March of Dimes Foundation Data Book for Policy Makers Maternal, Infant, and Child Health in the United States

Transcription

1 March of Dimes Foudatio Data Book for Policy Makers Materal, Ifat, ad Child Health i the Uited States

2 2009 by the March of Dimes. Permissio to copy, dissemiate or otherwise use iformatio from the Data Book for Policy Makers is grated as log as appropriate ackowledgmet is give. Prepared by: Office of Govermet Affairs March of Dimes th Street, NW, Sixth Floor Washigto, DC Telephoe (202) Fax (202) For additioal copies: March of Dimes P.O. Box Atlata, GA Phoe (800) marchofdimes.com Item umber

3 The March of Dimes Data Book for Policy Makers: Materal, Ifat, ad Child Health i the Uited States 2010 provides atioal ad state data highlightig ifat mortality, birth defects, preterm ad low birthweight births, health isurace coverage for wome ad childre, ad prevetio strategies. This easy-to-use resource guide is aimed at public policy makers ad others seekig quick facts at their figertips. Readers iterested i more detail ad regular updates of may of the data preseted i this book should visit PeriStats, the March of Dimes iteractive data resource at marchofdimes.com/peristats. Except where oted, iformatio i this Data Book is for the Uited States. Where possible, data for Puerto Rico are icluded. The March of Dimes Data Book for Policy Makers was produced by Collee Soosky, Kate Morrad, ad Maria L. Weiss of the Office of Govermet Affairs. Rebecca Russell, Todd Dias, Hui Zheg, ad Vai Bettegowda of the March of Dimes Periatal Data Ceter prepared much of the data. Do Komai of Watermark Desig ad Chita Parikh from Publishig Resources provided services to assist the March of Dimes with the productio of the publicatio. the Foudatio works to improve the health of wome, ifats ad childre by prevetig birth defects, premature birth ad ifat mortality through research, commuity services, educatio ad advocacy. The March of Dimes is a uique partership of scietists, cliicias, parets, members of the busiess commuity ad other voluteers affiliated with chapters i all 50 states, the District of Columbia, ad Puerto Rico. We trust this Data Book ad other March of Dimes resources that ca be foud at com (Spaish laguage site www. acersao.org) will be helpful as we work together toward the day whe every baby is bor healthy. Dr. Bruce C. Vladeck, Chair Natioal Public Affairs Committee March of Dimes Dr. Jeifer L. Howse, Presidet March of Dimes The March of Dimes is a atioal volutary health agecy fouded i 1938 by Presidet Frakli D. Roosevelt to support research ad services related to polio. Today,

4 About PeriStats PeriStats, the March of Dimes iteractive web resource (marchofdimes. com/peristats) offers the latest data o materal, ifat, ad child health at atioal, state, ad local levels. Users from the geeral public to policy makers, researchers, providers, ad studets will fid the site comprehesive ad easy to use. Look for the PeriStats logo o pages throughout the Data Book for Policy Makers. It s a sigal that more detailed ad perhaps more curret iformatio is available o the website. Updated at least aually, PeriStats covers data for multiple years for topics like birth rates, ifat mortality, prematurity, ad low birthweight; tobacco, alcohol, ad illicit drug use; cesarea sectio rates; ewbor screeig; ad health isurace coverage. Iformatio by race, ethicity, ad materal age is also available for may of these idicators. Users ca compare data for couties, states, ad the Uited States ad ca choose various output formats, icludig graphs, maps, tables, ad slides which they ca use i reports or presetatios. Together, PeriStats ad the Data Book are powerful tools for helpig iform policy to improve materal, ifat, ad child health i the Uited States. marchofdimes.com/peristats

5 Cotets Materal, Ifat, ad Child Health Objectives for O a average day i the Uited States 2 Quick stats for the Uited States 3 Ifat ad Materal Mortality Ifat Mortality i the Uited States 6 Ifat Mortality ad Race/Ethicity of Mother 8 Leadig Causes of Ifat Mortality 10 Materal Mortality 12 Birth Defects Icidece of Birth Defects 16 Birth Defects Moitorig Programs 18 Newbor Screeig 20 Newbor Screeig: Categories of Disorders 22 Preterm ad Low Birthweight Births Preterm Births 26 Prematurity ad Low Birthweight 28 Risk of Preterm Births 30 Prematurity ad Race/Ethicity of Mother 32 Costliess of Preterm ad Low Birthweight Babies 34 Prevetio Importace of Preatal Care 38 Patters of Preatal Care 39 Beefits of Folic Acid 40 Smokig Durig Pregacy 42 Alcohol ad Other Drug Use 44 Obesity 46 Childhood Immuizatio 48 Health Isurace Health Isurace ad Access to Care 50 Health Isurace Coverage for Wome of Childbearig Age 52 Health Isurace Coverage for Childre 54 Medicaid s Role i Materal ad Child Health 56 Childre s Health Isurace Program 58 Medicaid ad CHIP: Eligibility ad Erollmet 60 State Data State Ifat Mortality Rates, Average 65 Live Births, by State, Newbor Screeig Requiremets, by State, Preterm ad Low Birthweight Births 72 Preatal Care 84 Health Isurace 90 Immuizatios 111 Newbor Screeig Terms: A Glossary 112

6 Cotets (cotiued) Data Sources 116 Figures ad Summary Tables Ifat Mortality, Ifat Mortality, by Regio, Ifat Mortality, by Race/Ethicity of Mother, Ifat Mortality, by Hispaic Ethicity of Mother, Leadig Causes of Neoatal ad Ifat Mortality, Materal Mortality, by Race, Hospital Costs of Birth Defects, State Activities i Birth Defects Moitorig, Orgaizatioal Locatio of Birth Defects Programs, Fudig Sources for Birth Defects Programs, State Newbor Screeig Requiremets, 2009: A Summary 21 Preterm ad Very Preterm Births, Percet Distributio of All Preterm Births, Icidece of Preterm ad Low Birthweight Births, Low ad Very Low Birthweight Births, Preterm ad Very Preterm Births, by Age of Mother, Preterm Births: Sigleto, Twi, ad Higher Order, Preterm ad Very Preterm Births, by Race/Ethicity of Mother, Preterm ad Very Preterm Births, by Hispaic Ethicity of Mother, Average Legth of Stay ad Average Medical Costs Amog Preterm ad Term Births, Coditios with the Highest Ipatiet Hospital Costs, Awareess of Folic Acid Beefits Amog Wome of Childbearig Age, 1995 ad Pregat ad Nopregat Wome Reportig Smokig Durig the Past Moth, State Medicaid Coverage: Smokig Cessatio Treatmets for Pregat Wome, Wome Ages Reportig Bige Drikig Durig Past Moth, Obesity Amog Wome Ages 18-44, Childre with No Usual Source of Medical Care, by Type of Isurace Coverage, Wome Ages 15-44, by Type of Health Isurace Coverage, Wome Ages Who Are Uisured, by Race/Ethicity, Childre Uder Age 19, by Type of Health Isurace Coverage, Childre Uder Age 19 Who Are Uisured, by Race/Ethicity, Medicaid Erollmet ad Expeditures, by Erollee Characteristics, Family Plaig Waiver Programs, by State, Childre s Health Isurace Program Erollmet, States with Presumptive or Cotiuous Eligibility Uder Medicaid ad CHIP,

7 State-by-State Data ad Tables State Ifat Mortality Rates, Average 65 Ifat Mortality Rates, by States, Average 66 Live Births, by State, Newbor Screeig Requiremets, by State, Preterm Births, by State, Late Preterm Births, by State, Very Preterm Births, by State, Low Birthweight Births, by State, Very Low Birthweight Births, by State, Preterm Birth Rates, by State, Childre s Health Isurace Program, by Type of Program, Births to Wome Who Received Early Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) 84 Births to Wome Who Received Early Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) 85 Births to Wome Who Received Late or No Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) 86 Births to Wome Who Received Late or No Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) 87 Births to Wome Who Received Adequate or Adequate-Plus Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) 88 Births to Wome Who Received Adequate or Adequate-Plus Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) 89 Wome Ages Without Health Isurace, by State, Average 90 Childre Uder Age 19 Without Health Isurace, by State, Average 92 Icome Eligibility Thresholds for Pregat Wome ad for Childre Uder Medicaid, by State, Icome Eligibility Thresholds for Pregat Wome ad for Childre Uder CHIP, by State, Presumptive ad Cotiuous Eligibility Uder Medicaid ad CHIP, by State, Medicaid Erollees, by Select Characteristics, by State, Fiscal Year Medicaid Expeditures, by Erollee Characteristics, by State, Fiscal Year Stad-Aloe ad Medicaid Expasio CHIP Erollees, by State, Childre s Health Isurace Program Federal Allotmets, by State, Fiscal Year Federal Matchig Rates for Medicaid ad CHIP, by State, Fiscal Year Births Fuded by Medicaid, by State, Medicaid Coverage of Smokig Cessatio Treatmets, by State, Percet of Childre Moths with Up-to-Date Immuizatios,

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9 Materal, Ifat, ad Child Health Objectives for 2010 Healthy People 2010, a series of atioal health objectives to be achieved by the year 2010, was released by the U.S. Departmet of Health ad Huma Services (HHS) i Jauary These objectives are beig used as a bechmark for measurig progress i health promotio ad disease prevetio. The broad goals of this iitiative are to icrease the quality ad years of healthy life ad elimiate racial ad ethic disparities i health status. A umber of the Healthy People 2010 objectives cocer materal, ifat, ad child health. Amog them are efforts to: q q q Reduce rates of ifat ad materal mortality, preterm ad low birthweight births, ad birth defects Icrease the proportio of wome receivig early ad adequate preatal care Esure appropriate ewbor screeig ad follow-up testig ad care May relevat objectives are referred to i this data book. More detailed iformatio about the iitiative is at the website healthypeople.gov. E v e r y 1 0 y E A r s, H H S A S S E S S E S A N D r E P O r T S O N S C I E N T I F I C I N S I G H T S A N D l E S S O N S l E A r N E D f r O M T H E P A S T D E C A D E, a l O N G W I T H N E W k N O W l E D G E O F c u r r E N T D A T A, t r E N D S, A N D I N N O v A T I O N S. H E A lt H y P E O P l e W I l l r E F l E C T A S S E S S M E N T S O F M A j o r r I S k s T O H E A lt H A N D W E l l N E S S, C H A N G I N G p u b l I C H E A lt H p r I O r I T I E S, A N D E M E r G I N G I S S u E S r e l A T E D T O o u r N A T I O N s H E A lt H p r E P A r E D N E S S A N D p r e - v E N T I O N. F o r I N F O r M A T I O N O N T H E D E v e l O P M E N T O F T H E r e v I S E D o r N E W O B j E C T I v E S S E T F O r H E A lt H y P E O P l e , S E E H E A lt H y P E O P l e. G O v / H P / 1

10 O a average day i the Uited States... 11,686 1, babies are bor babies are bor preterm (less tha 37 completed weeks gestatio) babies are bor low birthweight (less tha 2,500 grams, or 5 1 /2 pouds) babies are bor with a birth defect* babies are bor very preterm (less tha 32 completed weeks gestatio) babies are bor very low birthweight (less tha 1,500 grams, or 3 1 /3 pouds) babies die before reachig their first birthday * Based o Ceters for Disease Cotrol ad Prevetio estimate of at least 120,000 babies bor aually with major structural birth defects. Note: Numbers are approximatios. Source: Natioal Ceter for Health Statistics, 2006 fial atality data ad 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

11 Quick stats for the Uited States... About every seve secods, a baby is bor. Every hour, about three babies die. Africa-America ifats are more tha twice as likely as white ifats to die before their first birthday. Birth defects are the leadig cause of ifat mortality, accoutig for oe i five ifat deaths. Each year, about 3,000 pregacies are affected with birth defects of the brai ad spial cord. About every four ad a half miutes, a baby is bor with a birth defect.* About oe i eight ifats is bor preterm. (less tha 37 completed weeks gestatio) About every oe ad a half miutes, a low birthweight baby is bor. (less tha 5 1 /2 pouds) Prematurity/low birthweight is the secod leadig cause of all ifat deaths ad the leadig cause of ifat deaths amog Africa Americas. Every year, about 4,900 babies are bor weighig less tha oe poud. About every miute, a baby is bor to a tee mother. * Based o Ceters for Disease Cotrol ad Prevetio estimate of at least 120,000 babies bor aually with major structural birth defects. Source: Natioal Ceter for Health Statistics, 2006 fial atality data ad 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 3

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13 Ifat ad Materal Mortality

14 Ifat Mortality i the Uited States Eve though ifat mortality i the Uited States dropped dramatically i the past cetury, sigificat room for improvemet remais. q The ifat mortality rate remaied relatively stable over the last several years. q More tha 28,000 ifats died before their first birthdays i 2005 a rate of 6.9 deaths per 1,000 live births. q I 2005, the ifat mortality rate was highest i the souther regio of the Uited States. Source: Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, I N F A N T M o r T A l I T y r E F E r s T O D E A T H u N D E r A G E O N E. T H E I N F A N T M O r - T A l I T y r A T E I S T H E u M B E r O F I N F A N T D E A T H S P E r 1, l i v e B I r T H S. 6 March of Dimes

15 Ifat Mortality, Deaths per 1,000 live births Source: Natioal Ceter for Health Statistics, fial mortality data, period liked birth/ifat death data. Prepared by March of Dimes Periatal Data Ceter, Year Goal Ifat Mortality by Regio, 2005 Deaths per 1,000 live births Midwest Northeast South West Source: Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 7

16 Ifat Mortality ad Race/Ethicity of Mother Africa-America ifats are early two ad a half times as likely as white ifats to die i the first year of life. Excludig babies of Hispaic origi, the 2005 ifat mortality rate for those bor to black mothers was 13.6 per 1,000 live births, compared with 5.8 for whites, 8.3 for Native Americas, ad 4.8 for Asia/Pacific Isladers. For Hispaics, the 2005 ifat mortality rate was 5.6 per 1,000 live births. Withi this group, Puerto Rica mothers had the highest rate of 8.3. O N E H E A lt H y P E O P l e O b j E C T I v e I S T O r E D u C E T H E r A T E O F I N F A N T D E A T H S F O r a l l r A C I A l / E T H N I C g r o u P S T O 4. 5 P E r 1, l i v e B I r T H S. 8 March of Dimes

17 Ifat Mortality, by Race/Ethicity of Mother, 2005 Deaths per 1,000 live births White Black Native America a a Native America icludes America Idia, Eskimo, ad Aleut. b People of Hispaic origi may be of ay race; racial categories displayed here are o-hispaic. Source: Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, Ifat Mortality, by Hispaic Ethicity of Mother, Asia/ Pacific Islader 5.6 Hispaic b 6.9 All Races/ Ethicities 4.5 Year 2010 Goal Deaths per 1,000 live births Mexica Puerto Rica Cuba Cetral or South America Other Hispaic Total Hispaic Source: Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 9

18 Leadig Causes of Ifat Mortality For more tha 20 years, birth defects have bee the leadig cause of ifat mortality (death i the first year of life). By cotrast, prematurity/low birthweight is the most commo cause of eoatal mortality (death i the first moth of life). Birth defects ad prematurity/low birthweight together were resposible for 36 percet of all ifat deaths ad 45 percet of all eoatal deaths i Birth defects aloe were resposible for early 21 percet of eoatal deaths i the same year. The leadig cause of ifat death differed by race. Amog o-hispaic whites, it was birth defects. Amog o-hispaic blacks, it was prematurity/low birthweight. The rate of deaths due to prematurity/low birthweight for o-hispaic black ifats was four times that for o-hispaic white ifats (305 versus 76 per 100,000 live births.) H E A l T H y P E O P l e H A S S E v e r a l O B j E C T I v E S T O r E D u C E T H E r A T E O F I N F A N T D E A T H S, I N C l u D I N G : F o r B I r T H D E F E C T S, l O W E r T H E i f a t D E A T H r A T E T O 1. 1 f r O M 1. 6 ( ) F o r s u D D E N I N F A N T D E A T H S y N D r O M E, o r S I D S, L O W E R T H E I N F A N T D E A T H R A T E T O F R O M ( ) ( R A T E S A R E P E R 1, L I V E B I R T H S. ) 10 March of Dimes

19 Leadig Causes of Neoatal ad Ifat Mortality, 2005 Prematurity/low birthweight Birth defects Materal complicatios Placeta/cord complicatios Respiratory distress sydrome Sudde ifat death sydrome Percet of Neoatal Deaths Percet of Ifat Deaths Note: Neoatal death occurs i the first moth of life (28 days). Ifat death occurs durig the first year of life. Source: Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 11

20 Materal Mortality After a marked declie, the rate of materal deaths i the Uited States has ot substatially improved sice the 1980s. There were 13.3 materal deaths per 100,000 live births i 2006, accordig to vital statistics data. This figure may be a udercout, however. The actual materal mortality rate is estimated to be 1.3 to 3 times higher. I 2006, Africa Americas were early three ad a half times as likely as whites to die from pregacy complicatios ad childbirth. Further reductios i materal mortality are possible, give that the World Health Orgaizatio estimates that 33 coutries have achieved lower materal mortality levels tha the Uited States. q q Experts estimate that up to half of all materal deaths i this coutry could be preveted through a variety of itervetios, icludig early diagosis ad appropriate medical care of pregacy complicatios. Oe Healthy People 2010 objective is to lower the materal mortality rate to 3.3 deaths per 100,000 live births. 12 Of the more tha 4 millio wome who give birth each year i the Uited States, at least 30 percet have a pregacy-related complicatio before, durig, or after delivery. Eve whe they do ot result i death, these complicatios may cause log-term health problems. Source: Materal mortality rates from the Natioal Ceter for Health Statistics, 2009a. Iteratioal rakig from the World Health Orgaizatio, All other iformatio from the Ceter for Disease Cotrol ad Prevetio, 1998 ad 1999a. A M A T E r N A l D E A T H I S D E F I N E D A S O N E T H A T O C C u r s d u r I N G p r E G N A N C y o r W I T H I N 4 2 D A y s O F T H E E N D O F a p r E G N A N C y. I r r E S P E C T I v e O F T H E d u r A T I O N A N D S I T E O F T H E p r E G N A N C y, f r O M A N y C A u S E r e l A T E D T O o r A G G r a v A T E D b y a W O M A N s p r E G N A N C y, b u t N O T f r O M A C C I D E N T A l o r I N C I D E N T A l C A u S E S

21 Materal Mortality, by Race, Materal deaths per 100,000 live births Total Black White Note: Rates from are based o race of child. Rates after 1988 are based o race of mother. Source: Natioal Ceter for Health Statistics, 2009a. March of Dimes 13

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23 Birth Defects

24 Icidece of Birth Defects Each year, a estimated 120,000 babies are bor with major structural birth defects. Oe i five ifat deaths is due to birth defects, makig them the leadig cause of ifat mortality Birth defects rak secod i leadig causes of death amog 1- to 4-year olds ad fifth amog 5- to 14-year olds. Birth defects of the heart ad circulatory system are the most commo, affectig roughly 1 i 115 ewbors. Hospital costs for stays due to birth defects totaled $2.6 billio for all birth defects ad all ages i More tha half of all hospital costs were related to cardiac ad circulatory birth defects. I 2004, a birth defect hospital admissio was more tha twice as costly as all other hospital admissios averagig $18,600. Severe birth defects may require special lifelog medical treatmet. Because may coditios caot be fully corrected, birth defects are a major cause of childhood ad adult disability. Sources: Ifat deaths from birth defects from the Natioal Ceter for Health Statistics, 2005 period liked/ifat death data. Childhood deaths from birth defects from the Natioal Ceter for Health Statistics, 2006 fial mortality data. Hospital costs from Russo, CA ad Elixhauser, A, March of Dimes

25 Hospital Costs of Birth Defects, 2004 Pricipal Diagosis Total # of Hospital Stays % of All Stays for Birth Defects Mea Costs (dollars) Aggregate Costs (dollars) All cardiac ad circulatory cogeital aomalies 46, % $29,600 $1,368,822,600 All digestive cogeital aomalies 25, % $11,700 $303,173,100 All geitouriary cogeital aomalies 12, % $8,900 $114,709,700 All ervous system cogeital aomalies 6, % $16,200 $112,164,200 Cleft lip with or without cleft palate 4, % $5,500 $27,155,800 Cogeital aomalies of skull ad facial boes 3, % $16,800 $61,329,500 Foot deformities 2, % $5,900 $16,873,900 Cleft palate without cleft lip 2, % $5,400 $15,506,700 All birth defects* 139, % $18,600 $2,566,067,700 * Icludes birth defects ot show. Source: Russo, CA ad Elixhauser, A, March of Dimes 17

26 Birth Defects Moitorig Programs States play a vital role i prevetig birth defects by maitaiig birth defects moitorig programs. These programs collect data for detectig birth defects treds ad suggest areas for further research. They also lik people to eeded services The Ceters for Disease Cotrol ad Prevetio (CDC) works through the states to collect data, operate research ceters, ad furish iformatio to the public o birth defects. These efforts are maaged by the Natioal Ceter o Birth Defects ad Developmetal Disabilities. q q q Almost three quarters (34) of all states plus Puerto Rico have some type of birth defects moitorig program, while aother ie ad the District of Columbia are plaig oe. CDC has give 15 states grats to develop or ehace their program ad to use the data they collect for prevetio ad referral activities. CDC fuds eight Ceters for Birth Defects Research ad Prevetio to collaborate o the largest multistate study of birth defects. The ceters are located i Arkasas, Califoria, Iowa, Massachusetts, New York, North Carolia, Texas, ad Utah. CDC also participates as the ith study site. The researchers at these ceters have a uique opportuity to look at the effects of geetics ad the eviromet o birth defects. CDC is also workig with the Natioal Birth Defects Prevetio Network (NBDPN) to compile state data. Sice state methods ad data sources vary, the etwork has developed guidelies to make iformatio more comparable across states. Also, they have developed atioal prevalece estimates for 21 birth defects. Sources: Ceters for Disease Cotrol ad Prevetio, 2009a. See also Ceters for Disease Cotrol ad Prevetio, 2006 ad Cafield, March of Dimes

27 State Activities i Birth Defects Moitorig, 2009 Operatioal program (33 ad Puerto Rico) Plaig program (9) No program (8 ad DC) Source: Ceters for Disease Cotrol ad Prevetio, 2009a. Orgaizatioal Locatio of Birth Defects Programs, 2009 Percet DOH Epidemiology /Eviromet DOH, Vital Heath Statistics 26 DOH, MCH/ CSHCN/ Family Health Source: Ceters for Disease Cotrol ad Prevetio, 2009a. 3 DOH, Geetic Services 5 4 Uiversity Other (oprofit, hospital CDC) Fudig Sources for Birth Defects Programs, 2009 Percet Geeral State Fuds (23/44 programs) 45 MCH (20/44 programs) 11 Geetic Screeig Reveue (5/44 programs) Source: Ceters for Disease Cotrol ad Prevetio, 2009a. 34 CDC Grat (15/44 programs 9 9 Other Federal Fudig (4/44 programs) March of Dimes Special BD Fud/Services Fees (4/44 programs) 19

28 Newbor Screeig Numerous iherited disorders ca be idetified shortly after birth ad treated early to prevet disability ad, i some cases, death. Treatmet ofte icludes a special diet, utritioal supplemets, ad medicatios. For example, ifats with pheylketouria (PKU) ca avoid severe metal retardatio by receivig a special formula begiig immediately after birth. Most tests ca be doe usig a simple heelstick blood sample collected before the ewbor leaves the hospital. The federal Advisory Committee o Heritable Disorders ad Geetic Disease i Newbors ad Childre i 2005 edorsed a report by the America College of Medical Geetics, recommedig screeig all ewbors for 29 specific coditios, icludig metabolic disorders, hearig impairmet, ad others. Newbor screeig requiremets vary by states. All states ad the District of Columbia scree for hemoglobiopathies ad amio acid metabolism disorders except Tyrosiemia type I. Twety-eight states ad the District of Columbia test for all 29 recommeded coditios. Fiacig of ewbor screeig varies by state as well. Some states pay for screeig usig federal Materal ad Child Health Block Grat fuds or other resources. I others, parets must pay part or all of these costs, which may ot be covered by isurace. Coverage for treatig disorders detected by ewbor screeig varies by health pla. Sources: America College of Medical Geetics, America Academy of Pediatrics Newbor Screeig Task Force, March of Dimes

29 State Newbor Screeig Requiremets, 2009: A Summary Coditio Amio Acid Metabolism Disorders Argiiosucciic acidemia Citrulliemia Homocystiuria Maple syrup urie disease Pheylketouria (PKU) Tyrosiemia type I Number of States Screeig All Newbors a Orgaic Acid Metabolism Disorders Hydroxymethylglutaric aciduria Glutaric acidemia type I Isovaleric acidemia Methylmaloic acidemia due to mutase deficiecy Propioic acidemia Beta-ketothiolase deficiecy Methylmaloic acidemia, cbla ad cblb forms 3-Methylcrotoyl-CoA carboxylase deficiecy Multiple carboxylase deficiecy Fatty Acid Oxidatio Disorders Log-chai 3-OH acyl-coa dehyrodgease deficiecy Medium-chai acyl-coa dehydrogease deficiecy (MCAD) Very log-chai acyl-coa dehydrogease deficiecy Caritie uptake defect Trifuctioal protei deficiecy Hemoglobiopathies Hb S/Beta-Thalassemia Sickle cell aemia Hb S/C disease Other Disorders Cogeital adreal hyperplasia (CAH) Cogeital hypothyroidism Classical galactosemia Biotiidase deficiecy Cystic fibrosis Hearig screeig a Testig is uiversally required by law or rule ad fully implemeted as of October For more iformatio o the uiform pael of 29 disorders, see the August 2004 report - Newbor Screeig: Toward a Uiform Screeig Pael ad System - developed by the America College of Medical Geetics. For more detailed iformatio o ewbor screeig status, please see the Natioal Newbor Screeig Status Report developed by the Natioal Newbor Screeig ad Geetics Resource Ceter. Source: Natioal Newbor Screeig ad Geetics Resource Ceter, March of Dimes 21

30 Newbor Screeig: Categories of Disorders I a report to the federal Advisory Committee o Heritable Disorders ad Geetic Disease i Newbors ad Childre, the America College of Medical Geetics recommeds screeig all ewbors for 29 disorders, for which effective treatmet is available. The disorders fall ito the followig five categories. q q q Amio Acid Metabolism Disorders: A diverse group of disorders, with varyig degrees of severity. Some affected idividuals lack ezymes that break dow amio acids, the buildig blocks of protei. I others, there are deficiecies i ezymes that help the body get rid of the itroge i amio acid molecules. Toxic levels of amio acids or ammoia ca build up i the body, causig a variety of sigs ad symptoms, ad eve death. Orgaic Acid Metabolism Disorders: Diseases i this group result from the loss of activity of ezymes that help break dow amio acids ad other substaces, such as lipids, sugars, ad steroids. As a result, toxic acids build up i the body. Without dietary treatmet ad prevetio of acute episodes, these disorders ca result i coma ad death durig the first moth of life. Fatty Acid Oxidatio Disorders: Iherited defects i ezymes eeded to covert fat ito eergy characterize disorders i the group. Whe the body rus out of glucose (sugar), it ormally breaks dow fat to support productio of alterate fuels (ketoes) i the liver. But this pathway is blocked i people with these disorders. So whe they ru out of glucose usually whe they are ill or skip meals their cells suffer a eergy crisis. Without treatmet, the brai ad may orgas ca be affected, sometimes resultig i coma ad death. 22 March of Dimes

31 q Hemoglobiopathies: These iherited diseases of red blood cells result i varyig degrees of aemia (shortage of red blood cells), serous ifectio, pai, ad damage to vital orgas. The symptoms are caused by abormal kids or amouts of hemoglobi (or both) the mai protei i red blood cells that carries oxyge from the lugs to every part of the body. I sicklig disorders, a abormal hemoglobi called HbS ca cause some red blood cells to become stiff ad abormally shaped. The stiffer red blood cells ca get stuck i tiy blood vessels, causig pai ad sometimes orga damage. q Other disorders: This mixed group of disorders icludes some diseases that are iherited ad others that are ot geetic. They vary greatly i severity, from mild to life-threateig. Note: Descriptios of the 29 disorders appear o pages March of Dimes 23

32

33 Preterm ad Low Birthweight Births

34 Preterm Births More tha 540,000 babies were bor prematurely (preterm) i 2006, facig a much higher risk of health problems ad death tha other ewbors. About oe i eight ifats is bor preterm a rate that has rise 16 percet i the past decade or so (from 11.0 percet of births i 1996 to 12.8 percet i 2006). Premature ifats are more tha 15 times as likely as other ifats to die i the first year of life. Late preterm ifats made up 71.4 percet of all preterm births i 2006 ad accouted for most of the icrease i preterm birth rates over the past two decades. More tha 86,000 babies were bor very preterm i These babies were more tha 75 times as likely as those ot bor preterm to die i the first year of life. Premature babies who survive may suffer lifelog cosequeces, such as metal retardatio, blidess, chroic lug disease, ad cerebral palsy. A p r E T E r m B I r T H O C C u r s B E F O r e 3 7 Sources: Lifelog cosequeces from Slattery ad Morriso, Impact of late preterm birth o risig preterm birth rates from Davidoff ad others, Ifat deaths from the Natioal Ceter for Health Statistics, 2005 period liked birth/ifat death data. All other data from the Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, C O M P l E T E D W E E k s G E S T A T I O N. A v e r y p r E T E r m B I r T H O C C u r s B E F O r e 3 2 C O M P l E T E D W E E k s G E S T A T I O N. A l A T E p r E T E r m B I r T H O C C u r s B E T W E E N 3 4 A N D 3 6 C O M P l E T E D W E E k s G E S T A T I O N. 26 March of Dimes

35 Preterm ad Very Preterm Births, Percet of live births Preterm Year 2010 goal Very Preterm Source: Natioal Ceter for Health Statistics, fial atality data. Prepared by the March of Dimes Periatal Data Ceter, Percet Distributio of All Preterm Births, 2006 Percet of preterm bir ths 5.9% (<28 weeks) 10.0% (28-31 weeks) 12.6% (32-33 weeks) 71.4% (34-36 weeks) Note: Due to roudig, percetages do ot total 100%. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 27

36 Prematurity ad Low Birthweight May ifats bor too soo are also bor too small. More tha 43 percet of babies bor preterm i 2006 were also bor low birthweight, while early 67 percet of low birthweight babies were preterm. About oe i 12 ifats is bor low birthweight, a rate that has rise 12 percet i the past decade or so (from 7.4 percet i 1996 to 8.3 percet i 2006). More tha 63,000 babies were bor very low birthweight i percet of live births. A l O W B I r T H W E I G H T B A B y W E I G H S l E S S T H A N 5 1 /2 P O u N D S ( 2, g r A M S ). A v e r y l O W B I r T H W E I G H T B A B y W E I G H S l E S S T H A N 3 1 /3 P O u N D S ( 1, g r A M S ). 28 March of Dimes

37 Icidece of Preterm ad Low Birthweight Births, 2006 Preterm (12.8% of live births) N=542,893 Low Birthweight (8.3% of live births) N=351,974 Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, Low ad Very Low Birthweight Births, Percet of live births Low birthweight Year 2010 goal Very low birthweight Source: Natioal Ceter for Health Statistics, fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 29

38 Risk of Preterm Births While the causes for half of preterm births are ukow, there are certai factors associated with icreased risk. Materal age plays a role, with higher preterm birth rates foud amog the yougest ad oldest mothers. I 2006, more tha 16 percet of births to tees uder 18 ad 17 percet of births to wome 40 ad older were preterm. Multiple births are aother factor. Compared with sigletos, babies bor i multiple births i 2006 were early six times as likely to be preterm: more tha 60 percet of twis ad early 93 percet of triplets ad higher-order births were preterm. A rise i the rate of multiple births, associated with older age at childbearig ad greater use of assisted reproductive techologies ad fertility drugs, has cotributed to the icrease i the preterm birth rate. Wome who have had oe preterm delivery are at greater risk of havig aother. Other possible risk factors researchers have idetified iclude certai ifectios, smokig, illicit drug use, extremes of materal weight, ad stress. The rise i preterm births has bee liked to risig rates of early iductio of labor ad c-sectios. Betwee 1996 ad 2004, the icrease i preterm sigleto births occurred primarily amog wome who delivered by c-sectio, ad the largest percetage icrease occurred amog late preterm births. Note: A sigleto is defied as a offsprig bor aloe. Sources: Istitute of Medicie, Data o icrease amog c-sectio deliveries from Bettegowda ad others, All other data from the Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

39 Preterm ad Very Preterm Births, by Age of Mother, 2006 Percet of live births ad uder ad over All Ages Preterm Very preterm Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, Preterm Births: Sigleto, Twi, ad Higher Order, 2006 Percet of live births Preterm 11.1 Sigletos Twi Triplet ad Higher Order Very preterm Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 31

40 Prematurity ad Race/Ethicity of Mother Prematurity/low birthweight is the leadig cause of death for Africa-America ifats. Africa-America ifats are more tha oe ad a half times as likely as white ifats to be bor preterm. I 2006, more tha 18 percet of ifats bor to o-hispaic black mothers were preterm, compared with early 12 percet of ifats bor to o-hispaic white mothers. Ifats bor to o-hispaic black mothers were early two ad a half times as likely as those bor to o-hispaic white mothers to be very preterm 4.1 percet of births, compared with 1.7 percet. Of ifats bor to Hispaics, 12.2 percet were preterm. Amog Hispaics, the rate was highest for babies bor to Puerto Rica mothers (14.4 percet i 2006). 32 March of Dimes

41 Preterm ad Very Preterm Births, by Race/Ethicity of Mother, 2006 Percet of live births White Black Preterm 14.3 Native America a 10.9 Asia/ Pacific Islader 12.2 Hispaic b 12.8 All Races/ Ethicities Very preterm a Native America icludes America Idia, Eskimo, ad Aleut. b People of Hispaic origi may be of ay race; racial categories displayed here are o-hispaic. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, Preterm ad Very Preterm Births, by Hispaic Ethicity of Mother, 2006 Percet of live births Mexica Puerto Rica Preterm 13.1 Cuba 12.1 Cetral or South America 14.2 Other Hispaic 12.2 Total Hispaic Very preterm Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 33

42 Costliess of Preterm ad Low Birthweight Babies I 2005, the aual societal ecoomic cost (medical, educatioal, ad lost productivity) associated with preterm birth i the Uited States was at least $26.2 billio. Average first-year medical costs, icludig both ipatiet ad outpatiet care were about 10 times greater for preterm ($32,325) tha for term ifats ($3,325) i The average legth of hospital stay i 2005 was early ie times as log for a preterm ifat (13 days) compared with a ifat bor at term (1.5 days). Four of the te most expesive hospital stays, regardless of age, are related to ifat care: ifat respiratory distress sydrome, prematurity/low birthweight, cardiac/circulatory birth defects, ad lack of oxyge i ifats. Cost associated with prematurity ad low birthweight are ot limited to the hospital stay at birth. q q Low birthweight accouts for 10 percet of all health care costs for childre. Prematurity may result i log-term physical ad metal disabilities, which geerate additioal costs. Childre bor prematurely are at greater risk of lower cogitive test scores ad behavioral problems, ad are more likely to be erolled i special educatio classes tha childre bor full term. Source: Costs ad legth of hospital stay related to preterm birth from the Istitute of Medicie, Lewit ad others, Bhutta ad others, 2002; ad Avche ad others, March of Dimes

43 Average Legth of Stay ad Average Medical Costs Amog Preterm ad Term Births, 2005 Days Dollars 15 40, $ 32,325 30, , , $ 3, Ifat Hospital Stays Medical Costs Preterm Term Source: Istitute of Medicie, Coditios with the Highest Ipatiet Hospital Costs, 2007 Rak Pricipal Diagosis Mea Mea Legth Costs a of Stay (days) 1 Ifat respiratory distress sydrome $45, Prematurity ad low birthweight 44, Spial cord ijury 41, Leukemia 40, Heart valve disorders 36, Cardiac ad circulatory birth defects 35, Hodgki s disease 29, Polio ad other brai or spial ifectios 29, Lack of oxyge i ifats (itrauterie hypoxia ad birth asphyxia) 27, Aeurysm 27, a Costs are for acute hospital care ad do ot iclude physicia ad other professioal fees, rehabilitatio expeses, or costs associated with follow-up care or home care. Source: Agecy for Healthcare Research ad Quality, March of Dimes 35

44

45 Prevetio

46 Importace of Preatal Care Wome who receive preatal care are more likely to have access to screeig ad diagostic tests that ca help to idetify problems early; services to maage developig ad existig problems; ad educatio, couselig, ad referral to reduce risky behaviors like substace use ad poor utritio. Such care may help improve the health of both mothers ad babies. I recet years, the US Prevetive Services Task Force (USPSTF) has issued a umber of recommeded medical itervetios related to pregacy that ca best be provided if the woma has comprehesive materity coverage. Amog the USPSTF recommedatios are: folic acid supplemetatio, screeig for preeclampsia, ad couselig o the value of breastfeedig. Possible barriers to preatal care iclude: q q q Lack of isurace Problems with trasportatio, child care, ad the service hours of health care providers Materal age, icome, educatio, ad cultural ad persoal factor. Preatal care ot oly must begi early, but should cotiue regularly: q Adequacy of preatal care varies by race ad ethicity. Native America, Africa-America, ad Hispaic wome were most likely to receive iadequate preatal care. E a r ly p r E N A T A l C A r e B E G I N S I N T H E F I r S T t r I M E S T E r. l A T E p r E N A T A l C A r e B E G I N S I N T H E T H I r d t r I M E S T E r. T H E A D E q u A C y O F P r E N A T A l C a r e u T I l i z A T I O N I N D E x C O N S I D E r s W H E N p r E N A T A l C A r e B E G I N S, H O W M A N y v I S I T S O C C u r, A N D T H E I N F A N T s G E S TAT I O N A l A G E. T H E I N D E x c l A S S I F I E S p r E N ATA l C A r e I N T O F O u r C AT E G O r I E S : I N A D E q u AT E, I N T E r M E D I AT E, A D E q u AT E, A N D A D E q u A T E - p l u s. S o u r C E : k O T E l C H u c k,

47 Patters of Preatal Care I 2003, some states bega usig the revised 2003 birth certificate, which icluded substative chages i the collectio of preatal care data. States have bee phasig i the revised birth certificate, ad as of 2006, 18 states had revised preatal care data. Data from the 2003 revisio are ot comparable to the 1989 revisio (used by 32 states, the District of Columbia ad New York City i 2006); therefore, atioal estimates of preatal care utilizatio are ot available. I the Uited States i 2006, the rate of early preatal care (begiig i the first trimester) for the 18 states usig revised certificates (35 percet of all births) was 69.0 percet ad for the 32 states, the District of Columbia, ad New York City usig urevised birth certificates (65 percet of all births) was 83.2 percet. I 2006, as i previous years, o-hispaic black ad Hispaic wome were more tha twice as likely as o- Hispaic white wome to receive care late (begiig i the 3rd trimester) or to receive o care at all, for both revised ad urevised reportig areas. Betwee 2005 ad 2006, the proportio of wome receivig early preatal care declied for o-hispaic white, o-hispaic black, ad Hispaic wome, for both revised ad urevised reportig areas. Amog states with revised birth certificates, the proportio of wome receivig late or o preatal care icreased amog o-hispaic white, o-hispaic black ad Hispaic wome betwee 2005 ad Similarly durig this time, amog urevised reportig areas, late or o preatal care rates icreased amog o- Hispaic white ad o-hispaic black wome ad were uchaged amog Hispaic wome. Source: Marti ad others, Details o preatal care ad the birth certificate revisio available at March of Dimes 39

48 Beefits of Folic Acid Sufficiet folic acid i wome s diets before ad durig pregacy ca reduce the risk of birth defects of the brai ad spial cord kow as eural tube defects. These are amog the most serious birth defects i the Uited States. Each year, about 3,000 pregacies are affected with eural tube defects. Studies have show that up to 70 percet of these cases could be preveted if wome cosumed the proper amouts of folic acid before becomig pregat ad durig early pregacy. The Istitute of Medicie s Food ad Nutritio Board ad the March of Dimes have recommeded that to reduce the risk of havig a child with a eural tube defect, wome who might become pregat should cosume 400 micrograms of sythetic folic acid every day from a vitami or from fortified foods, i additio to eatig a healthy diet rich i atural sources of folate. Sice fortificatio of eriched grai products with folic acid was made madatory i 1998, the rate of eural tube defects has decreased by 26 percet. While public awareess is improvig, most wome of childbearig age do ot kow about the beefits of folic acid. Although 84 percet have heard of folic acid, oly 39 percet take a daily vitami cotaiig it. Oly 20 percet kow that folic acid prevets birth defects, ad oly 11 percet kow it should be take before pregacy. Health professioals have ot bee the mai source of wome s iformatio about folic acid. Of wome aware of folic acid, 49 percet leared about it from the media, but oly 33 percet from their physicia or other health care provider. Sources: Dietary guidelies ad beefits of folic acid from the Istitute of Medicie, 1998a. Estimates of prevetive effects of folic acid from the Ceters for Disease Cotrol, Decrease i eural tube defects from Mersereau ad others, Public awareess iformatio from the March of Dimes, March of Dimes

49 Awareess of Folic Acid Beefits Amog Wome of Childbearig Age, 1995 ad 2008 Heard of folic acid Kew folic acid should be take before pregacy 2 11 Kew folic acid ca prevet birth defects 4 20 Take vitami cotaiig folic acid daily Percet Note: Icludes wome ages oly. Source: March of Dimes, o e H E A l T H y P E O P l e o b j E C T I v e I S T O I N C r E A S E T O 8 0 P E r C E N T T H E S H A r e O F N O N P r E G N A N T W O M E N i 5 T O 4 4 W H O C O N S u M E M I C r O G r A M S O F F O l I C A C I D D A I l y. A N O T H E r O B j E C T I v e I S T O r E D u C E T H E O C C u r r E N C E O F S P I N A B I F I D A A N D O T H E r N E u r a l t u B E D E F E C T S b y 5 0 P E r C E N T f r O M S I x C A S E S ( ) T O T H r E E P E r 1 0, l i v e B I r T H S. March of Dimes 41

50 Smokig Durig Pregacy Wome who smoke durig pregacy are more likely tha osmokers to have a low birthweight or preterm baby. Further, babies of smokers weigh, o average, 200 grams less tha osmokers babies. While pregat wome are less likely to smoke tha others, recet surveys foud that 16 percet of pregat wome ages 15 to 44 reported smokig cigarettes durig the past moth. No-Hispaic white (21 percet) mothers are more likely tha o-hispaic black (16 percet) or Hispaic (6 percet) mothers to smoke durig pregacy. Studies show that wome who stop smokig before becomig pregat or early i pregacy decrease their risk of havig a low birthweight baby to early that of wome who have ever smoked. Smokig cessatio services for pregat wome are amog a hadful of itervetios that save eough i later medical expeses to completely offset the iitial ivestmet, ad actually result i cost savigs. Studies suggest that effective smokig cessatio itervetios durig pregacy have the potetial to reduce excess eoatal costs, or the costs that could be saved from the reduced use of eoatal itesive care uits. Joit estimates by the CDC ad the Ceters for Medicare ad Medicaid Services, have foud that smokig-attributable eoatal health care costs for Medicaid total almost $228 millio, or about $738 per pregat smoker. Pregat wome o Medicaid are more likely tha other pregat wome to smoke, accordig to state data. While Medicaid programs i 43 states provide some form of tobacco depedece treatmet for these wome, oly 27 covered at least oe form of tobacco cessatio couselig, the treatmet of choice for all pregat smokers. Sources: Smokig ad preterm birth from Shah ad Bracke, Birthweight ad the effects of quittig early i pregacy from the Surgeo Geeral, 2004 Race/ethicity smokig data from the Substace Abuse ad Metal Health Services Admiistratio, Natioal Survey o Drug Use ad Health, Smokig Cessatio cost savig from Ayadi ad others, Medicaid programs from the Ceters for Disease Cotrol ad Prevetio, March of Dimes

51 Pregat ad Nopregat Wome Reportig Smokig Durig Past Moth, Percet Pregat Nopregat Note: Icludes wome ages oly. Data are aggregated for two-year period. Source: Substace Abuse ad Metal Health Services Admiistratio, Natioal Survey o Drug Use ad Health, State Medicaid Coverage: Smokig Cessatio Treatmets for Pregat Wome, 2006 Type of Coverage Number of States Ay type of coverage for pregat wome 43 Pharmacotherapies (gum, patch, Zyba, ihaler, 39 asal spray) At least oe form of couselig coverage 27 Comprehesive couselig (group, idividual, ad 3 telephoe) Note: Icludes the District of Columbia. Source: Ceters for Disease Cotrol ad Prevetio, March of Dimes 43

52 Alcohol ad Other Drug Use Use of alcohol ad other drugs durig pregacy is related to higher rates of adverse birth outcomes. Alcohol Some 4.5 percet of pregat wome reported bige alcohol use (havig four or more driks o at least oe occasio durig the past moth) durig (average). Heavy alcohol cosumptio durig pregacy ca lead to a combiatio of physical ad metal birth defects called fetal alcohol sydrome (FAS), which affects roughly oe i 1,000 ewbors aually. Alcohol abuse is the leadig kow prevetable cause of metal retardatio. I 2008, 14.8 percet of wome ages reported bige alcohol use. This is a slight declie from 15.5 percet i Other Drug Use Amog pregat wome, 5.1 percet reported usig illicit drugs i the past moth durig (average). Alcohol cosumptio, cigarette smokig, ad illicit drug use are liked. About oe-third of wome who reported usig at least oe illicit drug durig pregacy also smoked cigarettes ad drak alcohol. Sources: Lik betwee alcohol, cigarettes, ad illicit drugs from the Natioal Istitute o Drug Abuse, Iformatio o pregat wome from the Substace Abuse ad Metal Health Services Admiistratio, Natioal Survey o Drug Use ad Health, March of Dimes

53 Wome Ages Reportig Bige Drikig Durig Past Moth, Percet Notes: Begiig i 2006, bige alcohol use is defied as havig four or more driks o at least oe occasio durig the past moth. Prior to 2006, bige alcohol use is defied as havig five or more driks o a least oe occasio durig the past moth. Percet reported is amog wome ages Source: Ceters for Disease Cotrol ad Prevetio, Behavioral Risk Factor Surveillace System Data prepared by the March of Dimes Periatal Data Ceter, H E A lt H y P E O P l e O B j E C T I v E S I N C l u D E I N C r E A S I N G T H E S H A r e O F p r E G N A N T W O M E N W H O A B S T A I N f r O M B I N G E d r I N k I N G, C I G A r E T T E S M O k I N G, A N D i l l I C I T d r u g u S E. March of Dimes 45

54 Obesity Obesity icreases the risk of poor pregacy outcomes. Obesity ca cause serious pregacy-related medical complicatios such as hypertesio ad diabetes that cotribute to prematurity ad icrease the likelihood of cesarea sectio. Babies bor to mothers who are obese are more likely to have health problems icludig icreased risk of eural tube defects, higher rates of birth ijuries, low Apgar scores, more admissios to eoatal itesive care uits, ad higher rates of preatal death. The proportio of wome ages 18 to 44 who were obese icreased early 55 percet over the past decade to early 24 percet i Itervetios developed ca take ito accout factors such as pre-pregacy body mass idex (BMI), race/ethicity, socioecoomic status, ad gestatioal weight gai for healthy pregacies. Such itervetios may iform state materal ad child health programs to help wome achieve ad maitai recommeded weight ad BMI before, durig, ad after pregacy. Note: The Apgar score is desiged to check a ifat s coditio at 1 miute ad 5 miutes after birth. Ifats with lower Apgar scores may eed extra watchig or special care. Source: Materal obesity ad pregacy from March of Dimes Medical Perspectives o Prematurity, Obesity ad birth outcomes from Riley, March of Dimes

55 Obesity Amog Wome Ages 18-44, Percet Note: Obesity is defied as a Body Mass Idex of 30 or more. Source: Ceters for Disease Cotrol ad Prevetio, Behavioral Risk Factor Surveillace System. Data prepared by the March of Dimes Periatal Data Ceter, T H E p r e v a l E N C E O F O B E S I T y o r B E I N G o v e r W E I G H T I S a M A j o r H E A lt H C O N C E r I N T H E u N I T E D S T A T E S, A N D W A S N A M E D O N E O F T H E T E N l E A D I N G H E A lt H I N D I C A T O r s u S E D T O M E A S u r e T H E H E A lt H O F T H E N A T I O N I N H E A lt H y P E O P l e March of Dimes 47

56 Childhood Immuizatio Prevetio of disease through vacciatio is oe of the 10 greatest public health achievemets of the 20th cetury, accordig to the Ceters for Disease Cotrol ad Prevetio. Rubella (Germa measles), a major cause of serious birth defects such as deafess ad blidess, was declared o loger edemic i the Uited States i 2005, thaks to successful vacciatio efforts. However, the disease is still beig itroduced here from borderig coutries ad by iteratioal travelers, ecessitatig ogoig use of the rubella vaccie. Vaccies are cost effective. For example, for every dollar spet, measles/mumps/rubella vaccie saves $26; diphtheria/tetaus/acellular pertussis vaccie saves $27; periatal hepatitis B vaccie saves early $15; ad varicella (chicke pox) vaccie saves more tha $5. The Advisory Committee o Immuizatio Practices recommeds that ifats be immuized agaist 12 diseases before age two. Because they are ot fully vacciated, some 27 percet of toddlers are vulerable to possible fatal illesses, icludig polio, measles, mumps, rubella, diphtheria, tetaus, whoopig cough, hepatitis B, ad varicella. Sources: Ceters for Disease Cotrol ad Prevetio, 1999b. Cost savigs from Ekwueme ad others, 2000; Zhou ad others, 2004; ad Lieu ad others March of Dimes

57 Health Isurace

58 Health Isurace ad Access to Care Havig isurace coverage affects how people use health care services. The uisured report poorer health status. They are also less likely to have a usual source of medical care ad more likely to delay or forgo eeded health care services. Uisured wome receive fewer preatal services ad report greater difficulty i obtaiig eeded care tha wome with isurace, a Istitute of Medicie study cocluded. Health isurace status is the sigle most importat ifluece i determiig whether health care is accessible to childre whe they eed it, accordig to aother Istitute of Medicie study. Though uisured ewbors are more likely tha isured babies to be sick, they receive fewer hospital services. Uisured childre are the most likely to have o usual source of medical care 30.9 percet, compared with oly 2.6 percet of privately isured yougsters ad 4.3 percet of childre i public isurace programs. Sources: Geeral iformatio o the uisured from Kaiser Family Foudatio, Uisured ewbors from Bravema ad others, Importace of health isurace to childre from the Istitute of Medicie, 1998b, ad March of Dimes

59 Childre with No Usual Source of Medical Care, by Type of Isurace Coverage, Percet Uisured Note: Data are average aual rates. Source: Natioal Ceter for Health Statistics, Medicaid/Other Public Private March of Dimes 51

60 Health Isurace Coverage for Wome of Childbearig Age Oe i five wome of childbearig age (15 to 44) 12.4 millio was uisured i These wome accouted for 27 percet of all uisured Americas; 62 percet had family icomes below 200 percet of poverty. Hispaic wome i this age group were more tha twice as likely as whites to be uisured: 37 percet, compared with 15 percet. Native Americas (29 percet), Africa- Americas (24 percet), ad Asias/Pacific Isladers (20 percet) were also likelier tha whites to be uisured. Lack of health isurace remais a problem for some pregat wome, although they are less likely to be uisured tha other wome. About eight percet of wome are uisured at delivery. Eve with health isurace, some wome still lack coverage for materity care: seve percet of plas offered by small employers (10 to 24 workers) did ot cover preatal care at delivery i Idividual health isurace plas usually exclude such coverage etirely or make it available subject to additioal premiums or limitatios. S O M E 4 5 M I l l I O N A M E r I C A N S ( P E r C E N T O F T H E P O P u l AT I O N u N D E r A G E 6 5 ) l A C k E D H E A l T H I N S u r A N C E C O v e r A G E I N Sources: Uisured pregat wome from Thorpe ad others, Exclusio of materity care from the March of Dimes, 2001, ad Chollet ad Kig, All other data from the U.S. Cesus Bureau, 2009a ad 2009b. A B O u t O N E q u a r T E r O F T H E P O O r D O N O T H A v e H E A lt H I N S u r A N C E. 52 March of Dimes

61 Wome Ages 15 44, by Type of Health Isurace Coverage, 2008 Percet Employer Based Other Private Medicaid* Other Public Uisured * Icludes State Childre s Health Isurace Program. Note: Colums may sum to more tha 100 percet because idividuals ca have more tha oe source of coverage. Source: US Cesus Bureau. 2009b. Wome Ages Who Are Uisured, by Race/Ethicity, 2008 Percet No- Hispaic White No- Hispaic Black Hispaic a Native America b Asia/ Pacific Islader All Races/ Ethicities a People of Hispaic origi may be of ay race. b Native America icludes America Idia ad Alaska Native. Source: US Cesus Bureau, 2009b. March of Dimes 53

62 Health Isurace Coverage for Childre I 2008, 8.1 millio 10 percet of the atio s 78.7 millio childre uder 19 lacked health isurace. About three-quarters of the eight millio uisured childre are eligible for, but uerolled i, Medicaid ad CHIP. Hispaic childre were more tha two times as likely as whites to be uisured 18 percet, compared with 7 percet. Native America (16 percet), Africa- Americas (11 percet), ad Asias/Pacific Isladers (11 percet) childre were also more likely tha whites to be uisured. Of more tha 4 millio ifats bor i the hospital, it is estimated that more tha 50,000 (5.3 percet) were uisured i Sources: Uisured ifats from the Agecy for Healthcare Research ad Quality, 2009 ad Dubay ad others, All other data from the U.S. Cesus Bureau 2009a. S O M E 6 3 P E R C E N T O F U N I N S u r E D C H I L D R E N L I V E D I N F A M I L I E S W I T H I N C O M E S B E L O W P E R C E N T O F P O V E R T Y, A N D M A Y H A V E B E E N E L I G I B L E F O R M E D I C A I D O R T H E C H I L D R E N S H E A LT H I N S u r A N C E P R O G R A M. 54 March of Dimes

63 Childre Uder Age 19, by Type of Health Isurace Coverage, 2008 Percet Employer Based Other Private Medicaid* Other Public Uisured * Icludes Childre s Health Isurace Program. Note: Colums may sum to more tha 100 percet because idividuals ca have more tha oe source of coverage. Source: US Cesus Bureau, 2009b. Childre Uder Age 19 Who Are Uisured, by Race/Ethicity, 2008 Percet No- Hispaic White No- Hispaic Black Hispaic a Native America b Asia/ Pacific Islader All Races/ Ethicities a People of Hispaic origi may be of ay race. b Native America icludes America Idia ad Alaska Native. Source: US Cesus Bureau, 2009b. March of Dimes 55

64 Medicaid s Role i Materal ad Child Health Medicaid is the major public source of fiacig health care services provided to pregat wome, ifats, ad childre. A joit federal-state health isurace program for low-icome Americas, Medicaid fiaced 41 percet of hospital births i 2003, ad covered about 30 millio childre i Medicaid is a key source of health isurace coverage for preterm ifats ad those bor with birth defects. q q Approximately 48 percet of hospital stays for preterm ifats were fiaced by Medicaid i Hospital costs for these babies averaged $45,900. Approximately 48 percet of ifat hospital stays due to birth defects were covered by Medicaid i While wome of child bearig age ad childre make up about 69 percet of all Medicaid erollees, they accout for oly 34 percet of all Medicaid spedig. Federal ad state Medicaid spedig for these groups totaled about $87 billio i By cotrast, 62 percet of Medicaid spedig was for the 23 percet of erollees who are elderly or disabled. Medicaid family plaig waiver programs allow states to provide family plaig services to low-icome wome who otherwise do ot qualify for Medicaid. Twety-seve states have opted to provide these services. A importat aim is to esure access to comprehesive precoceptio care. a a Family plaig waiver programs ca cover all wome uder a give icome threshold, wome who have exhausted Medicaid postpartum coverage, or wome who have lost Medicaid coverage for ay reaso. Sources: Medicaid fiacig of births from the Natioal Goverors Associatio, Medicaid erollmet from the Ceters for Medicare ad Medicaid Services, 2009a. Medicaid fiacig of hospital births ad hospital stays based o a pricipal diagosis of prematurity ad birth defects from the Agecy for Healthcare Research ad Quality, Markus, March of Dimes

65 Medicaid Erollmet ad Expeditures, by Erollee Characteristics, 2006 Percet Disabled ad Elderly All childre Erollmet Total=58 millio Wome (odisabled) Other 9.3 Expeditures Total=$257 billio 3.9 Source: Ceters for Medicare ad Medicaid Services, MSIS Statistical Report, 2009a. Family Plaig Waiver Programs, by State, No Family Waiver (24) Icome-based (19) Postpartum (5) Sources: Markus, March of Dimes Loss of Medicaid (2) 57

66 Childre s Health Isurace Program Over five millio childre were erolled i the Childre s Health Isurace Program (CHIP) at some poit durig fiscal year This joit federal-state program was re-authorized i 2009 to secure fudig to cover those curretly erolled, ad a additioal 4 millio uisured childre. Uder the Childre s Health Isurace Reauthorizatio Act of 2009, P.L (CHIPRA), more tha $30 billio i federal matchig fuds are available to the states through New state optios are available to: q q q Eroll icome eligible pregat wome; Eroll legal immigrat pregat wome ad childre; ad Combie CHIP with private isurace. As of August 2009, ie states plus the District of Columbia were usig CHIP fuds to expad Medicaid coverage, 18 states were coverig childre through a separate program, ad 23 were usig a combiatio of these two approaches. States that elect to use CHIP fuds to operate a separate statedesiged program may choose a beefit package that differs from Medicaid. These programs may also require erollees to pay premiums, copaymets, or both, A r e AvA I l A B l e T O S TAT E S u N D E r C H I P R A F O r : although cost sharig is subject to I N C r E A S E D E N r o l l M E N T limitatios. I 2006, premiums were required by 32 states ad copaymets by 21. CHIP eligibility varies amog the states ad rages from 150 to 300 percet of poverty. Nearly all states cover childre with family icomes up to or over 200 percet of poverty ($36,620 for a family of three i 2009). Sources: Ceters for Medicare ad Medicaid Services, 2009b. Kaiser Commissio o Medicaid ad the Uisured, 2007a. 58 March of Dimes P e r F O r M A N C E B O N u s Pay M E N T S O F M E D I C A I D e l I G I B l e c h i l d r E N S t r E A M l I N E D E N r o l l M E N T A N D r E T E N T I O N P r O C E D u r E S ( AT l E A S T 4 O F T H E F O l l O W I N G ) : 1 2 M O N T H C O N T I N u o u s E l I G I B I l I T y E l I M I N AT I O N O F A S S E T T E S T E l I M I N AT I O N O F I N - P E r S O N I N T E r v I E W r e q u i r E M E N T j O I N T A P P l I C AT I O N S t r E A M l I N E D r E N E WA l P r E S u M P T I v e e l I G I B I l I T y E x p r E S S l A N E

67 Childre s Health Isurace Program Erollmet, I Millios Fiscal Year Separate program Medicaid expasio Note: Number of childre ever erolled durig the fiscal year. See pp for State-by-State data. Source: Ceters for Medicare ad Medicaid Services, March of Dimes 59

68 Medicaid ad CHIP: Eligibility ad Erollmet States ca determie eligibility for Medicaid ad CHIP i ways that prevet paperwork from delayig erollmet of eligible pregat wome ad childre, thus eablig prompt access to health care. Presumptive eligibility allows states to cover applicats temporarily util eligibility ca be fully determied. States may permit health care providers, schools, ad other agecies to determie presumptive eligibility. Medicaid programs i 30 states provided presumptive eligibility to pregat wome i 2007, while 15 states did so for childre. q q Presumptive eligibility icreases the proportio of pregat wome o Medicaid who receive early preatal care. Parets of uisured childre reported beig much more likely to eroll their yougsters i Medicaid if they could do so immediately or through a doctor s office or cliic. Cotiuous eligibility allows states to provide coverage to childre for up to 12 moths, regardless of chages i family icome or eligibility. All states must exted Medicaid coverage to pregat wome through 60 days after delivery ad automatically eroll ifats bor to wome o Medicaid. I 35 states, Medicaid programs provided 12 moths of cotiuous eligibility i 2007, at least to ewbors, ad 36 states did so uder CHIP. q q Cotiuous eligibility ca prevet eedless coverage disruptios. Oe study foud that whe parets had to recertify childre s eligibility, half dropped out of CHIP, but up to oe quarter retured withi two moths. I additio, reewal processes such as telephoe follow-up to mail otices, reduced verificatio requiremets, ad use of eligibility iformatio from other state programs ca help prevet eligible childre from losig coverage. Sources: State use of presumptive ad cotiuous eligibility from the Natioal Goverors Associatio, 2008 ad Kaiser Family Foudatio, March of Dimes

69 States with Presumptive or Cotiuous Eligibility Uder Medicaid ad CHIP, Eligibility Feature ad Program Presumptive Eligibility Medicaid Pregat Wome Childre Presumptive Eligibility CHIP a Pregat Wome Childre Cotiuous Eligibility for Childre Medicaid 12 moths b 6 moths Cotiuous Eligibility for Childre CHIP a 12 moths 6 moths Number of States a Icludes oly states with a CHIP pla separate from Medicaid b I 9 states applies oly to ewbors/ifats. Source: Natioal Goverors Associatio, 2008 ad Kaiser Family Foudatio, March of Dimes 61

70

71 State Data

72 More detail ad regular updates of state data are available from PeriStats (marchofdimes.com/peristats), the March of Dimes olie iteractive data resource. State rakigs ca be a helpful tool for comparig states success i achievig their health care goals. I some cases, however, differeces i rates or percetages are mior, which should be cosidered whe iterpretig these rakigs. I additio, data from idividual state sources may differ from those foud i atioal databases. I particular, atality ad ifat death data reported by state vital statistics offices may differ from the Natioal Ceter for Health Statistics iformatio used i may of these state tables.

73 State Ifat Mortality Rates, Average Ifat deaths per 1,000 live births Uder 6.2 (17) (18) Over 7.6 (16) Value i ( ) = umber of states (icludes District of Columbia) Source: Natioal Ceter for Health Statistics, period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 65

74 Ifat Mortality Rates, by State, Average State Alabama Alaska Arizoa Arkasas Califoria Colorado Coecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa Nebraska March of Dimes Ifat Rak Mortality Rate Ifat Mortality Rate No-Hispaic No-Hispaic Hispaic White Black

75 State Ifat Rak Mortality Rate Ifat Mortality Rate No-Hispaic No-Hispaic Hispaic White Black Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a /a /a Uited States Note: Ifat mortality rate = ifat deaths per 1,000 live births. People of Hispaic origi may be of ay race. idicates fewer tha 20 ifat deaths. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, , period liked birth/ifat death data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 67

76 Live Births, by State, 2006 No-Hispaic No-Hispaic State Total Births White Black Hispaic Alabama 63,232 38,118 19,333 4,724 Alaska 10,996 6, Arizoa 102,429 43,372 3,594 45,521 Arkasas 40,961 27,679 7,843 4,397 Califoria 562, ,426 32, ,322 Colorado 70,751 42,127 2,975 22,813 Coecticut 41,820 25,665 5,171 8,485 Delaware 11,989 6,580 2,996 1,883 District of Columbia 8,523 2,143 4,846 1,329 Florida 236, ,433 51,081 70,059 Georgia 148,633 69,494 48,693 23,657 Hawaii 18,982 4, ,039 Idaho 24,184 19, ,792 Illiois 180,572 95,207 31,207 44,342 Idiaa 88,631 67,950 10,374 8,454 Iowa 40,607 34,511 1,585 3,226 Kasas 40,968 29,673 2,994 6,587 Ketucky 58,250 49,224 5,251 2,774 Louisiaa 63,376 35,222 24,271 2,344 Maie 14,151 13, Marylad 77,494 37,016 25,397 10,087 Massachusetts 77,676 53,644 7,104 10,749 Michiga 127,483 87,157 22,680 8,682 Miesota 73,525 54,061 6,306 6,027 Mississippi 46,056 22,650 21,075 1,556 Missouri 81,385 62,115 12,333 4,556 Motaa 12,508 9, Nebraska 26,727 19,976 1,715 3,999 Nevada 40,027 16,828 3,334 15, March of Dimes

77 No-Hispaic No-Hispaic State Total Births White Black Hispaic New Hampshire 14,378 12, New Jersey 115,020 56,974 17,459 29,210 New Mexico 29,936 8, ,514 New York 250, ,405 42,453 59,331 North Carolia 127,859 71,382 29,712 21,217 North Dakota 8,621 7, Ohio 150, ,914 23,781 6,737 Oklahoma 54,016 34,915 4,888 7,065 Orego 48,689 33,856 1,096 9,939 Pesylvaia 149, ,602 20,871 13,279 Rhode Islad 12,372 6, ,557 South Carolia 62,171 34,211 20,458 5,874 South Dakota 11,919 9, Teessee 84,355 57,172 17,422 7,939 Texas 399, ,916 46, ,259 Utah 53,504 42, ,224 Vermot 6,511 6, Virgiia 107,817 62,502 23,414 14,467 Washigto 86,876 56,249 3,750 15,796 West Virgiia 20,931 19, Wiscosi 72,340 54,543 7,024 6,870 Wyomig 7,672 6, Puerto Rico 48,744 /a /a /a Uited States 4,265,555 2,308, ,247 1,039,077 Notes: People of Hispaic origi may be of ay race. /a = ot available. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 69

78 Newbor Screeig Requiremets, by State, 2009 State Births % of US Births Number of Core Coditios Tested a Alabama 63, % 28 Alaska 10, % 29 Arizoa b 102, % 28 Arkasas c 40, % 29 Califoria 562, % 28 Colorado 70, % 29 Coecticut 41, % 29 Delaware 11, % 29 District of Columbia 8, % 29 Florida 236, % 28 Georgia 148, % 28 Hawaii 18, % 29 Idaho 24, % 28 Illiois 180, % 29 Idiaa 88, % 29 Iowa 40, % 29 Kasas d 40, % 29 Ketucky 58, % 28 Louisiaa 63, % 29 Maie 14, % 28 Marylad 77, % 29 Massachusetts 77, % 26 Michiga 127, % 29 Miesota 73, % 29 Mississippi 46, % 29 Missouri e 81, % 29 Motaa f 12, % 29 Nebraska 26, % 28 Nevada 40, % March of Dimes

79 State Births % of US Births Number of Core Coditios Tested a New Hampshire 14, % 27 New Jersey 115, % 29 New Mexico 29, % 29 New York 250, % 29 North Carolia 127, % 27 North Dakota 8, % 28 Ohio 150, % 28 Oklahoma g 54, % 28 Orego 48, % 28 Pesylvaia 149, % 29 Rhode Islad 12, % 29 South Carolia 62, % 29 South Dakota 11, % 28 Teessee h 84, % 28 Texas i 399, % 27 Utah 53, % 29 Vermot 6, % 29 Virgiia 107, % 29 Washigto 86, % 27 West Virgiia j 20, % 29 Wiscosi 72, % 28 Wyomig 7, % 29 Notes: a Core coditios are 29 disorders idetified by the America College of Medical Geetics. Testig is uiversally required by law or rule ad fully implemeted as of October Source: Number of coditios tested from Natioal Newbor Screeig ad Geetics Resource Ceter, Births from Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by March of Dimes Periatal Data Ceter, March of Dimes 71

80 Preterm Births, by State, 2006 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity Alabama 10, Alaska 1, Arizoa 13, Arkasas 5, Califoria 57, Colorado 8, Coecticut 4, Delaware 1, District of Columbia 1, Florida 32, Georgia 20, Hawaii 2, Idaho 2, Illiois 23, Idiaa 11, Iowa 4, Kasas 4, Ketucky 8, Louisiaa 10, Maie 1, Marylad 10, Massachusetts 8, Michiga 15, Miesota 7, Mississippi 8, Missouri 10, Motaa 1, Nebraska 3, March of Dimes No-Hispaic No-Hispaic Hispaic White Black

81 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity No-Hispaic No-Hispaic Hispaic White Black Nevada 5, New Hampshire 1, New Jersey 14, New Mexico 4, New York 30, North Carolia 17, North Dakota 1, Ohio 20, Oklahoma 7, Orego 4, Pesylvaia 17, Rhode Islad 1, South Carolia 9, South Dakota 1, Teessee 12, Texas 54, Utah 6, Vermot Virgiia 12, Washigto 9, West Virgiia 2, Wiscosi 8, Wyomig Puerto Rico 9, /a /a /a Uited States 542, Notes: Preterm is less tha 37 completed weeks gestatio. People of Hispaic origi may be of ay race. idicates fewer tha 20 births. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 73

82 Late Preterm Births, by State, 2006 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity Alabama 7, Alaska Arizoa 9, Arkasas 4, Califoria 41, Colorado 6, Coecticut 3, Delaware 1, District of Columbia Florida 23, Georgia 15, Hawaii 1, Idaho 2, Illiois 16, Idiaa 8, Iowa 3, Kasas 3, Ketucky 6, Louisiaa 7, Maie 1, Marylad 7, Massachusetts 6, Michiga 11, Miesota 5, Mississippi 6, Missouri 7, Motaa 1, Nebraska 2, March of Dimes No-Hispaic No-Hispaic Hispaic White Black

83 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity No-Hispaic No-Hispaic Hispaic White Black Nevada 4, New Hampshire 1, New Jersey 10, New Mexico 3, New York 21, North Carolia 12, North Dakota Ohio 14, Oklahoma 5, Orego 3, Pesylvaia 12, Rhode Islad 1, South Carolia 6, South Dakota 1, Teessee 8, Texas 39, Utah 4, Vermot Virgiia 9, Washigto 7, West Virgiia 2, Wiscosi 5, Wyomig Puerto Rico 7, /a /a /a Uited States 387, Notes: Late preterm is betwee completed weeks gestatio. People of Hispaic origi may be of ay race. idicates fewer tha 20 births. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 75

84 Very Preterm Births, by State, 2006 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity Alabama 1, Alaska Arizoa 1, Arkasas Califoria 8, Colorado 1, Coecticut Delaware District of Columbia Florida 5, Georgia 3, Hawaii Idaho Illiois 4, Idiaa 1, Iowa Kasas Ketucky 1, Louisiaa 1, Maie Marylad 1, Massachusetts 1, Michiga 2, Miesota 1, Mississippi 1, Missouri 1, Motaa Nebraska March of Dimes No-Hispaic No-Hispaic Hispaic White Black

85 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity No-Hispaic No-Hispaic Hispaic White Black Nevada New Hampshire New Jersey 2, New Mexico New York 5, North Carolia 3, North Dakota Ohio 3, Oklahoma 1, Orego Pesylvaia 3, Rhode Islad South Carolia 1, South Dakota Teessee 2, Texas 8, Utah Vermot Virgiia 2, Washigto 1, West Virgiia Wiscosi 1, Wyomig Puerto Rico 1, /a /a /a Uited States 86, Notes: Very preterm is less tha 32 completed weeks gestatio. People of Hispaic origi may be of ay race. idicates fewer tha 20 births. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 77

86 Low Birthweight Births, by State, 2006 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity Alabama 6, Alaska Arizoa 7, Arkasas 3, Califoria 38, Colorado 6, Coecticut 3, Delaware 1, District of Columbia Florida 20, Georgia 14, Hawaii 1, Idaho 1, Illiois 15, Idiaa 7, Iowa 2, Kasas 2, Ketucky 5, Louisiaa 7, Maie Marylad 7, Massachusetts 6, Michiga 10, Miesota 4, Mississippi 5, Missouri 6, Motaa Nebraska 1, March of Dimes No-Hispaic No-Hispaic Hispaic White Black

87 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity No-Hispaic No-Hispaic Hispaic White Black Nevada 3, New Hampshire New Jersey 9, New Mexico 2, New York 20, North Carolia 11, North Dakota Ohio 13, Oklahoma 4, Orego 2, Pesylvaia 12, Rhode Islad South Carolia 6, South Dakota Teessee 8, Texas 33, Utah 3, Vermot Virgiia 8, Washigto 5, West Virgiia 2, Wiscosi 4, Wyomig Puerto Rico 6, /a /a /a Uited States 351, Notes: Low birthweight is less tha 2,500 grams (5 ½ pouds). People of Hispaic origi may be of ay race. idicates fewer tha 20 births. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 79

88 Very Low Birthweight Births, by State, 2006 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity Alabama 1, Alaska Arizoa 1, Arkasas Califoria 6, Colorado Coecticut Delaware District of Columbia Florida 3, Georgia 2, Hawaii Idaho Illiois 2, Idiaa 1, Iowa Kasas Ketucky Louisiaa 1, Maie Marylad 1, Massachusetts 1, Michiga 2, Miesota Mississippi 1, Missouri 1, Motaa Nebraska March of Dimes No-Hispaic No-Hispaic Hispaic White Black

89 State Number (Average) Percet of Live Births Rak Percet of Live Births by Materal Race/Ethicity No-Hispaic No-Hispaic Hispaic White Black Nevada New Hampshire New Jersey 1, New Mexico New York 3, North Carolia 2, North Dakota Ohio 2, Oklahoma Orego Pesylvaia 2, Rhode Islad South Carolia 1, South Dakota Teessee 1, Texas 5, Utah Vermot Virgiia 1, Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a Uited States 63, Notes: Very low birthweight is less tha 1,500 grams (3 1/3 pouds). People of Hispaic origi may be of ay race. idicates fewer tha 20 births. /a = ot available. Rakigs are based o more tha 1 decimal place. Source: Natioal Ceter for Health Statistics, fial atality data. Puerto Rico Health Departmet, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 81

90 Preterm Birth Rates, by State, 2006 Percet of live births Over 13.6 (16) (18) Uder 12.0 (17) Value i ( ) = umber of states (icludes District of Columbia). Source: Natioal Ceter for Health Statistics, fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

91 Childre s Health Isurace Program, by Type of Program, 2009 Separate State Child Health Plas (18) Medicaid Expasios (6 states ad D.C.) Combiatio Programs (26) Source: Ceters for Medicare ad Medicaid Services, March of Dimes 83

92 Births to Wome Who Received Early Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) State Number Percet of Live Births Alabama 51, Alaska 8, Arizoa 79, Arkasas 30, Califoria 479, Colorado 55, Coecticut 35, District of Columbia 5, Georgia 117, Hawaii 14, Illiois 148, Idiaa 67, Iowa 33, Louisiaa 54, Maie 12, Marylad 61, Massachusetts 67, Michiga 105, Miesota 58, Mississippi 36, Missouri 67, Motaa 10, Nevada 26, New Jersey 87, New Mexico 20, New York City 89, North Carolia 104, Oklahoma 40, Orego 37, Rhode Islad 10, Utah 42, Virgiia 89, West Virgiia 16, Wiscosi 60, Notes: Early preatal care starts i the first trimester (oe to three moths). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Birth are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

93 Births to Wome Who Received Early Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) State Number Percet of Live Births Delaware 8, Florida 157, Idaho 16, Kasas 28, Ketucky 40, Nebraska 19, New Hampshire 9, New York (excludig New York City) 88, North Dakota 6, Ohio 97, Pesylvaia 96, South Carolia 38, South Dakota 8, Teessee 53, Texas 243, Vermot 5, Washigto 53, Wyomig 5, Notes: Early preatal care starts i the first trimester (oe to three moths). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Birth are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 85

94 Births to Wome Who Received Late or No Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) State Number Percet of Live Births Alabama 2, Alaska Arizoa 6, Arkasas 1, Califoria 15, Colorado 3, Coecticut District of Columbia Georgia 5, Hawaii Illiois 4, Idiaa 3, Iowa Louisiaa 1, Maie Marylad 3, Massachusetts 1, Michiga 3, Miesota 1, Mississippi 1, Missouri 1, Motaa Nevada 3, New Jersey 5, New Mexico 1, New York City 5, North Carolia 3, Oklahoma 3, Orego 2, Rhode Islad Utah 2, Virgiia 4, West Virgiia Wiscosi 2, Notes: Late preatal care starts i the third trimester (seve to ie moths). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Births are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Puerto Rico Health Departmet, 2004 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

95 Births to Wome Who Received Late or No Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) State Number Percet of Live Births Delaware Florida 16, Idaho 1, Kasas 1, Ketucky 3, Nebraska 1, New Hampshire New York (excludig New York City) 5, North Dakota Ohio 8, Pesylvaia 8, South Carolia 4, South Dakota Teessee 7, Texas 45, Vermot Washigto 4, Wyomig Notes: Late preatal care starts i the third trimester (seve to ie moths). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Births are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Puerto Rico Health Departmet, 2004 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 87

96 Births to Wome Who Received Adequate or Adequate-Plus Preatal Care, by State, 2006 (1989 Birth Certificate Revisio) State Number Percet of Live Births Alabama 48, Alaska 6, Arizoa 69, Arkasas 25, Califoria 437, Colorado 45, Coecticut 32, District of Columbia 4, Georgia 98, Hawaii 11, Illiois 133, Idiaa 60, Iowa 31, Louisiaa 51, Maie 11, Marylad 52, Massachusetts 62, Michiga 99, Miesota 51, Mississippi 34, Missouri 60, Motaa 8, Nevada 23, New Jersey 71, New Mexico 16, New York City 66, North Carolia 98, Oklahoma 35, Orego 33, Rhode Islad 8, Utah 43, Virgiia 79, West Virgiia 15, Wiscosi 55, Notes: Adequate or adequate-plus preatal care begiig i the first four moths of pregacy with the appropriate umber of visits for gestatioal age (accordig to the Adequacy of Preatal Care Idex). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Births are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes

97 Births to Wome Who Received Adequate or Adequate-Plus Preatal Care, by State, 2006 (2003 Birth Certificate Revisio) State Number Percet of Live Births Delaware 8, Florida 157, Idaho 17, Kasas 28, Ketucky 42, Nebraska 17, New Hampshire 10, New York (excludig New York City) 83, North Dakota 5, Ohio 89, Pesylvaia 83, South Carolia 40, South Dakota 7, Teessee 53, Texas 247, Vermot 5, Washigto 47, Wyomig 5, Notes: Adequate or adequate-plus preatal care begiig i the first four moths of pregacy with the appropriate umber of visits for gestatioal age (accordig to the Adequacy of Preatal Care Idex). Preatal care data based o 1989 ad 2003 U.S. Revisios of the Certificate of Live Births are ot comparable. For more iformatio, visit marchofdimes.com/peristats/calc/pc. Source: Natioal Ceter for Health Statistics, 2006 fial atality data. Prepared by the March of Dimes Periatal Data Ceter, March of Dimes 89

98 Wome Ages Without Health Isurace, by State, Average State Number Percet Rak (i thousads) Alabama Alaska Arizoa Arkasas Califoria 1, Colorado Coecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa March of Dimes

99 State Number Percet Rak (i thousads) Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas 1, Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a Uited States 12, Notes: Figures are three-year averages. Small sample sizes make sigle-year state data less reliable. /a=ot available. Rakigs are based o more tha 1 decimal place. Source: U.S. Cesus Bureau, 2009a. State rakigs computed by the March of Dimes Periatal Data Ceter. March of Dimes 91

100 Childre Uder Age 19 Without Health Isurace, by State, Average State Number Percet Rak (i thousads) Alabama Alaska Arizoa Arkasas Califoria 1, Colorado Coecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa March of Dimes

101 State Number Percet Rak (i thousads) Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas 1, Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a Uited States 8, Notes: Figures are three-year averages. Small sample sizes make sigle-year state data less reliable. The data iclude all people uder age 19, whether or ot they are depedets. Rakigs are based o more tha 1 decimal place. /a = ot available. Source: U.S. Cesus Bureau, 2007a. State rakigs computed by the March of Dimes Periatal Data Ceter. March of Dimes 93

102 Icome Eligibility Thresholds for Pregat Wome ad for Childre Uder Medicaid, by State, 2009 State Alabama Alaska Arizoa Arkasas Califoria Colorado Coecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa Nebraska March of Dimes Pregat Wome Eligibility as Percetage of Federal Poverty Level Ifats Ages 0-1 Childre Ages 1-5 Childre Ages 6-19

103 State Pregat Wome Eligibility as Percetage of Federal Poverty Level Ifats Ages 0-1 Childre Ages 1-5 Childre Ages 6-19 Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a /a Source: Kaiser Commissio o Medicaid ad the Uisured, Jauary March of Dimes 95

104 Icome Eligibility Thresholds for Pregat Wome ad for Childre Uder CHIP, by State, 2009 State/ Program Type Eligibility as Percetage of Federal Poverty Level Pregat Wome/ Materity Care Childre Uder 19 Alabama (S) /a 200 Alaska (M) /a 164 Arizoa (S) /a 200 Arkasas a (C) Califoria a (C) Colorado b (S) Coecticut (S) /a 300 Delaware (C) /a 200 District of Columbia c (M) Florida (C) /a 200 Georgia (S) /a 235 Hawaii (M) /a 200 Idaho c (C) Illiois a (C) Idiaa (C) /a 200 Iowa (C) /a 200 Kasas (S) /a 200 Ketucky (C) /a 200 Lousiaa a (C) Maie (C) /a 200 Marylad (M) /a 300 Massachusetts a (C) Michiga a (C) Miesota a (C) Mississippi c (S) Missouri (M) /a 300 Motaa (S) /a 150 Nebraska (M) /a March of Dimes

105 State/ Program Type Eligibility as Percetage of Federal Poverty Level Pregat Wome Nevada b (S) New Hampshire (C) /a 300 New Jersey b (C) New Mexico (M) /a 235 New York (S) /a 250 North Carolia (C) /a 200 North Dakota (C) /a 140 Ohio c (M) Oklahoma c (M) Orego (S) /a 185 Pesylvaia (S) /a 200 Rhode Islad a,b (C) South Carolia (M) /a 150 South Dakota (C) /a 200 Teessee (C) /a Texas a (S) Utah (S) /a 200 Vermot (S) /a 300 Virgiia b (C) Washigto a (S) West Virgiia (S) /a 220 Wiscosi a (C) Wyomig c (S) Puerto Rico /a /a Childre Uder 19 Notes: M = Medicaid expasio. S = separate pla. C = combiatio. a: State coverage of Materity care through ubor child regulatio (67 Federal Regulatio /2/02) b: State coverage of pregat wome through sectio 1115 or HIFA waiver c: State reported coverage of pregat wome i Natioal Goveror s Associatio, /a = ot available Sources: Natioal Goverors Associatio, 2008; Kaiser Family Foudatio March of Dimes 97

106 Presumptive ad Cotiuous Eligibility Uder Medicaid ad CHIP, by State, State Alabama Alaska p p Arizoa a /a Arkasas l Califoria l l l Colorado l l l Coecticut l l Delaware a l District of Columbia l Florida b l l /p Georgia l Hawaii Idaho l Illiois l l l Idiaa Presumptive Eligibility for Pregat Wome (Medicaid) Presumptive Eligibility for Childre (Medicaid)) Presumptive Eligibility for Childre (CHIP) Cotiuous Eligibility for Childre (Medicaid) Iowa a l Kasas l l Ketucky a l Cotiuous Eligibility for Childre (CHIP) Louisiaa l l Maie l Marylad a /a Massachusetts l l l Michiga l l l Miesota c /p Mississippi Missouri l l Motaa l Nebraska l p p 98 March of Dimes

107 State Nevada /a /a New Hampshire l l New Jersey l l l New Mexico l l New York l l l North Carolia l North Dakota Ohio a Oklahoma l Orego c p Pesylvaia l Rhode Islad South Carolia South Dakota Teessee l Texas l p Utah l Vermot Virgiia Presumptive Eligibility for Pregat Wome (Medicaid) Presumptive Eligibility for Childre (Medicaid) Presumptive Eligibility for Childre (CHIP) Cotiuous Eligibility for Childre (Medicaid) Washigto West Virgiia Wiscosi a l l Wyomig l Puerto Rico /a /a /a /a /a Cotiuous Eligibility for Childre (CHIP) l = presumptive eligibility provided = 12 moths cotiuous eligibility p = 6 moths cotiuous eligibility = ot applicable; o S-CHIP separate from Medicaid. /a=ot available. a Cotiuous eligibility is for ewbors/ifats oly. b Cotiuous eligibility uder Medicaid is 12 moths for childre uder age 5 ad 6 moths for others. c Cotiuous eligibility uder Medicaid lasts 12 moths for ewbors ad 6 moths for older childre. Source: Natioal Goverors Associatio, 2007; Kaiser Family Foudatio March of Dimes 99

108 Medicaid Erollees, by Select Characteristics, by State, Fiscal Year 2006 State Erollees (i thousads) Wome ad Childre as Nodisabled Childre Total Percet of Wome Ages Uder 19 Total Alabama Alaska Arizoa , Arkasas Califoria 3,188 4,276 10, Colorado Coecticut Delaware District of Columbia Florida 444 1,644 3, Georgia 274 1,106 1, Hawaii Idaho Illiois 389 1,263 2, Idiaa , Iowa Kasas Ketucky Louisiaa , Maie Marylad Massachusetts , Michiga 293 1,013 1, Miesota Mississippi Missouri , Motaa Nebraska March of Dimes

109 State Erollees (i thousads) Wome ad Childre as Nodisabled Childre Total Percet of Wome Ages Uder 19 Total Nevada New Hampshire New Jersey New Mexico New York 973 1,897 5, North Carolia , North Dakota Ohio 367 1,051 2, Oklahoma Orego Pesylvaia 316 1,016 2, Rhode Islad South Carolia South Dakota Teessee , Texas 467 2,731 4, Utah Vermot Virgiia Washigto , West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a /a Uited States 11,131 29,348 58, /a = ot available Source: Ceters for Medicare ad Medicaid Services, 2009a. March of Dimes 101

110 Medicaid Expeditures, by Erollee Characteristics, by State, Fiscal Year 2006 State Expeditures (i millios) Wome ad Childre as Nodisabled Childre Total Percet of Wome Ages Uder 19 Total Alabama , Alaska Arizoa 702 1,502 3, Arkasas 153 1,039 2, Califoria 2,905 6,589 28, Colorado , Coecticut , Delaware District of Columbia , Florida 1,095 3,084 11, Georgia 770 1,941 5, Hawaii Idaho , Illiois 785 1,898 8, Idiaa 494 1,231 4, Iowa , Kasas , Ketucky 398 1,129 3, Louisiaa , Maie , Marylad 508 1,263 5, Massachusetts 651 1,968 8, Michiga 613 1,537 5, Miesota 399 1,308 5, Mississippi , Missouri 383 1,182 4, Motaa Nebraska , March of Dimes

111 State Expeditures (i millios) Wome ad Childre as Nodisabled Childre Total Percet of Wome Ages Uder 19 Total Nevada , New Hampshire New Jersey 328 1,366 7, New Mexico , New York 3,058 5,897 39, North Carolia 822 2,285 8, North Dakota Ohio 1,185 2,203 11, Oklahoma , Orego , Pesylvaia 858 2,672 10, Rhode Islad , South Carolia , South Dakota Teessee 778 1,414 5, Texas 1,141 5,517 13, Utah , Vermot Virgiia 361 1,141 4, Washigto 551 1,179 4, West Virgiia , Wiscosi , Wyomig Puerto Rico /a /a /a /a Uited States 23,926 63, , /a = ot available Source: Ceters for Medicare ad Medicaid Services, 2009b. March of Dimes 103

112 Stad-Aloe ad Medicaid CHIP Erollees, by State, 2007 ad 2008 State/Program Type Childre (Medicaid CHIP) (2007) Childre (Medicaid CHIP) (2008) Childre (Stad-Aloe CHIP) (2007) Childre (Stad-Aloe CHIP) (2008) Total (2007) Total (2008) Alabama(S) /a /a 106, , , ,821 Alaska(M) 17,558 18,707 /a /a 17,558 18,707 Arizoa(S) /a /a 104, , , ,072 Arkasas(C) 85,863 89,646 3,779 3,800 89,642 93,446 Califoria(C) 265, ,918 1,273,359 1,387,169 1,538,416 1,692,087 Colorado(S) /a /a 84,649 99,555 84,649 99,555 Coecticut(S) /a /a 23,632 22,270 23,632 22,270 Delaware(C) ,998 11,111 11,143 11,192 D.C. (M) 6,566 8,746 /a /a 6,566 8,746 Florida(C) 1,594 1, , , , ,385 Georgia(S) /a /a 356, , , ,234 Hawaii(M) 23,958 28,803 /a /a 23,958 28,803 Idaho(C) 19,019 19,772 14,041 23,754 33,060 43,526 Illiois(C) 157, , , , , ,460 Idiaa(C) 95,836 92,488 34,532 32, , ,954 Iowa(C) 17,926 17,709 32,312 32,681 50,238 50,390 Kasas(S) /a /a 49,536 51,162 49,536 51,162 Ketucky(C) 43,277 43,073 26,920 24,644 70,197 67,717 Louisiaa(C) 152, ,691 1,877 5, , ,863 Maie(C) 21,966 21,660 9,071 9,287 31,037 30,947 Marylad(M) 120, ,864 12,530 /a 132, ,864 Massachusetts(C) 93, ,097 90, , , ,950 Michiga(C) 11,254 14,885 53,517 52,878 64,771 67,763 Miesota(C) ,346 5,543 5,408 5,621 Mississippi(S) /a /a 81,565 84,370 81,565 84,370 Missouri(M) 81,764 52,920 /a 83,215 81, ,135 Motaa(S) /a /a 20,115 22,679 20,115 22,679 Nebraska(M) 46,199 48,827 /a /a 46,199 48,827 Nevada(S) /a /a 41,862 38,592 41,862 38, March of Dimes

113 State Childre (Medicaid CHIP) (2007) Childre (Medicaid CHIP) (2008) Childre (Stad-Aloe CHIP) (2007) Childre (Stad-Aloe CHIP) (2008) Total (2007) Total (2008) New Hampshire(C) ,467 11,524 12,088 12,236 New Jersey(C) 49,286 56, ,991 95, , ,805 New Mexico(M) 16,525 14,944 /a /a 16,525 14,944 New York(S) /a /a 651, , , ,256 North Carolia(C) 67,197 70, , , , ,653 North Dakota(C) 1,808 1,672 3,661 5,945 5,469 7,617 Ohio(M) 231, ,278 /a /a 231, ,278 Oklahoma(M) 117, ,208 /a 3, , ,507 Orego(S) /a /a 63,090 73,686 63,090 73,686 Pesylvaia(S) /a /a 227, , , ,627 Rhode Islad(C) 24,234 24,038 1,833 1,993 26,067 26,031 South Carolia(M) 59,920 67,799 /a 5,821 59,920 73,620 South Dakota(C) 11,561 11,713 3,421 3,564 14,982 15,277 Teessee(C) 35,589 32,751 5,774 30,868 41,363 63,619 Texas(S) /a /a 710, , , ,916 Utah(S) /a /a 44,785 51,092 44,785 51,092 Vermot(S) /a /a 6,132 6,496 6,132 6,496 Virgiia(C) 68,075 70,715 76,088 84, , ,289 Washigto(S) /a /a 14,734 16,831 14,734 16,831 West Virgiia(S) /a /a 38,582 37,645 38,582 37,645 Wiscosi(C) 56,904 48,846 5,619 4,094 62,523 52,940 Wyomig(S) /a /a 8,570 8,976 8,570 8,976 Puerto Rico /a /a /a /a /a /a Uited States 2,002,194 2,069,812 5,095,390 5,298,667 7,097,584 7,368,479 Notes: S = separate child health program. M = Medicaid expasio program. C = combiatio program. /a = ot available. Source: Ceters for Medicare ad Medicaid Services, 2009b. March of Dimes 105

114 Childre s Health Isurace Program Federal Allotmets, by State, Fiscal Year 2009 State FY2009 CHIPRA FY2009 Spedig Remaiig Allotmet to Date Available from the FY2009 Allotmet Alabama $ 140,300,600 $ 71,056,418 $ 69,244,182 Alaska 24,565,200 10,419,103 14,146,097 Arizoa 171,133, ,074,041 22,059,177 Arkasas 133,752,696 50,409,786 83,342,910 Califoria 1,552,909, ,172, ,737,432 Colorado 100,696, ,696,200 Coecticut 45,644, ,644,506 Delaware 15,096, ,096,397 District of Columbia 14,180, ,180,255 Florida 356,095, ,095,478 Georgia 302,054, ,553, ,500,991 Hawaii 20,888, ,888,564 Idaho 44,514, ,514,800 Illiois 344,561, ,658, ,902,840 Idiaa 137,584, ,584,700 Iowa 65,255,300 34,057,616 31,197,684 Kasas 57,163,700 37,854,500 19,309,200 Ketucky 126,013,800 67,371,232 58,642,568 Louisiaa 207,402,800 94,386, ,016,800 Maie 39,271,706 16,895,000 22,376,706 Marylad 194,773,700 86,201, ,572,700 Massachusetts 321,658, ,552, ,106,700 Michiga 221,124, ,173,055 74,951,145 Miesota 83,960,234 48,613,498 35,346,736 Mississippi 192,938,900 81,428, ,510,900 Missouri 158,829,000 81,870,388 76,958,612 Motaa 32,989,000 14,489,345 18,499,655 Nebraska $ 41,955,100 $ 22,516,181 $ 19,438, March of Dimes

115 State FY2009 CHIPRA FY2009 Spedig Remaiig Allotmet to Date Available from the FY2009 Allotmet Nevada $ 61,397,036 $ 0 $ 61,397,036 New Hampshire 14,844, ,844,500 New Jersey 505,395, ,570, ,825,000 New Mexico 280,720, ,817, ,902,618 New York 433,472, ,472,600 North Carolia 241,660, ,117, ,542,787 North Dakota 15,821,554 7,885,338 7,936,216 Ohio 285,275, ,285, ,989,906 Oklahoma 151,399,600 70,828,185 80,571,415 Orego 100,197, ,197,900 Pesylvaia 310,308, ,008, ,300,597 Rhode Islad 69,525,150 28,195,000 41,330,150 South Carolia 106,862, ,862,800 South Dakota 20,655,800 10,862,735 9,793,065 Teessee 156,629, ,629,000 Texas 867,350, ,350,000 Utah 65,264, ,264,100 Vermot 9,498, ,489,700 Virgiia 175,860,300 96,877,519 78,982,781 Washigto 94,285, ,285,111 West Virgiia 43,263,469 25,009,711 18,253,758 Wiscosi 204,275,500 69,563, ,712,338 Wyomig 11,326, ,326,700 Puerto Rico 111,800, ,800,000 TOTAL $ 9,372,603,578 $ 3,427,772,592 $ 5,944,822,932 Source: U.S. Departmet of Health ad Huma Services, FY 2009 CHIPRA Allotmets, (Jue 19, 2009), available at Notes: The remaiig available from the FY2009 allotmet represets the FY2009 CHIPRA allotmet mius the spedig to date (as of 6/19/09,) which icludes the states allotmets uder the Medicare, Medicaid, ad SCHIP Extesio Act, ay FY2006 redistritubuted fuds, ad ay shortfall fuds the state received. The total CHIPRA allotmet does ot iclude fudig to the territories. March of Dimes 107

116 Federal Matchig Rates for Medicaid ad CHIP, by State, Fiscal Year 2010 Federal Percetage Federal Percetage State Medicaid CHIP State Medicaid CHIP Alabama Alaska Arizoa Arkasas Califoria Colorado Coecticut Delaware D.C Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico Source: Departmet of Health ad Huma Services, March of Dimes

117 Births Fuded by Medicaid, by State, 2003 State Percet State Percet Alabama 46 Alaska 55 Arizoa 50 Arkasas 52 Califoria 45 Colorado 37 Coecticut 28 Delaware 41 District of Columbia 34 Florida 50 Georgia 50 Hawaii 27 Idaho 40 Illiois 40 Idiaa 41 Iowa 28 Kasas 40 Ketucky 44 Louisiaa 59 Maie 47 Marylad 34 Massachusetts 29 Michiga 35 Miesota 37 Mississippi 60 Missouri 45 Motaa 35 Nebraska 40 Nevada* 32 New Hampshire 23 New Jersey* 26 New Mexico* 67 New York 40 North Carolia 48 North Dakota 30 Ohio 32 Oklahoma 50 Orego 43 Pesylvaia 31 Rhode Islad 37 South Carolia 55 South Dakota 36 Teessee 46 Texas* 49 Utah 30 Vermot 48 Virgiia 28 Washigto 46 West Virgiia 50 Wiscosi 38 Wyomig 46 Puerto Rico /a Uited States 41 Notes: Asterisked data from data uavailable for this state. /a = state did ot respod to survey. Source: Natioal Goverors Associatio, March of Dimes 109

118 Medicaid Coverage of Smokig Cessatio Treatmets, by State, 2006 State Pharmacotherapy a Couselig b State Pharmacotherapy a Couselig b Alabama Alaska N, Rx I Arizoa Rx I Arkasas N, Rx I Califoria N, Rx G, I Colorado N, Rx G, I Coecticut /a Delaware N, Rx D.C. N, Rx Florida N, Rx G, I Georgia Hawaii N, Rx Idaho /a Illiois N, Rx Idiaa N, Rx G, I Iowa /a I Kasas N, Rx Ketucky /a G, I Louisiaa N, Rx Maie N, Rx I Marylad N, Rx I Massachusetts Rx G, I Michiga N, Rx Miesota N, Rx G, I Mississippi N, Rx G, I Missouri /a Motaa N, Rx Nebraska Nevada N, Rx New Hampshire N, Rx G, I New Jersey Rx New Mexico N, Rx G, I New York N, Rx G North Carolia N, Rx North Dakota N, Rx G, I Ohio N, Rx Oklahoma N, Rx I Orego N, Rx G, I, T Pesylvaia N, Rx G, I Rhode Islad N, Rx G, I South Carolia N, Rx G, I South Dakota Rx Teessee Texas N, Rx Utah N, Rx G, I, T Vermot N, Rx Virgiia Rx G, I Washigto Rx I West Virgiia N, Rx I, T Wiscosi Rx G, I Wyomig Puerto Rico /a /a a Pharmacotherapies cosist of icotie replacemet treatmet such as gum ad the patch (N), ad prescriptio or oprescriptio medicatios (Rx). b Couselig cosists of Group Couselig (G), Idividual Couselig (I), ad/or Telephoe Couselig (T). idicates o treatmets covered by Medicaid uder this category /a = ot available Source: Ceters for Disease Cotrol ad Prevetio, March of Dimes

119 Percet of Childre Moths with Up-to-Date Immuizatios, 2008 State Polio a 4:3:1:3:3 Varicella c State Polio a 4:3:1:3:3 Varicella c Series b Series b Alabama Alaska Arizoa Arkasas Califoria Colorado Coecticut Delaware D.C Florida Georgia Hawaii Idaho Illiois Idiaa Iowa Kasas Ketucky Louisiaa Maie Marylad Massachusetts Michiga Miesota Mississippi Missouri Motaa Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolia North Dakota Ohio Oklahoma Orego Pesylvaia Rhode Islad South Carolia South Dakota Teessee Texas Utah Vermot Virgiia Washigto West Virgiia Wiscosi Wyomig Puerto Rico /a /a /a Uited States a Polio = three or more doses of poliovirus vaccie. b 4:3:1:3:3 series is four or more doses of diphtheria ad tetaus toxoids ad pertussis vaccie (DTP), three or more doses of poliovirus vaccie, oe or more doses of measles cotaiig vaccie, three or more doses of Haemophilus ifluezae type b vaccie, ad three or more doses of Hepatitis B vaccie. c Varicella = oe or more doses of varicella at or after child s first birthday, uadjusted for history of varicella illess. /a = ot available. Source: Ceters for Disease Cotrol ad Prevetio, March of Dimes 111

120 Newbor Screeig Terms: A Glossary Amio Acid Metabolism Disorders Pheylketouria (PKU) (>1 i 25,000). Iability to process the essetial amio acid pheylalaie, which accumulates ad damages the brai. Ca lead to severe metal retardatio uless detected soo after birth ad treated with a special formula ad a low-protei diet. Maple syrup urie disease (<1 i 100,000). Geetic metabolic disorder with mild to severe symptoms, which ca lead to metal retardatio or death. Treatmet cosists of a special diet, cotiued idefiitely. Homocystiuria (<1 i 100,000). Lack of a ezyme that coverts the amio acid homocysteie ito cystathioie, eeded for ormal brai developmet. Utreated, leads to metal retardatio, eye problems, skeletal abormalities, ad stroke. Treatmet cosists of a special diet, oe or more vitamis (B6 or B12), ad other supplemets (betaie). Citrulliemia (<1 i 100,000). Buildup of citrullie ad ultimately ammoia, which utreated ca lead to seizures, coma, brai damage, ad death. Treatmet with lowprotei diet, medicatios to prevet ammoia buildup, ad utritioal supplemets allows ormal developmet. Argiiosucciic acidemia (<1 i 100,000). Buildup of argiiosucciic acid ad ultimately ammoia, leadig to brai swellig, coma, ad sometimes death. Treatmet cosists of a low-protei diet, frequet meals, medicatios to prevet ammoia buildup, utritioal supplemets, ad sometimes liver trasplat. Tyrosiemia type I (<1 i 100,000). Lack of a ezyme that causes the byproducts of the amio acid tyrosie, particularly a very toxic compoud (succiylacetoe), to build up i the liver. Fatal liver ad kidey failure may result. Drug therapy is effective. Orgaic Acid Metabolism Disorders Isovaleric acidemia (<1 i 100,000). Iability to process the amio acid leucie. Ca cause coma, brai damage, or death i ifacy, or emerge later i childhood after ifectious illess. Early diagosis ad treatmet with lowprotei diet ad utritioal supplemets allow most childre to develop ormally. Glutaric acidemia type I (>1 i 75,000). Ofte urecogized for up to 18 moths, util childhood illess triggers oset of symptoms. Without early diagosis ad prompt treatmet whe eeded, ca lead to brai damage, low muscle toe, cerebral palsy-like symptoms, ad death. 112 March of Dimes Hydroxymethylglutaric aciduria (<1 i 100,000). Iability to process leucie, leadig to low blood sugar ad accumulatio of several orgaic acids, especially after illess or missed meals. Utreated, ca lead to brai damage, metal retardatio, coma, ad death. Treatmet icludes a diet low i protei ad fat, ad high i carbohydrates. Multiple carboxylase deficiecy (<1 i 100,000). Defect i a ezyme that activates several other ezymes, leadig to buildup of lactic acid ad other orgaic acids. Utreated, ca cause brai damage, coma, ad death. Symptoms, icludig ski rashes ad hair loss, usually begi betwee birth ad 15 moths. Treatmet with a B vitami, bioti, allows ormal developmet. Methylmaloic acidemia due to mutase deficiecy (>1 i 75,000). Defect i processig four amio acids, resultig i illess i first week of life. Severity varies, but death durig first moth ad lifelog brai damage are commo. Treatmet icludes low-protei diet, vitami B12 ijectios, ad utritioal supplemets. Methylmaloic acidemia, cbla ad cblb forms (<1 i 100,000). Iherited vitami metabolism defect. Ca lead to buildup of acids i blood, brai damage, seizures, paralysis, coma, ad death. Treatmet icludes B12 ijectios ad a low-protei diet. 3-Methylcrotoyl-CoA carboxylase deficiecy (>1 i 75,000). Defect i processig leucie, leadig to brai damage, seizures, liver failure, ad ifat death, or sometimes o symptoms util adulthood. Symptoms may develop after childhood illess. Treatmet icludes a lowprotei diet. Propioic acidemia (>1 i 75,000). Defect i processig four amio acids leadig to illess i ewbors, icludig brai damage, coma, ad death. Eve with treatmet, which icludes a low-protei diet ad utritioal supplemets, some childre have developmet delays, seizures, icreased muscle toe, frequet ifectios, ad heart problems. Beta-ketothiolase deficiecy (<1 i 100,000). Periodic episodes of acid buildup, ofte triggered by illess, which ca lead to coma, brai damage, ad death. Itraveous treatmet to regulate blood sugar ad blood acid levels ca permit ormal developmet. Fatty Acid Oxidatio Disorders Medium-chaiacyl-CoA dehydrogease deficiecy (>1 i 25,000). Seemigly well ifats ad childre suddely develop seizures (due

121 to low blood sugar), liver failure, coma, ad death. Treatmet icludes utritioal supplemets ad frequet meals. Very log-chaiacyl-coa dehydrogease deficiecy (>1 i 75,000). Uless treated, ifats ofte develop heart ad liver failure, dyig before age oe. Treatmet icludes a highcarbohydrate/low-fat diet, utritioal supplemets, frequet meals, ad limitig exercise. Log-chai 3-OH acyl-coa dehydrogease deficiecy (>1 i 75,000). Symptoms ca begi soo after birth, resultig i heart, lug or liver failure, ad death. Treatmet icludes a high-carbohydrate/low-fat diet, utritioal supplemets, ad frequet meals. Trifuctioal protei deficiecy (<1 i 100,000). Seemigly healthy ifats ca die of what appears to be sudde ifat death sydrome. Other ifats may develop low muscle toe, seizures, heart failure, ad coma, ofte followig illess. Treatmet based o frequet meals, a low-fat diet, ad utritioal supplemets. Caritie uptake defect (<1 i 100,000). Cells caot readily absorb caritie, eeded to trasfer fatty acids ito mitochodria (which supply cells with eergy). Results iclude low blood sugar ad sudde death i ifacy. Older childre may preset with progressive heart failure. High-dose caritie permits ormal developmet. Hemoglobiopathies Sickle cell aemia (Hb SS) (>1 i 5,000; i Africa-Americas, 1 i 400). Blood disease that ca cause pai, vital orga damage, stroke, ad sometimes childhood death. Youg childre are especially proe to dagerous bacterial ifectios like peumoia ad meigitis. Vigilat medical care ad peicilli ca reduce the risk of these effects. Hb S/Beta Thalassemia (Hb S/Th) (>1 i 50,000). A form of sickle cell aemia, i which the child iherits oe sickle cell gee ad oe gee for beta thalassemia, aother iherited aemia. Symptoms are milder tha for Hb SS, though severity varies. Routie treatmet with peicilli may ot be recommeded for all affected childre. Hb S/C disease (Hb S/C) (>1 i 25,000). Aother form of sickle cell disease, i which the child iherits oe sickle cell gee ad oe gee for aother abormal type of hemoglobi. Hb S/C teds to be milder tha Hb SS; therefore, treatmet with peicilli may ot be recommeded. Other Iherited ad No-Geetic Disorders Cogeital hypothyroidism (>1 i 5,000). Thyroid hormoe deficiecy that severely retards growth ad brai developmet. If detected shortly after birth, ca be treated with oral doses of thyroid hormoe to permit ormal developmet. Biotiidase deficiecy (>1 i 75,000). A iherited disorder resultig i lack of the ezyme that recycles the vitami bioti. May cause frequet ifectios, ucoordiated movemet, hearig loss, seizures, ad metal retardatio. Udiagosed ad utreated, ca lead to coma ad death. If coditio detected soo after birth, problems ca be preveted with oral high-dose bioti. Cogeital adreal hyperplasia (CAH) (>1 i 25,000). A group of iherited disorders resultig from deficiecies of hormoes produced by the adreal glad. Severe forms of CAH, if udetected ad utreated, cause life-threateig salt loss via urie. Treatmet icludes hormoe replacemet. Galactosemia (>1 i 50,000). Lack of the liver ezyme eeded to covert galactose, a major sugar i milk, ito glucose (blood sugar). Galactose the accumulates i ad damages vital orgas, leadig to blidess, severe metal retardatio, ifectio, ad death. Milk ad other diary products must be elimiated from the baby s diet for life. This greatly improves the outlook for affected ifats, but risk of mild developmetal delays remais. Hearig impairmet (>1 i 5,000). Amog the most commo abormalities preset at birth. Without early testig, most babies with hearig loss are ot diagosed util age two or three. By the, they ofte have delayed speech ad laguage developmet. Early diagosis allows use of hearig aids by six moths, helpig prevet serious speech ad laguage problems. Cystic fibrosis (>1 i 5,000). A commo iherited disorder, resultig i lug ad digestive problems, ad death by age 35, o average. Early diagosis ad treatmet may improve the growth of babies ad childre with CF. *The symbols < ad > deote less tha ad greater tha, respectively. Terms are ordered i accordace with the table o page 21, which summarizes state requiremets. March of Dimes 113

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123 Data Sources