Defining Health and Wellness - The Health Of The United States

A primary indicator of the well-being of a nation is the health of its people. Many factors can affect a person's health: heredity, race/ethnicity, gender, income, education, geography, exposure to violent crime, exposure to environmental agents, exposure to infectious diseases, and access to and availability of health care.

Whereas physicians and other health practitioners observe the influences of these factors as they care for individual patients, epidemiologists (public health researchers who study the occurrence of disease in populations) examine the distribution and rates of diseases and injuries in the population. The practitioner and epidemiologist each apply the scientific method to achieve their objectives, but they use it in varying ways. For instance, in the "database" step of the scientific method, the practitioner uses history and physical examination to determine a patient's health; the epidemiologist uses surveillance and descriptive epidemiology. The practitioner seeks to deliver appropriate treatment to individual patients; the epidemiologist recommends actions to prevent the spread of disease or otherwise improve the health of an entire community or population.

Epidemiologists and other public health professionals assess health by determining the incidence and prevalence rates of disease and disability in a given community. Incidence is a measure of the rate at which people without a disease develop the disease during a specific time period, and it describes the continuing occurrence of disease over time. For example, a researcher might report that men in a given community age sixty-five and older have a 2 percent incidence of heart disease. Prevalence describes a group or population at a specific point in time. For example, the prevalence of high blood pressure found during screening at a health fair on a specific day might be 22 percent.

Other measures of the health of a population, such as natality (birth) and mortality (death) rates, are known as vital health statistics. This chapter provides an overview of vital health statistics and the health status of Americans.

Birthrates and Fertility Rates

The birthrate is the number of live births per 1,000 women. The fertility rate, however, is the number of live births per 1,000 women between fifteen and forty-four years of age, generally considered a woman's prime child-bearing years.

The National Center for Health Statistics (NCHS) estimated that there were more than four million live births (4,021,726) in the United States in 2002, which basically did not change from 2001. This was a birthrate of 13.9 births per 1,000 women—the lowest rate ever recorded for the United States. (See Table 1.1.) Between the most recent high point, in 1990, and the most recent low point, in 1997, the number of births declined 7 percent. The number of births increased 5 percent between 1997 and 2000, but it has declined slightly since. In fact, the birth rate, fertility rate, and total fertility rates all declined 1 percent in 2002. The teenage birth rate dropped 5 percent, reaching another record low.

For the first time in about a decade, in 2002 there was a decline in the birthrate for women ages thirty to thirty-four—91.5 births per 1,000 women (from 91.9 in 2001). The birthrates for women aged thirty-five to thirty-nine years, which has been increasing dramatically since 1980, increased by 2 percent in 2002—41.4 births per 1,000 women (from 40.4 births per 1,000 women in 2001). According to the NCHS, the birthrate for this age group increased by 31 percent between 1990 and 2002, with an average increase of 3 percent a year. The number of births to women in this age group also reached a record high in 2002 (453,927)—a steady increase of 43 percent since 1990 (317,583), compared with a 9 percent increase in the population of this age group.

Birthrates and the number of births to teenagers have continued to decline for teenagers aged fifteen to nineteen years. The birthrate for teenagers aged fifteen to seventeen years decreased 5 percent, from 45.3 per 1,000 in 2001 to 43.0 in 2002. Since 1991, it has declined 30 percent. The rate for teens aged eighteen and nineteen years was 72.8 per 1,000 in 2002, down 4 percent from 2001 (76.1) and 23 percent from 1991 (94.0). The number of births to fifteen-to seventeen-year-olds declined to 138,731, the fewest in fifty years (138,578 in 1953); births to eighteen- and nineteen-year-olds also decreased markedly (to 286,762)—the fewest reported since 1946 (235,282).

Women ages twenty to twenty-nine continued to have the highest birthrates, although the proportion of births to these women has declined in recent years, dropping from approximately two-thirds of all births in 1980 to about half in 2002.

Fertility rates focus on live births to mothers in the primary childbearing age group, fifteen to forty-four. In 2002 the fertility rate for American women was 64.8 births per 1,000 women, which is a decline of 1 percent from 2001 (65.3) and a decline of 9 percent from 1990 (70.9). (See Table 1.1.) Total fertility rates, which offer an

TABLE 1.1
U.S. live births, birth rates, and fertility rates, 1989–2002
[Birth rates are live births per 1,000 population in specified group. Fertility rates are live births per 1,000 women aged 15–44 years in specified group. Population enumerated as of April 1 for 1990 and 2000, and estimated as of July 1 for all other years]

		Hispanic						Non-Hispanic
Measure and year	All origins¹	Total	Mexican	Puerto Rican	Cuban	Central and South American	Other and unknown Hispanic	Total²	White	Black
Number
2002	4,021,726	876,642	627,505	57,465	14,232	125,981	51,459	3,119,944	2,298,156	578,335
2001	4,025,933	851,851	611,000	57,568	14,017	121,365	47,901	3,149,572	2,326,578	589,917
2000	4,058,814	815,868	581,915	58,124	13,429	113,344	49,056	3,199,994	2,362,968	604,346
1999	3,959,417	764,339	540,674	57,138	13,088	103,307	50,132	3,147,580	2,346,450	588,981
1998	3,941,553	734,661	516,011	57,349	13,226	98,226	49,849	3,158,975	2,361,462	593,127
1997	3,880,894	709,767	499,024	55,450	12,887	97,405	45,001	3,115,174	2,333,363	581,431
1996	3,891,494	701,339	489,666	54,863	12,613	97,888	46,309	3,133,484	2,358,989	578,099
1995	3,899,589	679,768	469,615	54,824	12,473	94,996	47,860	3,160,495	2,382,638	587,781
1994	3,952,767	665,026	454,536	57,240	11,889	93,485	47,876	3,245,115	2,438,855	619,198
1993	4,000,240	654,418	443,733	58,102	11,916	92,371	48,296	3,295,345	2,472,031	641,273
1992³	4,049,024	643,271	432,047	59,569	11,472	89,031	51,152	3,365,862	2,527,207	657,450
1991³	4,094,566	623,085	411,233	59,833	11,058	86,908	54,053	3,434,464	2,589,878	666,758
1990⁴	4,092,994	595,073	385,640	58,807	11,311	83,008	56,307	3,457,417	2,626,500	661,701
1989⁵	3,903,012	532,249	327,233	56,229	10,842	72,443	65,502	3,297,493	2,526,367	611,269
Birth rate
2002⁶	13.9	22.6	24.2	16.5	10.0	22.4	(⁶)	12.6	11.7	16.1
2001⁶	14.1	23.0	24.8	17.8	10.3	21.8	(⁶)	12.8	11.8	16.6
2000⁶	14.4	23.1	25.0	18.1	9.7	21.8	(⁶)	13.2	12.2	17.3
1999⁶	14.2	22.5	24.2	18.0	9.4	21.7	(⁶)	13.0	12.1	17.1
1998⁶	14.3	22.7	24.6	17.9	9.7	21.7	(⁶)	13.2	12.2	17.5
1997⁶	14.2	23.0	25.3	17.2	10.0	21.3	(⁶)	13.1	12.2	17.4
1996⁶	14.4	23.8	26.2	17.2	10.6	22.5	(⁶)	13.3	12.3	17.6
1995⁶	14.6	24.1	25.8	18.9	10.7	24.2	(⁶)	13.5	12.5	18.2
1994⁶	15.0	24.7	26.1	20.8	10.7	24.9	(⁶)	13.9	12.8	19.5
1993⁶	15.4	25.4	26.8	21.5	10.5	26.3	(⁶)	14.3	13.1	20.7
1992^6,7	15.8	26.1	27.4	22.9	10.1	27.5	(⁶)	14.8	13.4	21.6
1991^6,7	16.2	26.5	27.6	23.3	9.8	28.3	(⁶)	15.2	13.9	22.4
1990^4,6	16.7	26.7	28.7	21.6	10.9	27.5	(⁶)	15.7	14.4	23.0
1989^5,6	6.3	26.2	25.7	23.7	10.0	28.3	(⁶)	15.4	14.2	22.8
Fertility rate
2002⁶	64.8	94.4	102.8	65.4	59.0	86.1	(⁶)	59.6	57.4	67.4
2001⁶	65.3	96.0	105.7	72.2	56.7	82.7	(⁶)	60.1	57.7	69.1
2000⁶	65.9	95.9	105.1	73.5	49.3	85.1	(⁶)	61.1	58.5	71.4
1999⁶	64.4	93.0	101.5	71.1	47.0	84.8	(⁶)	60.0	57.7	69.9
1998⁶	64.3	93.2	103.2	69.7	46.5	83.5	(⁶)	60.0	57.6	70.9
1997⁶	63.6	94.2	106.6	65.8	53.1	80.6	(⁶)	59.3	56.8	70.3
1996⁶	64.1	97.5	110.7	66.5	55.1	84.2	(⁶)	59.6	57.1	70.7
1995⁶	64.6	98.8	109.9	71.3	52.2	89.1	(⁶)	60.2	57.5	72.8
1994⁶	65.9	100.7	109.9	78.2	53.6	93.2	(⁶)	61.6	58.2	77.5
1993⁶	67.0	103.3	110.9	79.8	53.9	101.5	(⁶)	62.7	58.9	81.5
1992^6,7	68.4	106.1	113.3	87.9	49.3	104.7	(⁶)	64.2	60.0	84.5
1991^6,7	69.3	106.9	114.9	87.9	47.6	105.5	(⁶)	65.2	60.9	87.0
1990^4,6	70.9	107.7	118.9	82.9	52.6	102.7	(⁶)	67.1	62.8	89.0
1989^5,6	69.2	104.9	106.6	86.6	49.8	95.8	(⁶)	65.7	60.5	84.8
¹Includes origin not stated.
²Includes races other than white and black.
³Excludes data for New Hampshire, which did not report Hispanic origin.
⁴Excludes data for New Hampshire and Oklahoma, which did not report Hispanic origin.
⁵Excludes data for Louisiana, New Hampshire, and Oklahoma, which did not report Hispanic origin.
⁶Rates for the Central and South American population includes other and unknown Hispanic.
⁷Rates are estimated for the United States based on birth data for 49 states and the District of Columbia. Births for New Hampshire that did not report Hispanic origin are included in the rates for non-Hispanic women.
Notes: Race and Hispanic origin are reported separately on birth certificates. Persons of Hispanic origin may be of any race. In this table Hispanic women are classified only by place of origin; non-Hispanic women are classified by race.
SOURCE: Joyce A. Martin, Brady E. Hamilton, Paul D. Sutton, "Table 6. Live Births, Birth Rates, and Fertility Rates by Hispanic Origin of Mother and by Race for Mothers of non-Hispanic Origin: United States, 1989–2002," inBirths: Final Data for 2002,vol. 52, no. 10, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, December 17, 2003

index of lifetime fertility among women, varied by ethnic origin and geography, ranging from highs in Alaska and Utah of 2.6 and 2.5 births per woman, respectively, to a low of 1.6 births per woman in Vermont. Six states, all of which are located west of the Mississippi River, experienced increasing numbers of births. Five of these states

TABLE 1.2
Live births by state, 2002
[By place of residence]

		Origin of mother
		Hispanic						Non-Hispanic
State	All origins	Total	Mexican	Puerto Rican	Cuban	Central and South American	Other and unknown Hispanic	Total¹	White	Black	Not stated
United States²	4,021,726	876,642	627,505	57,465	14,232	125,981	51,459	3,119,944	2,298,156	578,335	25,140
Alabama	58,967	2,569	1,919	91	18	237	304	56,344	37,402	18,276	54
Alaska	9,938	799	276	61	6	72	384	6,902	4,427	267	2,237
Arizona	87,837	37,938	36,029	252	68	729	860	48,950	39,033	2,545	949
Arkansas	37,437	3,050	2,581	31	8	403	27	34,190	26,001	7,415	197
California	529,357	263,061	230,386	2,030	699	24,842	5,104	262,036	164,649	31,450	4,260
Colorado	68,418	21,029	16,581	283	63	767	3,335	47,382	41,858	2,761	7
Connecticut	42,001	6,982	803	4,054	74	1,723	328	34,680	27,685	4,932	339
Delaware	11,090	1,316	735	308	10	256	7	9,760	6,629	2,684	14
District of Columbia	7,498	954	94	9	3	782	66	6,494	1,733	4,563	50
Florida	205,579	51,619	12,689	8,866	10,093	18,677	1,294	153,581	102,294	45,257	379
Georgia	133,300	16,819	13,220	568	168	2,716	147	114,706	68,269	42,001	1,775
Hawaii	17,477	2,422	499	720	16	68	1,119	15,021	3,200	442	34
Idaho	20,970	2,788	2,219	15	5	76	473	17,849	17,074	100	333
Illinois	180,622	41,022	34,793	2,633	182	1,765	1,649	139,537	99,346	31,604	63
Indiana	85,081	6,169	5,347	296	13	413	100	78,545	67,894	9,271	367
Iowa	37,559	2,390	1,907	44	6	335	98	35,093	32,709	1,243	76
Kansas	39,412	5,023	4,192	92	21	305	413	33,994	29,563	2,846	395
Kentucky	54,233	1,630	1,187	107	75	218	43	52,573	46,811	4,923	30
Louisiana	64,872	1,383	528	70	62	139	584	63,452	35,428	26,611	37
Maine	13,559	167	37	27	2	36	65	13,347	12,852	167	45
Maryland	73,323	6,062	1,361	369	60	3,142	1,130	66,964	39,093	24,007	297
Massachusetts	80,645	9,592	430	4,505	66	4,395	196	70,530	58,313	6,635	523
Michigan	129,967	7,265	5,961	411	72	422	399	120,687	93,831	22,217	2,015
Minnesota	68,025	4,646	3,601	99	30	588	328	62,499	52,744	4,750	880
Mississippi	41,518	823	538	25	8	46	206	40,633	21,749	18,191	62
Missouri	75,251	3,267	2,462	123	44	415	223	71,879	59,079	10,983	105
Montana	11,049	382	160	8	1	23	190	10,471	8,967	32	196
Nebraska	25,383	3,313	2,630	33	13	467	170	21,487	19,121	1,416	583
Nevada	32,571	11,386	9,403	212	178	1,089	504	20,959	15,638	2,534	226
New Hampshire	14,442	503	113	96	9	203	82	13,383	12,690	182	556
New Jersey	114,751	24,664	4,695	6,659	810	12,304	196	89,944	61,741	18,010	143
New Mexico	27,753	14,623	7,556	61	44	173	6,789	13,125	8,759	475	5
New York	251,415	54,700	8,838	12,960	401	24,207	8,294	195,819	130,189	45,206	896
North Carolina	117,335	15,064	11,490	702	133	2,622	117	102,170	70,234	27,434	101
North Dakota	7,757	149	89	8	7	10	35	7,483	6,499	87	125
Ohio	148,720	4,817	2,706	1,255	49	522	285	143,560	117,990	22,354	343
Oklahoma	50,387	5,259	4,774	114	13	250	108	45,110	34,370	4,676	18
Oregon	45,192	8,040	7,417	81	45	326	171	36,870	32,949	897	282
Pennsylvania	142,850	8,696	1,771	5,255	101	527	1,042	133,040	108,620	19,727	1,114
Rhode Island	12,894	2,328	184	655	14	1,369	106	9,051	7,356	1,027	1,515
South Carolina	54,570	3,175	2,274	170	27	506	198	51,311	32,203	18,143	84
South Dakota	10,698	318	198	14	4	77	25	10,368	8,376	103	12
Tennessee	77,482	4,348	3,244	213	39	669	183	73,109	55,316	16,267	25
Texas	372,450	178,968	156,592	1,144	305	9,641	11,286	192,038	137,618	41,007	1,444
Utah	49,182	6,952	5,287	91	10	617	947	42,051	39,533	312	179
Vermont	6,387	32	7	8	3	8	6	6,276	6,131	43	79
Virginia	99,672	9,790	2,509	676	69	5,861	675	89,641	61,694	21,920	241
Washington	79,028	12,349	10,381	296	54	681	937	65,293	53,387	3,263	1,386
West Virginia	20,712	84	51	7	1	6	19	20,578	19,749	677	50
Wisconsin	68,560	5,295	4,204	653	28	249	161	63,252	53,820	6,349	13
Wyoming	6,550	622	557	5	2	7	51	5,927	5,540	53	1

(Arizona, California, Colorado, Nevada, and Texas) have substantial proportions (31–49 percent) of births to Hispanic women, the population group with the largest absolute increase in births in 2002. (See Table 1.2.)

Factors other than age, race, and ethnicity can have dramatic effects on fertility and birthrates. For example, women who are currently married and living with their husbands have much higher fertility rates than those women who have never married or are separated, widowed, or divorced. According to a news release published in July 2001 by the National Center for Health Statistics, studies conducted by the Centers for Disease Control and Prevention (CDC) suggest that teen birthrates have declined in response to several factors, which include a leveling-off of sexual activity among teens, as well as health education programs emphasizing prevention of pregnancy through abstinence (avoiding sexual contact) and contraception (measures to prevent pregnancy).

TABLE 1.2
Live births by state, 2002
[By place of residence]

		Origin of mother
		Hispanic						Non-Hispanic
State	All origins	Total	Mexican	Puerto Rican	Cuban	Central and South American	Other and unknown Hispanic	Total¹	White	Black	Not stated
Puerto Rico	52,747	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	52,747
Virgin Islands	1,634	323	11	262	2	–	48	1,240	83	1,086	71
Guam	3,212	54	22	16	1	7	8	3,069	220	39	89
American Samoa	1,627	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	1,627
Northern Marianas	1,290	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	- - -	1,289
- - - Data not available.
–Quantity zero.
¹Includes races other than white and black.
²Excludes data for the territories.
Notes: Race and Hispanic origin are reported separately on birth certificates. Persons of Hispanic origin may be of any race. In this table Hispanic women are classified only by place of origin; non-Hispanic women are classified by race.
SOURCE: Joyce A. Martin, Brady E. Hamilton, Paul D. Sutton, "Table 12. Live Births by Hispanic Origin of Mother and by Race for Mothers of Non-Hispanic Origin: United States, Each State and Territory, 2002," inBirths: Final Data for 2002,vol. 52, no. 10, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, December 17, 2003

Prenatal Care, Prematurity, and Low Birthweight

Early prenatal care, defined as pregnancy-related care started in the first trimester (one to three months), can detect and often correct many potential health problems early in pregnancy. Regular visits to a physician or clinic usually give the mother-to-be information and encouragement about eating properly; exercising regularly; taking prenatal vitamins; and avoiding harmful substances such as alcohol, drugs, and tobacco. The benefits of these preventive measures literally can make a lifetime of difference for a newborn.

Sophisticated diagnostic medical procedures, such as obstetric ultrasound scans and amniocentesis, can be performed to detect possible birth defects and other prenatal problems. Ultrasound uses high-frequency sound waves to compose a picture of the fetus and is used to detect and assess fetal development and malformations in the fetus. During amniocentesis, a physician inserts a needle through the abdominal wall into the uterus to obtain a small sample of the amniotic fluid surrounding the fetus. When tested in a laboratory, this fluid can reveal chromosomal abnormalities, metabolic disorders, and physical abnormalities.

Pregnant women older than age thirty-five often are advised to undergo amniocentesis and other diagnostic testing because they are at somewhat greater risk than younger women of giving birth to babies with chromosomal abnormalities such as Down syndrome (also called Down's syndrome). Instead of the normal forty-six chromosomes, newborns with Down syndrome have an extra copy of chromosome 21, giving them a total of forty-seven chromosomes. These children have varying degrees of mental retardation, and approximately 40 percent have congenital heart diseases. The CDC estimates the prevalence of Down syndrome at birth as approximately five cases per 10,000 live births.

Ideally, every woman should receive prenatal care, and according to the NCHS, the United States is capable of delivering prenatal care to nearly all pregnant women during the first trimester of pregnancy. Not all mothers-to-be, however, seek or receive early prenatal care. According to the March of Dimes Birth Defects Foundation, a national voluntary organization that seeks to improve infant health by preventing birth defects, in 2000 about 26 percent of expectant mothers failed to receive adequate/adequate plus prenatal care. (See Table 1.3.) Adequate/adequate plus prenatal care is defined as pregnancy-related care beginning in the first four months of pregnancy with the appropriate number of visits for gestational age, according to the Adequacy of Prenatal Care Utilization Index.

The percentage of expectant mothers receiving adequate/adequate plus prenatal care steadily increased more than 9 percent between 1991 and 2000, but many states continue to report higher than average rates of inadequate prenatal care. The U.S. average rate of inadequate prenatal care was 11.9 percent between 1997 and 2000. (See Figure 1.1 and Figure 1.2.) The March of Dimes cited lack of health insurance, transportation, and child care; inconvenient health care provider service hours; unplanned pregnancies; and cultural and personal factors as obstacles preventing expectant mothers from receiving prenatal care.

The race, ethnicity, education, and age of mothers also were associated with obtaining prenatal care. Between 1998 and 2000 white women were more likely

TABLE 1.3
Health indicators for newborns, 2000

	Number	Rate
Adequate/adeq + prenatal care	2,870,998	74.1%
Early prenatal care¹	3,284,256	83.2%
Preterm	467,201	11.6%
Low birthweight	307,030	7.6%
Very low birthweight²	57,967	1.4%
Infant mortality³	27,960	6.9
¹Live births to women receiving first trimester pregnancy-related care
²Live births less than 1500 grams or 3 1/3 pounds
³Per 1,000 live births
SOURCE: "Health Indicators, 2000," inPerinatal Profiles: Statistics for Monitoring State Maternal and Infant Health, United States 2003 Edition, March of Dimes Birth Defects Foundation, January 2003

to obtain prenatal care than African-American (black) or Hispanic women. The percentage of mothers receiving prenatal care also increased steadily with advancing age, with an average of nearly 80 percent of mothers age thirty and older receiving adequate prenatal care between 1998 and 2000. (See Table 1.4.) The National Vital Statistics Reports (NVSR) found slightly higher percentages of women receiving early prenatal care in 2002 (approximately 83 percent). However, the 2002 rates for Hispanic and African-American women (76.7 and 75.2 percent, respectively) were still about 10 percent less than those for white women (85.4 percent). The NVSR also showed wide geographic variation, from a low of 69.0 percent of women in New Mexico to a high of 91.5 percent of women in New Hampshire receiving prenatal care during the first three months of pregnancy. (See Table 1.5.) According to the NVSR, the percentage of mothers with late or no care has improved dramatically since 1990, down to 3.6 percent in 2002 from 6.1 percent.

Early prenatal care can prevent or reduce the risk of low birthweight. Infants who weigh less than 2,500 grams (5 pounds, 8 ounces) at birth are considered to be of low birthweight. Those born weighing less than 1,500 grams (3 pounds, 4 ounces) are termed "very low birthweight." Low birthweight may result from premature birth (infants born before thirty-seven weeks of pregnancy are considered premature), poor maternal nutrition, teen pregnancy, drug and alcohol use, smoking, or sexually transmitted diseases.

Infants who are premature or have low birthweights are at the greatest risk of death and disability. About 80 percent of women at risk for delivering a low-birthweight infant can be identified in the first prenatal visit and interventions can be made to try to prevent problems. Between 1991 and 2002, the proportion of newborn babies weighing less than 2,500 grams increased from 7.1 percent to 7.6 percent. (See Figure 1.3.) As in previous years, in 2002 the percentage of low birthweight infants declined (from 13.9 percent to 5.6 percent) with increasing maternal weight gain through 36 to 40 pounds. (See Table 1.6.)

FIGURE 1.1
Mothers receiving adequate or good prenatal care, 1991–2000

The usual length of pregnancy is forty weeks from the first day of the woman's last menstrual period. Infants born prematurely do not have fully formed organ systems. If, however, the premature infant is born with a birth-weight comparable to a full-term baby and has organ systems only slightly undeveloped, the chances of survival are great. Premature infants of very low birthweight are susceptible to numerous risks and are less likely to survive than full-term infants. If they survive, they may suffer from mental retardation, developmental disabilities, and other abnormalities of the nervous system.

A severe medical condition called hyaline membrane disease, or respiratory distress syndrome (RDS), commonly affects premature infants. It is caused by the inability of immature lungs to function properly. Occurring immediately after birth, the disease may cause infant death within hours. Intensive care of affected infants includes the use of a mechanical ventilator to facilitate breathing. Also, premature infants' immature gastrointestinal systems preclude them from taking in nourishment properly. Unable to suck and swallow, they must be fed through a nasogastric feeding tube (nutrient-rich formula enters through a tube inserted into the stomach via the nose).

African-American mothers were nearly twice as likely as white and Hispanic women to give birth to low-birthweight infants. In 2001, 12.95 percent of African-American mothers, 6.68 percent of white mothers, and 6.47 percent of Hispanic mothers delivered low-birthweight babies. (See Table 1.7.) The increase in low-and FIGURE 1.2
Births to mothers who received inadequate prenatal care, 2002 very low-birthweight babies during the 1990s is attributed to the increase in the multiple birthrate (multiple births are at much greater risk of having low birth-weight than single births).

Birth Defects

The March of Dimes Birth Defects Foundation reports that every 3.5 minutes a baby is born with a birth defect, and one in five infant deaths is caused by birth defects. The March of Dimes reports that despite research and many medical advances, birth defects have persisted as a leading cause of infant death (after preterm birth and low birthweight). A birth defect may be a structural defect, a deficiency of function, or a disease that an infant has at birth (congenital). Some birth defects are genetic—inherited abnormalities such as Tay-Sachs disease (a fatal disease that generally affects children of eastern European Jewish ancestry) or chromosomal irregularities such as Down syndrome. Other birth defects result from environmental factors—infections during pregnancy, such as rubella (German measles), or drugs used by the pregnant woman. Although the specific causes of some birth defects are unknown, scientists believe that many result from a combination of genetic and environmental factors.

NEURAL TUBE DEFECTS.

Neural tube defects (NTDs) are abnormalities of the brain and spinal cord resulting from the failure of the neural tube to develop properly during early pregnancy. The neural tube is the embryonic

TABLE 1.4
Infant health indicators, by maternal race/ethnicity and age, 1998–2000

		Maternal race/ethnicity			Maternal age (years)
	All	White, non-Hispanic	Black, non-Hispanic	Hispanic	<20	20–29	30–39	40+
Adequate/adeq+ prenatal care	74.4%	79.2%	67.3%	65.8%	63.2%	73.5%	79.6%	78.4%
Low birthweight	7.6%	6.6%	13.2%	6.4%	9.6%	7.1%	7.4%	10.4%
Preterm	11.7%	10.4%	17.5%	11.4%	14.0%	11.1%	11.5%	15.1%
Infant mortality*	7.0	5.8	13.9	5.7	10.1	6.9	6.0	8.3
*Rate per 1,000 live births
SOURCE: "Health Indicators, United States 1998–2000 Averages," in Perinatal Profiles: Statistics for Monitoring State Maternal and Infant Health, United States 2003 Edition, March of Dimes Birth Defects Foundation, January 2003

nerve tissue that eventually develops into the brain and the spinal cord. Every year, about 4,000 unborn children are affected with NTDs. Of these, approximately 2,500 cases involve infants born with the two most common NTDs—anencephaly and spina bifida.

ANENCEPHALY.

According to the U.S. National Institutes of Health (NIH), anencephaly (absence of a major part of the brain, skull, and scalp) occurs in about four out of 10,000 births. The exact number is unknown because many of these pregnancies end in miscarriage. Infants with anencephaly either die before birth (in utero or stillborn) or shortly thereafter.

The incidence of anencephaly decreased significantly from 1991 to 2000 in the states where data were reported. The Birth Defects Monitoring Program (BDMP) of the CDC was discontinued in 1993, which accounts for a lack of more recent national data on the prevalence of birth defects. Subsequently, twenty states began conducting their own surveillance of NTDs. In March 1998 the Birth Defects Prevention Act (PL105-168) was passed, "expressing the sense of Congress that birth defects are a major public health problem and need to be addressed."

Some physicians and ethicists agree that even if babies with anencephaly have a brainstem, they should be considered brain dead. Lacking a functioning higher brain, these babies can feel nothing; they have no consciousness. Others fear, however, that declaring babies with anencephaly dead might be a first step on the "slippery slope" of eventually including those with other birth defects, such as spina bifida, which is also a neural tube defect. Spina bifida defects range from mild to severe. Still others are concerned that babies with anencephaly may be kept alive exclusively for the purpose of harvesting their organs for research or transplant at a later date.

SPINA BIFIDA.

Spina bifida, which literally means "divided spine," is caused by the failure of the vertebrae (backbone) to cover the spinal cord completely early in fetal development, leaving the spinal cord exposed. Depending on the amount of nerve tissue exposed, spina bifida defects range from minor developmental disabilities to paralysis.

Before the advent of antibiotics in the 1950s, most babies with severe spina bifida died soon after birth. With antibiotics and numerous medical advances, some of these newborns now can be saved.

PREVENTION.

Scientists now know that daily consumption of 0.4 mg (400 micrograms) of the B vitamin folic acid by women before and during the first trimester of pregnancy greatly reduces the risk of spina bifida and other birth defects. Because half of all pregnancies in the United States are unplanned or incorrectly timed and because neural tube defects occur during the first month of pregnancy—before most women know they are pregnant—in 1992 the U.S. Public Health Service began recommending that all women of childbearing age consume 0.4 mg of folic acid daily. To comply with a mandate from the U.S. Food and Drug Administration (FDA), as of January 1998 all enriched cereal grain products must be fortified with folic acid. According to the March of Dimes, if all women consumed the recommended amount of folic acid before conception and throughout the first month of pregnancy, as many as 70 percent of NTDs could be prevented.

After a significant increase in the spina bifida rate from 1992 to 1995 there was a significant decline from 1995 to 1999. From 1999 to 2002 the rate did not change much, but for the years 1999–2002, the rates were much lower than in 1997. The rate of spina bifida in 2002 was 20.13 per 100,000 live births. (Figure 1.4 shows case rates per 100,000 live births.) Additionally, a study published in the Journal of the American Medical Association in June 2001 found a 23 percent decline in the birth prevalence of spina bifida following folic acid fortification of the U.S. food supply. The decline is an early indicator of successful efforts to prevent this defect by increasing folic acid consumption among women of childbearing age.

The March of Dimes found further evidence of the effectiveness of education about folic acid consumption to

TABLE 1.5
Percent of mothers beginning prenatal care in the first trimester and percent of mothers with late or no prenatal care, 2002
[By place of residence]

	Percent beginning care in first trimester						Percent late¹ or no care
		White		Black				White		Black
State	All races²	Total³	Non-Hispanic	Total³	Non-Hispanic	Hispanic⁴	All races²	Total³	Non-Hispanic	Total³	Non-Hispanic	Hispanic⁴
United States⁵	83.7	85.4	88.6	75.2	75.2	76.7	3.6	3.1	2.2	6.2	6.2	5.5
Alabama	83.3	87.7	90.0	73.6	73.6	53.9	3.8	2.9	1.8	5.7	5.7	19.0
Alaska	80.3	84.2	83.5	83.9	84.6	76.8	4.6	3.8	3.8	*	*	5.9
Arizona	76.5	77.1	87.2	76.4	77.4	66.7	6.6	6.5	2.7	5.5	5.1	10.4
Arkansas	79.6	82.1	83.7	70.5	70.4	68.4	4.9	4.2	3.6	7.5	7.5	9.4
California	86.4	86.6	90.4	83.0	83.0	84.1	2.6	2.6	1.8	3.4	3.4	3.1
Colorado	79.1	79.5	86.2	70.2	70.7	65.9	4.5	4.4	2.7	7.3	7.0	7.9
Connecticut	88.3	89.3	92.2	81.7	82.1	77.0	2.0	1.8	1.3	3.5	3.5	3.8
Delaware	87.1	88.5	91.1	82.3	82.3	75.2	3.5	2.9	2.3	5.7	5.6	5.9
District of Columbia	76.4	85.1	90.8	70.5	70.6	73.5	7.4	3.7	1.9	10.0	9.8	7.9
Florida	85.4	87.8	89.8	77.1	77.0	83.7	2.9	2.3	1.9	4.9	5.0	3.3
Georgia	84.7	87.3	90.5	79.1	78.9	73.6	3.4	2.9	1.9	4.5	4.6	7.1
Hawaii	83.9	88.4	89.1	94.2	94.7	82.5	3.5	2.5	2.2	*	*	3.2
Idaho	82.1	82.3	84.3	81.8	81.3	70.2	3.4	3.3	2.8	*	*	6.4
Illinois	84.9	87.2	90.8	74.3	74.2	78.4	2.9	2.1	1.6	6.7	6.7	3.5
Indiana	81.4	82.9	84.5	69.6	69.7	65.1	3.5	3.0	2.6	7.1	7.1	7.9
Iowa	88.8	89.3	90.4	78.1	78.3	74.7	2.2	2.0	1.8	5.5	5.4	5.6
Kansas	86.8	87.5	90.0	79.6	79.6	72.3	2.8	2.5	1.9	5.0	5.0	6.6
Kentucky	86.8	87.5	88.0	80.8	80.7	72.6	2.5	2.3	2.1	4.4	4.4	6.6
Louisiana	83.8	90.4	90.7	74.7	74.7	83.3	3.6	1.7	1.7	6.1	6.1	3.4
Maine	87.9	88.2	88.3	73.0	72.5	83.2	1.6	1.6	1.5	*	*	*
Maryland	84.1	88.1	90.8	76.5	76.5	70.6	3.6	2.3	1.8	6.2	6.2	5.9
Massachusetts	89.9	91.4	92.7	80.7	79.2	82.9	2.0	1.5	1.3	5.1	5.6	3.0
Michigan	85.6	88.6	89.4	71.3	71.2	77.4	3.5	2.5	2.4	7.9	7.9	4.7
Minnesota	85.5	88.0	89.8	70.1	70.1	68.0	2.3	1.7	1.4	6.2	6.3	5.8
Mississippi	83.8	90.1	90.7	76.1	76.1	74.7	3.1	1.8	1.6	4.6	4.6	6.6
Missouri	87.8	89.3	89.9	79.7	79.7	78.1	2.7	2.1	2.0	5.6	5.6	4.8
Montana	83.7	86.1	86.4	70.3	68.8	79.4	2.8	1.9	1.8	*	*	*
Nebraska	83.4	84.5	87.0	70.6	70.4	69.2	3.1	2.8	2.1	6.0	6.1	6.8
Nevada	75.9	76.2	85.3	70.6	70.5	63.4	7.1	7.0	4.0	8.6	8.6	11.1
New Hampshire	91.5	91.8	92.2	80.4	79.7	84.8	1.4	1.4	1.3	*	*	*
New Jersey	80.3	83.6	89.0	64.0	63.8	68.7	4.9	3.7	2.4	11.0	11.3	7.1
New Mexico	69.0	70.4	76.8	68.5	68.6	66.4	7.9	7.4	5.0	7.9	8.1	8.8
New York	81.6	84.5	88.2	72.1	71.9	75.0	4.7	3.7	2.8	8.4	8.5	5.9
North Carolina	84.3	87.3	90.9	75.5	75.5	70.2	2.9	2.2	1.4	5.1	5.1	6.1
North Dakota	86.1	88.6	88.9	82.2	81.6	83.6	2.7	1.9	1.8	*	*	*
Ohio	87.8	89.3	89.8	78.9	78.9	78.0	2.9	2.3	2.2	6.2	6.2	5.1
Oklahoma	76.8	78.6	80.8	69.4	69.3	63.6	5.4	4.9	4.4	7.5	7.5	8.3
Oregon	81.6	81.9	84.6	76.0	75.8	71.4	3.8	3.7	3.2	4.5	4.5	5.5
Pennsylvania	84.6	86.9	88.0	71.0	71.1	72.4	3.5	2.8	2.5	7.8	7.8	5.7
Rhode Island	89.6	91.0	92.4	79.9	79.2	86.1	1.5	1.2	1.0	3.4	3.2	2.1
South Carolina	78.4	82.5	84.7	70.3	70.3	60.4	4.7	3.4	2.7	7.1	7.1	10.4
South Dakota	77.7	81.8	82.4	61.2	61.2	64.8	4.4	2.7	2.4	*	*	10.8
Tennessee	82.8	85.7	87.8	72.3	72.3	58.7	3.9	2.9	2.2	7.5	7.5	12.2
Texas	80.5	80.6	87.8	76.7	76.7	75.1	5.0	5.0	2.8	5.8	5.8	6.6
Utah	79.5	80.5	83.6	59.7	58.4	62.4	4.9	4.5	3.6	14.2	15.1	9.5
Vermont	88.9	89.0	89.2	71.8	71.1	81.3	1.7	1.6	1.5	*	*	*
Virginia	85.2	87.9	90.7	76.6	76.6	70.1	3.5	2.7	2.0	5.9	5.9	7.5
Washington	83.4	83.9	86.0	78.1	77.8	74.2	3.1	2.9	2.4	4.6	4.5	5.2
West Virginia	85.9	86.3	86.4	75.6	75.5	75.0	2.2	2.1	2.0	4.4	4.4	*

prevent birth defects. A 1995 telephone survey of approximately 2,000 English-speaking women ages eighteen to forty-five found that 52 percent of women surveyed had heard of folic acid, but only 4 percent knew it helped to prevent birth defects. By 2002, 80 percent of women surveyed reported hearing of folic acid (up almost 30 percent since 1995) and 20 percent knew it prevented birth defects. (See Figure 1.5.)

BIRTH DEFECTS PREVENTION ACT OF 1998.

On April 21, 1998, then-President Bill Clinton signed into law the Birth Defects Prevention Act (PL105-168) that authorized a nationwide network of birth defects research and prevention programs and called for a nationwide information clearinghouse on birth defects. Dr. Jennifer L. Howse, president of the March of Dimes Birth Defects Foundation, noted: "This legislation will help us find the causes of major birth defects, devise new ways to help prevent them, and better apply what we already know."

On December 3, 2003, the "Birth Defects and Development Disabilities Prevention Act" (H.R. 398 and S. 286) was passed into law. This bill revises and extends the Birth Defects Prevention Act of 1998 to expand and adjust