Journal Issue: U.S. Health Care for Children Volume 2 Number 2 Winter 1992
We have considered the impact of prenatal, obstetrical, and neonatal care on the most important and easily measured outcomes of infant health, namely the rate of low birth weight births and the rate of infant mortality. Though not all the studies published to date have been well controlled, abundant evidence has accumulated demonstrating that these two outcome measures do respond to the application of appropriate health services.
Despite the recent slowing in the rate of decline of infant mortality and the leveling off in the decline of the low birth weight rate, there are continued reasons for optimism. The discrepancies that persist between white and nonwhite low birth weight rates imply that an improved distribution of prenatal care services could have a significant impact on the rate of low birth weight births. The development of new agents to aid in the treatment of respiratory distress syndrome raises hope that more widespread application of such treatments will significantly improve neonatal survival as well. Finally, expanded regionalization of prenatal, obstetric, and neonatal care in a coordinated approach to the entire continuum of gestation, labor, delivery, and early development holds out the promise of greater progress on both fronts. Though there is reason to be optimistic, recent experience has highlighted the needs of mothers and infants with emerging special problems. These include the increase in high-risk pregnancies caused by maternal substance abuse (see the Spring 1991 issue of The Future of Children, which deals with this problem) and pregnancies complicated by HIV infection which, although few in number, present the problems of severe chronic illness in both the mother and the infant (see the article by Perrin and Guyer in this [Winter 1992] journal issue for a more complete discussion of HIV infection in children). Perhaps the greatest challenge, however, because of the sheer number of individuals affected, is to improve birth outcomes in the face of increasing rates of poverty and an increase in the number of births to poor families.18
The advance of obstetrical technology into more advanced genetic and fetal screening,73 fetal therapies to ameliorate potentially serious infant conditions before birth,74,75 and other technologies such as home uterine monitoring to detect possible premature labor76 as well as continued advances in neonatology may present both problems and benefits. Though there is clearly progress to be made, the politics of competing claims on limited resources dictates that those programs and activities which can deliver the greatest potential improvement in newborn survival for the least investment are likely to prove the most attractive to decision makers. The effort to identify such programs and activities deserves a prominent place on the research agenda in the immediate future.