Introduction

Infant and maternal mortality are key indicators of overall health in a society, since these deaths are largely preventable. The strongest predictor of infant survival and subsequent quality of life is infant birth weight, and the most important risk factors associated with low birth weights are the lack of adequate prenatal care and late access to care. Maternal deaths defined as the death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management are also largely due to lack of early and adequate prenatal care. Improving these outcomes requires a sound primary health care infrastructure that encourages pregnant women to obtain early prenatal care. Removing financial barriers to care and including culturally competent providers are key components of efforts to promote early prenatal care. It is also crucial to encourage pregnant women to abstain from alcohol and tobacco use during pregnancy. Year 2000 objectives were selected to measure progress not only in birth outcomes, including mortality of both mother and child as well as birth weight, but also in access to prenatal care, and use of alcohol and tobacco during pregnancy.

The number of infant deaths has declined over the past two decades in both the total population and among black infants, but increased again in 1996. It is not clear whether this is just a one-year anomaly in an overall downward trend, as in 1988, or a reversal in the trend. In any event, even if the trend in infant mortality continues downward in future years, significant disparities between white and black infants persist. In the area of maternal deaths it is unlikely that the targets will be achieved, and the rate of maternal death for black women continues to be more than double the rate for the population as a whole.

Outlook For Reaching Specific Objectives:
	Achieve target:		Likely	Unlikely	Uncertain
2A.	Reduction in infant deaths for:
		the total population
		blacks
2B.	Reduction in low birth weight babies for:
		the total population
		blacks
2C.	Reduction in very low birth weight babies for:
		total population
		blacks
2D.	Increase in mothers receiving early prenatal care for:
		total births
		black births
		Hispanic births
2E.	Reduction in mothers receiving no prenatal care for:
		total births
		black births
2F.	Increase in use of WIC services
2G.	Increase in women abstaining from alcohol and tobacco during pregnancy:
		tobacco
		alcohol
2H.	Reduction in maternal deaths for:
		total women
		black women

Data Update

2A. Reduce the number of infant deaths per 1,000 live births to:

7.0 for the total population
11.0 for the black population

Achieve target:	Likely	Unlikely	Uncertain
total population
blacks

The number of infant deaths has declined over the past two decades in both the total population and among black infants. However, the most recent data, from 1996, reflects an upturn. The mortality rate for the total population of infants went below the year 2000 objective in 1995 for the first time, and is expected to remain below the target level. For black infants there has been a sharp decline in the mortality rate since 1985, but it is not certain the year 2000 objective will be achieved.

2B. Reduce the percentage of infants with birth weight less than 2,500 grams to:

5.0% of total births
9.0% of black births

Achieve target:	Likely	Unlikely	Uncertain
total population
blacks

In spite of the overall decline in infant mortality, the percentage of newborns with low birth weight (under 2,500 grams, or 5 lbs. 8 ozs.) has continued to rise since 1988, suggesting that lack of adequate prenatal care continues to be a problem. There is an apparent contradiction between decreasing infant mortality and increasing rates of low birth weight babies, since infant mortality was customarily correlated with low birth weight. Technological advancements in hospital neonatal intensive care units (NICUs), which increase the ability of these units to sustain low birth weight infants, along with the regionalization of perinatal services have contributed to the significantly reduced mortality of high risk infants. Despite this technological progress, it remains preferable to focus on preventing low birth weight. The trends to date suggest that the year 2000 objectives will not be achieved.

2C. Reduce the percentage of infants with birth weight less than 1,500 grams to:

1.2% of total births
2.5% of black births

Achieve target:	Likely	Unlikely	Uncertain
total population
blacks

The percentage of very low birth weight infants (under 1,500 grams or 3 lbs. 5 ozs.) has also increased in both the total and black populations over the past decade. Their survival is again largely a tribute to advances in NICU technology. However, the primary objective continues to be prevention of low birth weight through adequate prenatal care, and the year 2000 targets in this area are unlikely to be achieved.

2D. Increase the percentage of live births whose mothers received prenatal care in the first trimester:

90.0% of total births
90.0% of black births*
90.0% of Hispanic births**

Achieve target:	Likely	Unlikely	Uncertain
total births
black births
Hispanic births

In 1996, 75.0 percent of all live births were to women who began prenatal care in the first trimester of pregnancy, a lower percent than in 1985. Black (60.9 percent) and Hispanic (68.6 percent) mothers were even less likely to obtain early prenatal care. There have been fluctuations in these percentages from year to year, but the overall trend does not suggest growth in the percentage of women getting early prenatal care, and the year 2000 objective is unlikely to be met. However, caution should be exercised in drawing conclusions from data, since a relatively large percentage of birth records include no information on the receipt of prenatal care. A revision in the birth certificate in 1989 may have led to more accurate reporting on prenatal care received.
___________________________
*Black births include those to both Hispanic and non-Hispanic women.
**Hispanic births include those to women of all races including blacks.

2E. Decrease the proportion of live births whose mothers received no prenatal care to:*

1.0% of total blacks
3.0% of black births

Achieve target:	Likely	Unlikely	Uncertain
total births
black births

Receiving no prenatal care has even more serious consequences than starting care late in pregnancy, and is more likely to be associated with low birth weight, low Apgar scores (a rating assigned to all newborns reflecting their basic health status), and other negative outcomes. It is difficult to interpret the trend since the baseline year of 1985, because a revision in the birth certificate in 1989 may have resulted in more accurate reporting of prenatal care received. The most recent data available suggest that the year 2000 target reduction in the proportion of total live births and black births whose mothers received no prenatal care is not likely to be met.
_________________________
*Unlike Objective 2D, no separate Hispanic objective was set, because the percentage of Hispanic mothers who do not receive any prenatal care has been 1.1 to 1.2 percent since the data became available in 1989. Since this is the same or better than the rate for the entire population, no separate Hispanic target was set.

2F. Increase the percentage of the eligible population served by the Women, Infants and Children Program (WIC) to:

100.0 percent

Achieve target:	Likely	Unlikely	Uncertain

The Women, Infants and Children (WIC) program has made substantial progress over the past decade in increasing the percentage of eligible women and children enrolled in the program to 62 percent. Despite this progress, the year 2000 target of enrolling 100 percent of eligible women is unlikely to be met, and questions have been raised about the reasonableness of this target.

2G. Increase the percentage of women who abstain from alcohol and tobacco during pregnancy to:

90.0% abstinence from tobacco
95.0% abstinence from alcohol

Achieve target:	Likely	Unlikely	Uncertain
tobacco abstinence
alcohol abstinence

The percentages of women who abstained from tobacco and alcohol, respectively, during pregnancy appear to have increased since 1989, when this information was first required to be reported on the birth certificate. At least part of the improvement may have been a result of increased familiarity with the reporting format on the part of those preparing birth certificates. However, the continued improvement may well reflect actual trends. Although the improvement in these measures is encouraging, in the case of tobacco it is unlikely the year 2000 target will be achieved. Reaching the target for alcohol abstinence is uncertain.

2H. Decrease the number of maternal deaths per 100,000 births to:

5.0 for all women
5.0 for black women

Achieve target:	Likely	Unlikely	Uncertain
total women
black women

A maternal death is defined by the World Health Organization as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." In New Jersey the Medical Society of New Jersey and the Department conduct an annual review of data to develop statistics on the maternal deaths among residents.

It should be noted that the annual number of maternal deaths in New Jersey is very small, ranging from 15 to 22 deaths of all women and 7 to 10 deaths of black women during the three year period measured. As a result, the rates can fluctuate considerably from year to year because of random variation. Nevertheless, the maternal mortality rates for all women and for black women remain well above the target level, and the year 2000 objectives are unlikely to be met. The black maternal mortality rate, although decreasing more rapidly, remains more than twice the rate for all women.

Discussion

Prevention costs less than the alternatives, and the majority of infant mortality is preventable with early and appropriate prenatal care. Blacks and Hispanics obtain prenatal care less often than the total population of pregnant women and/or begin prenatal care at a later stage of pregnancy. NICU technologies for treating low birth weight infants are effective, but expensive. The average hospital charges for treating surviving infants born at very low birth weights (below 1,500 grams) were $41,000 in 1990, $59,900 in 1991, and $39,600 in 1992. Moreover, NICUs are limited in their ability to treat high-risk, low birth weight newborns, since they intervene after the problem occurs.

Most additional gains in reducing infant mortality and achieving New Jersey's 2000 objectives for infant mortality rates are likely to come from steps taken before birth to improve women's chances of delivering normal birth weight infants. To address the continuing disparity in mortality between black and white infants, the Department convened a Blue Ribbon Panel on Black Infant Mortality. The panel issued a report in September 1997 calling for increasing availability of culturally competent care as well as an outreach campaign to increase awareness among the black community of the problem of infant mortality. A Task Force is developing curriculum and training modules on cultural competency to be used by providers throughout New Jersey. In addition, in 1999 the Department will begin a one million dollar black infant mortality awareness campaign.

New Jersey's WIC program remains a central component of the strategy to improve birth outcomes, and is considered a model for successful outreach, especially to the wide variety of minorities who reside in New Jersey. WIC provides food supplementation, as well as counseling on nutrition and other health matters to low-income pregnant women and their young children. Researchers at the University of Medicine and Dentistry of New Jersey (UMDNJ) concluded in a 1997 study of birth outcomes and delivery costs for Medicaid clients that participation in WIC has positive results. Medicaid clients enrolled in WIC were more likely to get adequate prenatal care, and less likely to have low or very low birth weight babies.

The Department, in cooperation with the Medical Society of New Jersey, operates a maternal mortality review program which examines the circumstances surrounding maternal deaths. Efforts are underway to improve this program by adapting the Florida Pregnancy Associated Mortality Review (PAMR) model. The Florida PAMR model uses a broader definition of pregnancy-associated mortality, defining it as death of a woman from any cause while she is pregnant or within one year of termination of pregnancy. After identifying all cases that match this definition, case summaries of selected cases are abstracted and forwarded to a multidisciplinary team for case review. By adopting the PAMR model New Jersey intends not only to use this broader definition, but also to implement a consistent methodology for medical records abstraction and broaden the case review team to include representatives from a variety of disciplines, such as physicians, nurses, social workers, nutritionists and others. The results of reviews will be used to plan and implement quality improvement activities statewide, directed at both consumers and providers.