Making babies bigger before birth.

Infants weighing as little as 1-1/2 pounds at birth can survive with the aid of costly, highly technical care -- incubators, respirators, pulse and breathing rate monitors and tube feedings. But U.S. medical resources are being strained by the ever-increasing need for this expensive treatment. Moreover, many infants born too small do not survive, even with high-tech care: A newborn weighing less than 5-1/2 pounds is 40 times more likely to die during the first month than is a heavier baby. Now the Institute of Medicine (IOM) of the National Academy of Sciences argues that it is time to turn to preventive approaches. It reports that much of the loss of newborns and much of the need for high-cost neonatal treatment could be prevented by increasing women's access to good-quality prenatal care.

The urgency of this argument is underscored by reports this week that the rate of decline in the U.S. rate has slowed. According to data of the Public Health Service, the infant mortality rate, which had dropped steadily from 24.7 per 1,000 live births in 1965, appears to be plateauing at about 11 deaths for each 1,000 births. Japan and several countries in northern Europe have rate below 9 per 1,000.

Birthweight is considered to be a major determining factor in infant survival. In addition, low-birthweight infants have an increased risk of such handicaps as cerebral palsy and mental retardation. "What's needed is a shift in emphasis from treating the effects of low birthweight to treating the causes," says Richard E. Behrman, chairman of the IOM committee and dean of the School of Medicine at Case Western Reserve University in Cleveland.

About a quarter of a million U.S. Infants are born each year weighing less than 5-1/2 pounds--the definition physicians use for a low-birthweight infant, a classification that includes both premature babies and those with intrauterine growth retardation (SN: 10/15/83, p. 250; 10/22/83, p. 266). The Public Health Service reports that the incidence of low birthweight stopped dropping in 1980. The proportion of U.S. babies that are of low birthweight--6.8 percent of live births -- is higher than the rate in at least 12 other developed countries.

"The overwhelming weight of the evidence indicates that prenatal care reduces the risk of low birthweight," says the IOM committee. But, Behrman says, there is evidence "that long progress in enrolling greater numbers of women in prenatal care early in pregnancy has halted and may even be deteriorating." The committee calculates that early and regular prenatal care for all women could reduce the annual incidence of low birthweight by 35,000 or more.

The groups at highest risk for having low-birthweight babies are also those least likely to receive adequate prenatal care. "Teenagers, unmarried women, the poor, black women and those with less than a high school education are much more likely than other women to have a low-birthweight baby," says Behrman. The committee calculates that for a target population of 1.4 million high-risk women, each dollar spent on prenatal care could save as much as $3.38 on specialized hospital care for low-birthweight infants. At a congressional hearing members of the committee stated that the entire cost of prenatal care for a woman, on the average $500 to $800, is less than that of a single day of hospitalization in the intensive care nursery for a low-birthweight infant. The committee cites current financial restraints, including Medicaid restrictions on the number of allowable prenatal visits, as a major barrier to adequate prenatal care.