MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES

RESEARCH REVIEWS 8: 215220 (2002)

PREMATURITY AT BIRTH: TRENDS, RACIAL

DISPARITIES, AND EPIDEMIOLOGY
Greg R. Alexander* and Martha Slay
Department of Maternal and Child Health, School of Public Health,
University of Alabama at Birmingham, Birmingham, Alabama

While infant mortality rates have continued to decline in the U.S.,

low birth weight and preterm rates have dramatically increased. Although
the combination of factors that underlies these trends has not been fully
described, there is growing concern that an appreciable part of the rise in
prematurity rates stems from efforts taken to improve the survival of these
high-risk infants. While advancements in medical technology and practice,
augmented by improvements in prenatal care use, may have adversely
effected prematurity rates and played a role in broadening racial disparities
in pregnancy outcomes, they have positively impacted infant survival. Although many risk factors for prematurity have been identified, there are
presently few areas for effective prevention. Accordingly, there is little
encouragement for a downturn in prematurity rates in the near future. The
prospect of continuing growth in the annual number of surviving preterm
infants in the U.S. highlights the need for early detection and treatment of
developmental problems for these high-risk survivors, and emphasizes the
importance of assuring that needed support services are available to these
2002 Wiley-Liss, Inc.
children and their families.
MRDD Research Reviews 2002;8:215220.

Key Words: preterm birth; low birth weight; epidemiology; infant mortality; racial disparities; medical technology

TRENDS
etween 1980 and 2000 in the United States, the infant
mortality rate (the number of infant deaths less than one
year of age per 1000 live births) was reduced 45%, from
12.6 to 6.9 per 1000 live births [CDCP, 2002]. This marked
two-decade decrease in the risk of infant death, capping a
century of ongoing improvement in infant mortality rates, represents a praiseworthy achievement in U.S. perinatal health. But
equally noteworthy about this phase of steady enhancement in
infant survival is that infant death rates continued to decline
during a period when the rates of premature births, both preterm and low birth weight, were increasing (Fig. 1). Between
1980 and 2000, low birth weight (2500 grams) rates rose from
6.8 to 7.6 percent of live births, a 12 percent increase, and very
low birth weight (1500 grams) rates rose 24 percent, from 1.15
to 1.43 percent of live births. Correspondingly, preterm birth
(37 weeks) rates increased approximately 17 percent [Guyer et
al., 1997; 1998; 1999; Mathews et al., 2002]. This disjunctive
pattern of falling infant mortality rates, coupled with no complementary improvement in the proportion of high-risk premature births, is not altogether unique. Indeed, a relatively similar
combination of intersecting infant mortality and prematurity
trends was noted between 1950 and 1975 [Lee et al., 1980].

2002 Wiley-Liss, Inc.

Understanding the determinants of this distinctive pattern of

changing U.S. perinatal health indicators is a fundamental challenge to researchers, practitioners, and policy-makers seeking to
further improve perinatal health outcomes in a cost-effective
manner.
Population-wide progress in infant survival can be evaluated as stemming from: 1) decreases in the proportion of highrisk premature births, e.g., reducing the percentage of low birth
weight or preterm births; and/or, 2) increases in infant survival,
i.e., improving birth weight or gestational age specific infant
mortality rates [Lee et al., 1980; Alexander et al., 1999; Allen et
al., 2000]. The lack of measurable gains in reducing the incidence of premature births, either low birth weight, very low
birth weight or preterm, strongly supports the proposition that
better infant survival is the primary mechanism underlying the
ongoing decline in infant mortality in the U.S. [Lee et al., 1980;
Paneth, 1990; 1995; Alexander et al., 1999; Allen et al., 2000;
Alexander et al., 2003]. As seen in Figure 2, which depicts the
percent change in infant mortality from 19857 to 19957 by
500 gram birth weight categories for single live births to U.S.
resident mothers, the risk of an infant death declined over 30
percent for all birth weight categories over 500 grams and
decreased nearly 50 percent for infants with birth weight between 1000 1499 grams. These data, drawn from the NCHS
Linked Live Birth-Infant Deaths files for these time periods,
reveal that reductions in infant mortality were most marked for
those higher risk infants at the extremes of the birth weight
distribution, where the mortality rates are the highest. These
continuing improvements in infant survival have allowed for the
ongoing decrease in overall infant mortality rates in the U.S.,
even while there has been a coterminous rise in the proportion
of high-risk low birth weight and preterm births.
Decreases in birth weight and gestational age specific
mortality rates, which underscore the improvements in U.S.
infant survival, have typically been attributed to advancements
Grant sponsor: DHHS, HRSA, MCHB; Grant number: T76MC00008.
*Correspondence to: Greg R. Alexander, Professor and Chair, Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham,
320-A Ryals Building, 1665 University Boulevard, Birmingham, Alabama 35294
0022. E-mail: alexandg@uab.edu
Received 1 July 2002; Accepted 9 September 2002
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/mrdd.10047

Fig. 1. 1980 2000 infant mortality rates & % low birth weight live births to U.S. resident
mothers.

Fig. 2. % change in infant mortality by birth weight (19851987 and 19951997 single live
births to U.S. resident mothers).

in medical knowledge, technical capacity, and practice modalities in obstetrics,

perinatology, maternal-fetal medicine
and neonatology [Avery et al., 1987;
Copper et al., 1993; Howell and Vert,
1993; Goldenberg, 1994; Schwartz et al.,
1994; Philip, 1995; Horbar and Lucey,
1995; Reger et al., 1995; Goldenberg
and Rouse, 1998; Eichenwald and Stark,
1999; Ballard, 2000; Curley and Halliday, 2001; Thorp et al., 2002]. In the
area of high-risk obstetrics, antenatal corticosteriods and intrapartum antibiotics
have been linked to reductions in neonatal morbidity and mortality [Ballard,
2000; Thorp et al., 2002]. High frequency ventilation, surfactant and postnatal steroid use have increased neonatal
survival [Avery et al., 1987; Copper et
216

al., 1993; Howell and Vert, 1993;

Schwartz et al., 1994; Horbar and Lucey,
1995; Reger et al., 1995; Eichenwald and
Stark, 1999; Curley and Halliday, 2001].
Regionalization of perinatal services by
level of care has been undertaken in parts
of the country to achieve greater access
to, and efficiencies in the use of, these
services by high-risk patients, thereby increasing their efficacy [Hulsey et al.,
1989]. Improvements in the early initiation and adequate use of prenatal care
over the same period in the U.S. may
have also facilitated the appropriate use
and access to these high-risk perinatal
services [Kogan et al., 1998; Alexander et
al., 2002]. In all, there is ample evidence
to support the contention that the decline in U.S. infant mortality rates is
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largely due to advancements in medical

service technology and practice and is
probably unrelated, or at best only marginally related, to efforts directed at the
prevention of preterm and low birth
weight infants.
While the decline in overall infant
mortality rates is positive news, the simultaneous increase in low birth weight
and preterm deliveries is troubling. A
number of possible explanations have
been suggested for the current trend in
rising prematurity rates [Kramer, 1998].
Changing maternal demographic characteristics (e.g., increasing proportions of
older and unmarried mothers), socioeconomic conditions, and behavioral risk
factors (e.g., smoking and drug use) may
have influenced trends in U.S. preterm
birth rates, although it should be noted
that cigarette smoking rates declined during the 1990s [Sepkowitz, 1994; Peacock
et al., 1995; Nordentoft et al., 1996;
Kogan and Alexander, 1998; Matthews,
2001; Mattison et al., 2001]. Changes in
vital record reporting practices could explain a portion of the increase in both
preterm and low birth weight percentages in so far as very small deliveries, once
reported as fetal deaths, are increasingly
being reported as live births [Kramer,
1998; Phelan et al., 1998; Allen et al.,
2000]. Although not related to increases
in low birth weight, growing use of ultrasound to establish gestational age,
noted for under-estimating the results of
other methods of measuring gestational
age, may have lead to an increase in the
proportion of births classified as preterm
[Kramer, 1998; Kramer et al., 1998;
Allen et al., 2000].
Increasing rates of multiple births,
which are more likely to be delivered
preterm and low birth weight, have also
been credited for part of the increase in
preterm birth rates [Kramer, 1998; Joseph et al., 1998; Cohen et al., 1999;
Anonymous, 2000; Kogan et al., 2000;
2002]. The increase in multiple births has
been attributed to both the growing use
of assisted reproductive technologies and
changing
maternal
demographics
[Kramer, 1998; Joseph et al., 1998; Cohen et al., 1999; Anonymous, 2000].
Moreover, an increase in preterm delivery among twin births has also been
noted and credited to changes in medical
practice [Kogan et al., 2000]. While the
soaring rates of multiple births in the
U.S. and other countries have attracted
considerable public and policy attention,
only a minor proportion of the recent
rise in rates of preterm and low birth
weight percentages can be attributed to
the increasing number of multiple deliv-

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eries [Blondel et al., 2002]. The underlying determinants for the majority of the
increase in prematurity rates appear to lie
elsewhere.
Other recent speculations about
the contributors to the increase in preterm and low birth weight rates have
pointed to the role of earlier therapeutic
deliveries [Kramer, 1998; Joseph et al.,
1998; Alexander et al., 1999; Allen et al.,
2000; Kogan et al., 2000; 2002, Blondel
et al., 2002]. This theory suggests that the
growing availability and use of ultrasound and other medical technologies,
used to screen for high-risk medical conditions, have allowed for the earlier detection of pregnancy complications. The
earlier detection of a fetus in crisis, coupled with the availability of effective
neonatal intensive care medical therapies
(i.e., steroids and surfactant) may lead to
an earlier therapeutic delivery for women
with acute high-risk pregnancy conditions. Earlier entry and more adequate
use of prenatal care may contribute to
this process, not only by high-risk
screening for and earlier detection of
medical problems, but by facilitating access to risk-appropriate perinatal care and
delivery services. In essence, technological advances in medical practice may be
linked to the increasing rates of preterm
births, while concurrently playing an important role in reducing infant and fetal
mortality rates.
The medical technology theory for
explaining the discordant trends in the
rates of infant mortality and prematurity
may have additional applications in furthering our understanding of the impact
of these pregnancy outcomes on efforts
to increase early access, availability, and
regular use of prenatal care, e.g., the expansion of Medicaid eligibility [Alexander and Howell, 1997]. During the last
20 years in the U.S., numerous program
and policy initiatives have been undertaken to remove financial barriers to the
receipt of prenatal care for the expressed
purpose of reducing the proportion of
high-risk low birth weight infants in the
hopes of lowering infant mortality rates.
Evaluations of these prenatal care initiatives have revealed that while eligibility
and enrollment in Medicaid increased,
along with more early and adequate use
of care, there was no decline in preterm
and very low birth weight rates [Alexander and Howell, 1997]. Any role prenatal care played in preventing some low
birth weight deliveries (e.g., reducing the
proportion of small-for-gestational age
term births through smoking or nutrition-related interventions) could well be
overshadowed by the theorized increase
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PREMATURITY

Fig. 3. 1980 2000 racial disparities in infant mortality, low birth weight, and very low birth
weight.

in prematurity rates stemming from advances in medical technology. As early

and appropriate access to high-risk medical care may have been facilitated by
prenatal care use, efforts to improve prenatal care utilization would share credit
for the enhancements in infant survival.
It remains unclear what proportion
of the increase in prematurity rates can be
attributed to medical technology developments. It has been suggested that the
role of other mechanisms, as well as any
beneficial impact of preterm prevention
efforts, may be obscured by the more
direct influence of medical care [Kramer
et al., 2001]. Nevertheless, it is most
likely that a substantial proportion of the
rise in low birth weight and preterm rates
in the U.S. stems from separate attempts
to improve reporting, improve fertility,
and improve survival and may not appreciably reflect an increase in higher risk
conditions surrounding pregnancy.
RACIAL DISPARITIES
Racial disparities in rates of infant
mortality, low birth weight, and preterm
delivery have been a persistent feature of
U.S. pregnancy statistics. While the last
20 years have witnessed a steady decline
in infant mortality rates for both Whites
and African-Americans, the risk of an
infant death for African-Americans,
compared to Whites, rose from 2.04 in
1980 to 2.46 in 2000 (Fig. 3) [CDCP,
2002]. However, similar racial disparity
trends were not apparent for low birth
weight. Although racial disparities in low
and very low birth weight increased during the late 1980s in the U.S., they unAT

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derwent a decline in the 1990s. Nevertheless, African-Americans continue to

have twice the risk of having a low birth
weight infant and over 2.5 times the risk
of a very low birth weight delivery, compared to Whites.
The recent decline in racial disparities in low birth weight percentages reflects a disproportionate increase in low
birth weight deliveries among White infants [Alexander et al., 1999; CDCP,
2002]. In essence, the White low birth
weight rate is rising, while there has been
little change in the rate for AfricanAmericans [CDCP, 2002]. A similar decrease in the racial disparity for preterm
births has also been reported [Allen et al.,
2000]. Differential changes in the proportion of White multiple births and
older and unmarried mothers are potential contributors to these decreasing racial
disparities in prematurity, as are changes
in vital record reporting practices and
access to medical care.
Given the growing gap in overall
infant mortality rates between these two
race groups, the trend toward narrowing
differences in the proportion of high-risk
premature births indicates that the rising
racial disparity in infant mortality rates is
being largely driven by differential improvements in birth weight and gestational age specific survival [Alexander et
al., 1999; Allen et al., 2000]. While racial
differences in very low birth weight and
preterm deliveries continue to play a major role in the overall racial disparity in
infant mortality, the ongoing increase in
the mortality disparity appears to be fueled by better improvements in the sur217

Table 1. Immutable
Medical Risk Factors
Associated With
Preterm Birth
Previous low birth weight or preterm
delivery
Multiple 2nd trimester spontaneous abortion
Prior first trimester induced abortion
Familial and intergenerational factors
History of infertility
Nulliparity
Placental abnormalities
Cervical and uterine anomalies
Gestational bleeding
Intrauterine growth restriction
In utero diethylstilbestrol exposure
Multiple gestations
Infant sex
Short stature
Low prepregnancy weight/low body
mass index
Urogenital infections
Pre-eclampsia

Table 2. Demographic Risk

Factors Associated With
Preterm Birth
Race/ethnicity
Single Marital Status
Low Socioeconomic status
Seasonality of pregnancy and birth
Maternal Age
Employment-related physical activity
Occupational exposures
Environment exposures

Table 3. Possibly Mutable

Risk Factors Associated With
Preterm Birth
No or inadequate prenatal care usage
Cigarette smoking
Use of marijuana and other illicit drugs
Cocaine use
Alcohol consumption
Caffeine intake
Maternal weight gain
Dietary intake
Sexual activity during late pregnancy
Leisure-time physical activities

vival of White high-risk infants [Alexander et al., 1999; Allen et al., 2000].
The factors that underlie the growing racial disparities in improving survival
for low birth weight and preterm infants
remain open to speculation. Some researchers have suggested that certain therapies, e.g., surfactant, have differentially
benefited low birth weight White infants,
who may be relatively more immature and
218

are known to be at greater risk of mortality

[Hamvas et al., 1996; Papiernik and Alexander, 1999; Allen et al., 2000]. At the
same time, racial variations in access to tertiary perinatal hospital care may be involved, although clear evidence has not
emerged from investigations of this proposal [Langkamp et al., 1990]. In some
parts of the country, African-Americans
may be more likely to deliver in a tertiary
care center than Whites [RNDMU, 2000]
but further investigation will be needed to
establish the extent to which racial variations in access to high-risk obstetric and
neonatal care exists, has changed over time,
and has influenced trends in infant mortality. Recent investigation of prenatal care
use by race groups in the U.S. has revealed
that racial disparities in early, adequate, and
intensive use of prenatal care were reduced
during the 1990s [Alexander et al., 2002].
RISK FACTORS AND
ETIOLOGIES
Little success has been achieved by
our numerous efforts to prevent preterm
birth [Alexander et al., 1991; Goldenberg,
1994; Alexander and Korenbrot, 1995; Alexander, 1998; Goldenberg and Rouse,
1998]. Moreover, we have had only modest success in accurately identifying women
at risk for preterm birth, although quite a
number of risk factors have been identified
[IOM, 1985; Berkowitz and Papiernik,
1993]. Unfortunately, many of the better
established and more predictive risk factors
are either essentially immutable in the current pregnancy or due to our present state
of knowledge pose significant challenges
for either prevention or effective intervention [Berkowitz and Papiernik, 1993].
These risk factors are detailed in Table 1
and include those that pre-date the pregnancy, e.g., previous low birth weight or
preterm delivery, multiple 2nd trimester
abortions, maternal stature and body mass,
and history of infertility. Multiple gestation,
placental abnormalities, cervical/uterine
anomalies and pre-eclampsia are additional
medical risk factors for prematurity that
cannot be readily prevented. Finally, intrauterine infection remains in this category of
risk factors as the efficacy of antibiotic therapy for prevention of preterm delivery
from these infections continues to be unclear [Thorp et al., 2002]. However, research into this area is ongoing and this is
one of the more promising areas for advancing our capacity to prevent preterm
births [Alexander, 1998].
Demographic risks associated with
preterm delivery include black race, single marital status, low socioeconomic status, maternal age, and others (Table 2)
[Berkowitz and Papiernik, 1993]. While
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demographic factors cannot cause the

premature expulsion of a fetus, these factors may antagonize some other deleterious factor [Kogan and Alexander, 1998].
A meta-analysis of factors associated with
preterm birth revealed that low socioeconomic status might correlate to other nutritional, toxic, anthropometric, or infectious factors that may themselves be
causal [Kramer, 1987].
Stress and maternal psychological
factors have frequently been linked to
pregnancy outcomes and chronic stress
has been related to low socioeconomic
status [Copper et al., 1996]. There have
been difficulties in measuring stress of life
events, but consistent associations have
been reported between perceived stress
and preterm birth [McCauley et al.,
1995; Nordentoft et al., 1996; Kramer et
al., 2001]. Chronic stressors may include
financial insecurities, poor and crowded
living conditions, unemployment, stressful working conditions, domestic violence, and unsatisfying marital relationships [Peacock et al., 1995; McCauley et
al., 1995; Muhajarine and DArcy, 1999;
Kramer et al., 2001]. Many of these risk
factors are multi-factorial and are deeply
intertwined with social class, culture, race
and ethnicity. Continued research is
needed in the area of stress and preterm
birth to determine the capacity for prevention. Essential to the development of
successful interventions in this area is the
elucidation of biological pathways by
which stressors influence preterm labor
and the identification of biologic markers
that are more specific indicators of risk
than current measures of demographics
and socioeconomic status.
While often difficult to modify, a
number of maternal behavioral risk factors for preterm delivery have been identified (Table 3) and are potentially mutable [Berkowitz and Papiernik, 1993;
Berkowitz and Lapinski, 1998]. Among
those that can be targeted for prevention
include cigarette smoking, prenatal care
utilization, and illicit drug use [Berkowitz and Papiernik, 1993; Alexander and
Korenbrot, 1995]. Illicit drug use during
pregnancy has been associated with a
more than two-fold increased risk of preterm premature rupture of membrane
[Berkowitz and Lapinski, 1998]. However, the proportion of the pregnant
population engaged in illicit drug use
may be small and, to the extent that
intervention efforts are effective in preventing drug use during pregnancy, the
potentially attainable decrease in overall
preterm birth rates from such intervention may be quite modest [Berkowitz and
Lapinski, 1998].

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The link between smoking and prematurity, including preterm delivery, low
birth weight and intrauterine growth, has
been well established [Longo, 1977;
Woods et al., 1987; Berkowitz and Lapinski, 1998]. According to the National Center for Health Statistics, rates of smoking
among pregnant women in the U.S. decreased in the 1990s [Matthews, 2001].
Among all racial/ethnic groups, the rates
decreased from 18.4% in 1990 to 12.3% in
1999, a 33% reduction. For Non-Hispanic
African-Americans, rates fell from 15.9% in
1990 to 9.1% in 1999, a 43% decrease
[Matthews, 2001]. Among Non-Hispanic
Whites, the rates dropped from 21.0% in
1990 to 15.7% in 1999 for a 25% decrease.
Despite their lower low birth weight rates,
White mothers continue to have higher
smoking rates than African-Americans.
More notable, given the association of tobacco use with prematurity, the rates of
preterm birth and low birth weight increased as smoking rates declined among all
racial/ethnic groups. Efforts to reduce tobacco use during pregnancy should certainly continue. But, given the progress
already made in this area, the potential for
future gains from smoking prevention efforts on prematurity rates has lessened along
with population attributed risk of smoking
for preterm birth.
Preterm birth is typically defined as
birth prior to 37 weeks of gestation. It is
an outcome defined by a single endpoint,
i.e., being born too soon, and often results in a low birth weight infant. In
addition to resulting from early delivery,
low birth weight also stems from being
born too small at term, i.e., being smallfor gestational age [Kramer, 1987]. Importantly, these distinct outcomes, being
born too early, or on time but too small,
result from a variety of unique causes.
Moreover, although preterm births may
be grouped together as a single adverse
birth outcome, there are several distinct
pathways or etiologies that can result in
early delivery. Accordingly, a single cure
for the multiple causes and types of prematurity is not only unlikely; it is probably unrealistic [Alexander, 1998].
Preterm births have been classified
into three separate categories according
to clinical presentation:

Births occurring after spontaneous

premature labor, related to premature contractions (50% of cases)
Spontaneous rupture of the membranes (roughly 30% of cases); and,
Indicated delivery of a premature
infant for the benefit of either
infant or mother (about 20% of

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cases) [Tucker et al., 1991;

Goldenberg and Rouse, 1998].
Not only is the classification of the risk
factors critical for targeting preterm birth
prevention efforts, but also classification
of the outcome itself is important to assure that interventions are targeted at
those who are truly at risk. To the extent
that interventions are focused on a specific etiological pathway but targeted
broadly to individuals at risk for preterm
birth in general, the intervention may
well appear to lack efficacy. While the
3-type classification of preterm birth is
recognized and used for study on the
prevention of preterm birth, some researchers combine spontaneous premature labor (contractions) and spontaneous
rupture of the membranes [Tucker et al.,
1991; Guinn et al., 1995; Klebanoff and
Shiono, 1995; Klebanoff, 1998]. Studies
have shown women with halted premature labor have higher rates of spontaneous rupture of membranes compared to
the expected rate [Tucker et al., 1991;
Guinn et al., 1995; Klebanoff and
Shiono, 1995; Klebanoff, 1998]. Also,
epidemiological studies indicate that risk
factors for spontaneous labor and rupture
of membranes are similar [Tucker et al.,
1991; Guinn et al., 1995; Klebanoff and
Shiono, 1995; Klebanoff, 1998]. Because
of the evidence that both spontaneous
rupture of membranes and spontaneous
labor are the result of similar processes,
many may categorize these into one
group. This distinguishes only a difference between indicated and spontaneous
delivery. Yet here again, some researchers suggest there is more etiological overlap between spontaneous and indicated
preterm birth than first suspected [Klebanoff, 1998]. As maternal hypertension
and intrauterine growth restriction are
indications for preterm delivery, there is
suspicion that these indications are risk
factors for spontaneous preterm birth.
One study noted that pre-pregnancy hypertension was associated with a 36% increase in the risk of spontaneous preterm
birth and that severe pregnancy-related
hypertension was associated with a three
to four-fold increased risk of spontaneous
preterm birth [Kramer et al., 1992]. Increasingly, attempts are being made to
identify and focus research efforts on distinct etiological pathways that lead to
preterm birth [Alexander, 1998].
CONCLUSIONS
While policy-makers may find
comfort in the steadily diminishing infant
mortality rates, there are reasons for concern about the manner in which this
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decline has been achieved. The medical

care advancements that have fueled these
declines in the last half century are costly
interventions, particularly when compared to the potential cost of an effective
prevention approach [Rogowski 1998;
Mattison et al., 2001; Johnston et al.,
2001]. Furthermore, the improvement in
infant survival that coincided with the
rise in premature births has increased the
actual number of high-risk preterm survivors. While the rate of disabilities and
morbidity may not have increased for
these survivors, the actual number of infants that face long-term developmental
problems has [Hack et al., 1994; Saigal et
al., 2000]. Allowing for greater infant
survival therefore has consequences for
long-term outcomes of not only the
child, but his or her entire family [Hack
et al., 1994; Allen et al., 2000; Saigal et
al., 2000]. Despite improvements in
many public health indicators and increased understanding of human biology
at the cellular and genetic level, preterm
delivery and low birth weight births continue to be leading public health and
health care concerns with major economic implications [Mattison et al.,
2001]. There is little reason at this time to
believe that prematurity rates will decline
in the near future. Moreover, the medical
advancements that may be contributing
to the current increase, while improving
fertility and infant survival, will undoubtedly continue. As such, due attention will
be needed to increase our early detection
and treatment of the developmental
problems facing these infants as they
grow older. Further, we will need to give
equal attention to the needs of their families. That will require the involvement
of policy-makers and, most certainly, will
require economic commitments to assure
the availability of needed services [Alexander et al., 2000]. f
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