Over the past 30 years, the United States has experienced a major decrease in infant mortality, especially mortality in the neonatal period. Despite this dramatic change, the United States remains at a very disadvantaged position among industrialized countries when they are ranked by infant mortality rate. This situation reflects the conjunction of two trends. The first is the increasing technological sophistication and success of perinatal services in sustaining the survival of ever tinier infants (Richardson et al., 1998). The second trend, which offsets the first, is the persistence of high rates of low birth weight and prematurity, and even increases in rates of such births among African Americans. Another contributing factor is the persistence of a steady rate of major congenital malformations. Despite the fact that most industrialized countries experience similar malformation rates, they have been able to reduce the percentage of preterm deliveries while also incorporating technological interventions into the care of those who are born prematurely (Guyer et al., 1996).

The strategy that has been advocated to reduce the rate of preterm and low birth weight births in the U.S. reflects a short-term, clinical approach that consists of increasing access to early and regular prenatal care (IOM, 1985, 1988). Advocates for changing financial and other barriers to prenatal care base their arguments on conclusions of cost-effectiveness of prenatal care in changing birth weight or duration of gestation (Gorsky and Colby, 1989; IOM, 1985; Korenbrot, 1984).