Policy and Position Statements


Improving Birth Outcomes - Position Statement

I. ASTHO Supports State and Territorial Efforts Designed to Improve Birth Outcomes

The Association of State and Territorial Health Officials (ASTHO) supports state and territorial health agencies in their work to improve birth outcomes through policy and comprehensive system-wide changes. Efforts that improve birth outcomes will enhance the health of mothers and their children across their lifespan. Health officials can leverage public health, social services, and primary care to improve care quality and reduce poor birth outcomes costs to the healthcare system and families.

II. ASTHO Recommendations for State and Territorial Health Officials:

  • Develop comprehensive and systematic approaches to improve birth outcomes by prioritizing prevention policies across disciplines, enabling and facilitating access to care, and improving state public health infrastructure, with an emphasis on reducing health disparities.
  • Use the executive leadership of state health officials to develop strategic partnerships at the local, tribal, state, and national levels that influence public, private, and nonprofit organizations to develop cross-cutting programs, inspire policy development, and provide consistent messaging.
  • Eliminate health disparities by incorporating approaches that modify or influence social determinants of health, such as changing the environments in which families live or improving the ability of families to thrive in their environments. This includes mobilizing community health and wellness resources, identifying individuals and communities of greatest need, and using proven practices to engage, inform, and deliver needed health and social services.
  • Develop, review, and enhance regional care systems, especially neonatal intensive care units (NICUs) and perinatal care, for high-risk pregnancies and deliveries in collaboration with healthcare provider organizations, hospitals, and payers.
  • Facilitate strategies to promote preconception health, intrapartum care, healthcare, and reproductive life planning within existing family planning, healthcare, educational, and public health settings.
  • Enhance prenatal and postnatal care interventions for women with Medicaid coverage and women who are at high risk for preterm birth.
  • Reduce non-medically-indicated elective inductions and cesarean sections by working closely with patients, providers, hospitals, private insurers, and Medicaid.
  • Work closely with insurers, health educators, and providers to ensure smoking cessation programs are offered as part of the care provided, including all appropriate screening, assessment, counseling, and treatment services.
  • Work closely with the public, new parents and their families, caretakers, and healthcare providers to implement infant safe sleep education campaigns.
  • Support and work closely with perinatal collaboratives and OB/GYN and neonatology providers to prevent, use prescription drug monitoring programs (PDMPs) to monitor, universally screen for, and appropriately manage substance abuse during pregnancy and neonatal abstinence syndrome.
  • Conduct strategic planning efforts among stakeholders and partners, including private and public insurers, to identify resource needs and opportunities to obtain federal, state, and private funding to serve all high‐risk families.
  • Coordinate with private insurers, the Children’s Health Insurance Program, and Medicaid to arrange insurance coverage for newborn screening and children with screened conditions, and when appropriate, link families to Children and Youth with Special Health Care Needs programs, education, and social services systems.
  • Periodically review and update state plans to assess effectiveness and reflect changes in science and technology.
  • Coordinate with Medicaid, healthcare providers, professional organizations, and other key stakeholders to improve identification of eligible women, increase availability of and access to 17P, and educate providers and patients on appropriate use of 17P.
  • Ensure programs and policies are continuously evaluated using public health surveillance systems to monitor progress in outcomes for populations, communities, states, and territories. Data sources for monitoring and assessment include vital statistics, hospital discharge data, electronic health records, and health surveillance systems, such as birth defects surveillance and fetal infant mortality review. Effective use of data at the state and territorial level will enable state and territorial health agencies to develop programs and policies informed by their own priorities and contribute to development and use of evidence-based practices.

III. ASTHO Recommendations for the Federal Government:

  • Work with the executive leadership of state health officials and agencies to develop strategic partnerships within states that leverage public, private, and nonprofit organizations to develop cross-cutting programs, influence policy development, and provide consistent messaging.
  • Support state and territorial health agency leaders in seamlessly providing a continuum of services to families by improving collaboration, coordination, and funding across public health, social, and medical programs. This includes programs such as the Title V Maternal and Child Health (MCH) Services Block Grant; Women, Infants, and Children (WIC) grants; Title X Family Planning grants; home visitation programs; and Medicaid, as well as many public health and medical programs, including services to children with special healthcare needs, HIV, injury and violence prevention, oral health, chronic disease, early learning, substance abuse, and behavioral health.
  • Fund and support perinatal collaboratives.
  • Fund and support further research on the causes of preterm birth using the lens of social determinants of health.
  • Fund and support rigorous quality improvement and program evaluation practices through optimal use of health data from local, state, regional, and national levels to demonstrate MCH program effectiveness.
  • Continuously evaluate the impact of programs using public health surveillance systems to track progress in populations, communities, states and territories. Provide continuous quality improvement training using state and territorial data sets and expand maternal and child health surveys and surveillance projects, like the Pregnancy Risk Assessment Monitoring System and fetal infant mortality review committees, to every state.
  • Establish standards for data collection:

○ Link data systems such as vital records and birth defects surveillance with newborn screening.
○ Promote data sharing and collaboration at the federal, regional, state, territorial, tribal, and local levels to develop guidelines on long-term follow up and treatment.
○ Track individuals through systems as they move geographically.
○ Provide assistance to states carrying out standards, such as updating and standardizing birth certificates, timeliness of data, access to and integrating with electronic health records, etc.

IV. Background

ASTHO’s members are responsible for ensuring the health of residents in their states and territories. State health officials and their leadership teams are uniquely positioned to affect maternal and child health outcomes in their states and communities. Led by the state health official, these leadership teams are key components of successfully engaging partners and implementing interventions through state health agencies at the state and local levels. In October 2011, ASTHO’s past President David Lakey declared improving birth outcomes as his President’s Challenge to all state and territorial health officials.

There are multiple strategies for improving birth outcomes including preventing preterm births, early elective deliveries, unplanned or closely spaced pregnancies, and infant mortality. Preterm birth is the leading cause of neonatal death, yet its causes are not well understood. Preterm births also increase the chance of disabilities and developmental delays among infants who survive. Infants born before 34 weeks gestation are more likely to die or experience lifelong morbidity. Most preterm infants have a low birth weight, which places the infant at greater risk of developing chronic conditions as an adult, such as diabetes and heart disease. In the United States, the preterm birth rate has increased more than 30 percent in the last 20 years, costing billions of dollars annually. The medical, educational, and lost productivity costs associated with preterm birth were more than $26 billion in 2005, equaling $51,600 per infant born preterm.

Progesterone, a hormone that plays a key role during pregnancy, treatment can help prevent preterm birth in at-risk women.i 17-alphahydroxyprogesterone (17P), an injectable form of progesterone, has been proven effective in preventing preterm birth if administered between 16 and 20 weeks gestation for women who have had a previous preterm birth.  Many women do not access prenatal treatment until after 20 weeks gestation, creating miss opportunities for 17P administration.  Coordinated efforts to promote the appropriate use of 17P will provide state and territorial health agencies the unique opportunity to reduce the incidence of PTB among eligible women.

Another priority from the President’s Challenge is preventing early elective deliveries. Babies delivered between 37 and 39 weeks have higher risk of complications than babies born at 39 and 40 weeks. Some complications include increased NICU admissions, the need for ventilator support, and difficulty breastfeeding. One study of a hospital system found that 44 percent of deliveries were scheduled C-sections, and 71 percent of those had no medical reason for early delivery.

The U.S. infant mortality rate of 6.14 deaths before age one per 1,000 live births is the lowest rate in U.S. history, but is still higher than the Healthy People 2020 target of 6.0 deaths per 1,000 live births. Although the United States is experiencing a decrease in infant mortality, the causes are not fully understood. Infant mortality rates in individual states range from 4.7 to 10.0 deaths per 1,000 births. One of the most important factors contributing to infant mortality is the preterm birth rate in the United States. Other risk factors include birth defects and congenital anomalies, the sleeping position, and location of infants, maternal smoking and secondhand smoke exposure, and overheating.
There are significant racial and ethnic inequities, at all economic levels, in preterm birth and infant mortality rates. In 2012, 16.53 percent of babies born to non-Hispanic black mothers were preterm, which is much higher for Asian/Pacific Islanders (10.15), non-Hispanic Whites (10.29), Hispanics (11.58), and American Indian/Alaska Natives (13.25). African Americans also experience an infant mortality rate more than twice the national average.

Approval History

Access Policy Committee Review and Approval: January 2015
Board Review and Approval: March 2015

Policy Expires: March 2018

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position statements are not voted on by the full ASTHO membership.

Related ASTHO Documents

Policy Statements

Position Statements


  1. Healthy Babies Are Worth the Wait: Preventing Preterm Births Through Community-Based Interventions: An Implementation Manual. March of Dimes. 2009.
  2. Goldenberg RL, Culhane JF. “Low birth weight in the United States.” American Journal of Clinical Nutrition. 2007. 85: 584S-590S. Available from: http://www.ajcn.org/content/85/2/584S.full. Accessed April 26, 2012.
  3. Martin JA, Kirmeyer S, Osterman M, Shepherd RA. “Born a bit too early: Recent trends in late preterm births.” Hyattsville, MD: National Center for Health Statistics. 2009. NCHS data brief, no 24.
  4. Board on Health Sciences Policy, Behrman RE, Butler AS (eds). Preterm Birth: Causes, Consequences, and Prevention. Committee on Understanding Premature Birth and Assuring Healthy Outcomes. National Academies Press. 2006. Available from: http://books.nap.edu/catalog.php?record_id=11622.  
  5. Clark S, Miller D, Belford M, Dildy G, Frye D, Meyers J. “Neonatal and maternal outcomes associated with elective term delivery.” American Journal of Obstetrics and Gynecology. 2009. 200:156.e1-.e4.
  6. Davidoff MJ, Dias T, Damus K, Russell R, Bettegowda VR, Dolan S, et al. “Changes in the gestational age distribution among U.S. singleton births: impact on rates of late preterm birth, 1992 to 2002.” Semin Perinatol. 2006. 30(1):8-15.
  7. March of Dimes. Get Ready for Labor: Why at Least 39 Weeks Is Best for Your Baby. Available from: http://marchofdimes.com/pregnancy/getready_atleast39weeks.html. Accessed February 5, 2012.
  8. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). March of Dimes. 2010. Available from: http://www.cdph.ca.gov/programs/mcah/Documents/MCAH-EliminationOfNon-MedicallyIndicatedDeliveries.pdf. Accessed April 26, 2012.
  9. Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary Data for 2010. Hyattsville, MD: National Center for Health Statistics. 2012. National Vital Statistics Reports; vol 60 no 4. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. Accessed April 26, 2012.
  10. Healthy People 2020. Maternal, Infant, and Child Health. Available from: www.healthypeople.gov. Accessed February 5, 2012.
  11. America’s Health Rankings. United States Infant Mortality 2011. United Health Foundation. Available from: http://www.americashealthrankings.org/ALL/IMR/2011. Accessed January 17, 2012.
  12. “Sudden, Unexplained Infant Deaths.” In Shapiro C. Sudden, Unexplained Infant Death Investigation: A Systematic Training Program for the Professional Infant Death Investigation Specialist. Department of Health and Human Services. 2007. Available from: http://www.cdc.gov/sids/trainingmaterial.htm. Accessed April 26, 2012.
  13. Martin JA. “Preterm Births: United States, 2007.” CDC Health Disparities and Inequalities Report — United States, 2011; Supplement vol 60. Hyattsville, MD: National Center for Health Statistics. 2011. Available from: http://www.cdc.gov/mmwr/pdf/other/su6001.pdf.  
  14. MacDorman MF, Mathews TJ. Recent Trends in Infant Mortality in the United States. Hyattsville, MD: National Center for Health Statistics. 2008. NCHS data brief, no 9. Available from: http://www.cdc.gov/nchs/data/databriefs/db09.pdf. Accessed April 26, 2012.
  15. Child Health USA 2013. Maternal and Child Health Bureau, U.S. Department of Health and Human Services. Available from: www.mchb.gov/chusa13/perinatal-health-status-indicators/p/preterm-birth.html.
  16. Infant Mortality and African Americans. Office of Minority Health. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=3021, accessed August 2014.

i. Medicaid Health Plans of America Center for Best Practices. “Preterm Birth Prevention: Evidence-Based Use of Progesterone Treatment: Issue Brief and Action Steps for Medicaid Health Plans.” November 2014. Available at: http://www.mhpa.org/_upload/PTBIssueBrief111714MHPA.pdf. Accessed January 16, 2015.