japanese and Chinese descent were h a l f t h a t o f t h e Caucasian p o p u l a t i o n ; these r a t e s a r e comparable t o t h e b e s t r e c o r d o f any group i n t h e w o r l d today. I t seems o f c r i t i c a l importance t o determine t h e v a l i d i t y o f these data and e v a l u a t e t h e s o c i a l , economic, c u l t u r a l and b i o l o g i c v a r i a b l e s associated w i t h t h i s favorable m o r t a l i t y experience. A l i t e r a t u r e r e v i e w o f s e l e c t e d s o c i a l , economic, c u l t u r a l and m e d i c a l care c h a r a c t e r i s t i c s o f Japanese- and Chinese-Americans w i l l be completed. W i t h c o o p e r a t i o n o f t h e C a l i f o r n i a S t a t e Department o f H e a l t h , crude infant m o r t a l i t y r a t e s among s p e c i f i c r a c i a l groups w i l l be a d j u s t e d f o r d i f f e r e n c e s i n m a t e r n a l age, p a r i t y and s o c i a l c l a s s . A f i e l d s t u d y w i l l be conducted i n c l u d i n g matched samples o f Caucasian, Negro and Mongolian p a r t i c i p a n t s who have had a l i v e b i r t h i n t h e S t a t e o f C a l i f o r n i a d u r i n g t h e c a l e n d a r year 1968, D e t a i l s o f s o c i a l , economic, c u l t u r a l and m e d i c a l care d a t a n o t a v a i l a b l e from v i t a l s t a t i s t i c a l m a t e r i a l , w i l l be o b t a i n e d t h r o u g h an e x t e n s i v e household interview. I I n c o n j u n c t i o n w i t h t h e C a l i f o r n i a S t a t e Department o f H e a l t h , a n a l y s i s of i n f a n t m o r t a l i t y r a t e s f o r t h e c o h o r t 1965-1967 by age o f i n f a n t deaths will be conducted on a r a c e - s p e c i f i c b a s i s d i f f e r e n t i a t i n g s u b j e c t s o f W h i t e , White w i t h Spanish surname, Negro, Japanese, Chinese, and F i l i p i n o descent. Utilizing
7. the u s u a l time d i v i s i o n s ( f e t a l , n e o n a t a l , p e r i n a t a l , p o s t n a t a l and i n f a n t ) , m o r t a l i t y r a t e s w i l l be c a l c u l a t e d by age a t time o f i n f a n t d e a t h f o r each o f these groups. These r a t e s w i l l then be a d j u s t e d f o r d i f f e r e n c e s i n age, p a r i t y and o c c u p a t i o n f o r each group, u s i n g t h e M a n t e l Haenszel C h i Square M o d i f i c a t i o n t o i n d i c a t e t h e r e l a t i v e r i s k o f d e a t h f o r each group. A s i m i l a r a n a l y s i s w i l l be conducted f o r t h e year 1968, u s i n g New York city l i n k e d b i r t h and i n f a n t death r e c o r d s . These d a t a i n c l u d e t h e e d u c a t i o n o f the mother and f a t h e r . A f t e r c o m p l e t i n g t h e a n a l y s i s o f t h e C a l i f o r n i a d a t a f o r t h q 1965-1967 c o h o r t , a d e c i s i o n w i l l be made as t o t h e v a l i d i t y o f t h e d i f f e r e n c e i n crude i n f a n t m o r t a l i t y f o r t h e s e v e r a l non-white groups. I t w i l l then be determined i f a f i e l d study i s i n d i c a t e d . V. F a c t o r s C o n t r i b u t i n g t o E s p e c i a l l y High R i s k I n v e s t i g a t i o n w i l l be made o f i n f a n t m o r t a l i t y among e s p e c i a l l y h i g h r i s k groups such as American I n d i a n s , r e s i d e n t s o f depressed areas ( i . e . A p p a l a c h i a ) and m i g r a n t w o r k e r s . The f e d e r a l government funds programs d i r e c t e d toward t h e improvement o f h e a l t h among t h i s p o p u l a t i o n . Using d a t a from f e d e r a l governmental agencies and s t a t e and l o c a l h e a l t h departments, comparison w i l l be made o f s e c u l a r t r e n d s , a g e - s p e c i f i c m o r t a l i t y r a t e s and causes o f i n f a n t deaths w i t h those f o r t h e g e n e r a l p o p u l a t i o n . Demographic, economic, s o c i a l and c u l t u r a l c h a r a c t e r i s t i c s w i l l be examined. A v a i l a b i l i t y and u t i l i z a t i o n o f resources f o r m a t e r n a l and c h i l d h e a l t h care w i l l be c o n s i d e r e d .
8. The p r e c e d i n g l i t e r a t u r e r e v i e w s and analyses o f raw d a t a w i l l p r o v i d e a more p r e c i s e p i c t u r e o f i n f a n t m o r t a l i t y w i t h i n t h e U n i t e d S t a t e s . Data from New York w i l l p e r m i t analyses o f t h e urban g h e t t o b l a c k i n f a n t m o r t a l i t y c o n d i - t i o n . The C a l i f o r n i a s t u d y w i l l p r o v i d e comparisons o f i n f a n t m o r t a l i t y e x p e r i - ence among t h r e e r a c i a l groups, i . e . , Caucasian, N e g r o i d and Mongoloid. Studies o f A p p a l a c h i a r e s i d e n t s , m i g r a n t s and t h e American I n d i a n w i l l p r o v i d e d a t a on the i n f a n t m o r t a l i t y e x p e r i e n c e among t h e r u r a l poor. Hypotheses such as t h e f o l l o w i n g may then be e x p l o r e d : 1) I n f a n t and p e r i n a t a l m o r t a l i t y r a t e s a r e independent o f r a c i a l s t o c k ; 2) i n f a n t m o r t a l i t y r a t e s a r e independent o f s o c i a l c l a s s w i t h i n r a c i a l groups; 3) i n f a n t b i r t h w e i g h t w i t h i n r a c i a l groups i s independent o f s o c i a l c l a s s ; 4) when causes o f d e a t h a r e separated by m e d i c a l care d e l i v e r y and e n v i r o n m e n t a l f a c t o r s , i n f a n t m o r t a l i t y r a t e s a r e independent o f cause o f d e a t h . Alternative programs and f i n a n c i n g f o r t h e d e l i v e r y o f m a t e r n a l and i n f a n t care w i l l be c o n s i d e r e d . E f f e c t s o f income r e d i s t r i b u t i o n w i l l be analyzed. High and low r i s k mothers w i l l be i d e n t i f i e d and recommendations made f o r a l l o c a - t i o n of services according t o r i s k . Analyses o f p o p u l a t i o n s w i t h f a v o r a b l e and u n f a v o r a b l e i n f a n t m o r t a l i t y r a t e s w i l l p e r m i t i d e n t i f i c a t i o n o f those v a r i a b l e s w h i c h need t o be a c t e d upon t o e f f e c t reduced i n f a n t m o r t a l i t y . Consideration o f these i n f a n t m o r t a l i t y i s s u e s may be a p p l i e d t o a c o n s i d e r a t i o n o f t h e gener- a l h e a l t h scene. D i s t r i b u t i o n o f h e a l t h manpower, and e f f e c t i v e a l l o c a t i o n o f funds may be analyzed f o r a v a r i e t y o f c o n d i t i o n s i n w h i c h t h e s e v e r i t y o f t h e m o r b i d i t y c o n d i t i o n s o r t h e magnitude o f the m o r t a l i t y rates are s t r o n g l y related t o b o t h e n v i r o n m e n t a l f a c t o r s and d i r e c t m e d i c a l care f o r c e s . F u r t h e r m o r e , when c o n s i d e r i n g a l t e r n a t i v e methods t o d e l i v e r c a r e , t h e use o f such s o c i a l d e v i c e s as i n c e n t i v e s t o o b t a i n i n g p r e n a t a l care and how g e n e r a l changes i n h e a l t h s e r v i c e s and r e l a t e d s o c i a l s e r v i c e s m i g h t be i n c o r p o r a t e d i n our p r e s e n t s o c i e t y must be
9. c r i t i c a l l y evaluated. Broad changes i n the s o c i a l s e r v i c e system o f the U n i t e d S t a t e s t h a t would c o n t r i b u t e d i r e c t l y t o the h e a l t h and w e l f a r e o f our citizens must be c o n s i d e r e d i n the l i g h t of these s p e c i f i c a n a l y s e s . Studies of s p e c i f i c issues such as i n f a n t m o r t a l i t y should p r o v i d e c o n c r e t e data on the use o f s o c i a l devices i n o t h e r s o c i e t i e s , how e f f e c t i v e they have been and how feasible i t might be t o i n c o r p o r a t e some f a c e t s o f t h e i r program i n t o the U n i t e d S t a t e s ' system.
