5 Years of Progress on the Prenatal-to-3 State Policy Roadmap

In September 2020, the Prenatal-to-3 Policy Impact Center launched our first annual State Policy Roadmap. The Roadmap was the first of its kind to provide state policy leaders with clear guidance on 11 policies and strategies that have a strong evidence base of positively impacting the lives of infants and toddlers and their parents. It also provided a baseline account of state level investments in the 11 effective solutions, which include a combination of broad-based economic and family supports as well as targeted interventions to support families’ health, economic security, and early development. The findings illustrated how state policy choices vary considerably, which leads to a patchwork of benefits and resources for families across the country.

In October 2024, the Policy Impact Center released our fifth annual State Policy Roadmap. Since the release of the first Roadmap, we added an additional effective strategy to the Roadmap for states to consider (community-based doulas) and tracked even more state policy levers to monitor state investments in children and families in the earliest years. Additionally, we created a tool (the Policy Impact Calculator) for states to illustrate how their policy choices interact to create a system of support for families.

This report, 5 Years of Progress on the Prenatal-to-3 State Policy Roadmap, provides a summary of the substantial investments that many states have made since 2020, and the impact of these investments on family resources. A detailed profile of the progress states have made on each effective Roadmap policy and strategy is also available, in addition to a summary of each state’s specific progress.

The Importance of Investment in Early Childhood

The newborns we highlighted in our first State Policy Roadmap are now in kindergarten. These little ones experienced the most sensitive and rapid period of development for their brain and body. The children who spent their earliest years in safe, stable, nurturing environments, with limited exposure to adversity, are set on a trajectory for life-long health and wellbeing. Unfortunately, not all of the children spent their earliest years in environments that promoted optimal development, and these children will need intensive supports to help them reach their full potential.

Approximately 3.7 million children are born each year, and currently there are approximately 11 million children under the age of 3. Among these children under age 3:

• Over 1.1 million in total were born preterm (before the 37^th week of pregnancy), which increases the likelihood of low birthweight, respiratory and feeding difficulties, vision and hearing problems, developmental delays, and learning disabilities, among other short- and long-term complications.
• Nearly 152,000 of children under 3 were maltreated each year, which increases the likelihood of short-term cognitive, emotional, and behavioral challenges, as well as physical and mental health difficulties in adulthood.
• Approximately 1.8 million children under 3 live in poverty each year, which means their families face difficulties meeting basic needs, including adequate shelter, nutrition, and medical care, and their families may be under significant stress, compromising parents’ ability to engage in the warm, responsive interactions that are critical to infants’ and toddlers’ healthy development.

The likelihood of poorer outcomes is disproportionately higher for children of color. Long-standing patterns of racism, reinforced through state policy choices, have continuously resulted in racial and ethnic disparities in access and outcomes. For example:

• Black children are over 3 times as likely as White children to live in poverty, and Hispanic children have rates of child poverty that are more than twice the rate of White children.
• The number of Black infants who die in the first year of life was more than double the number of White or Hispanic infants.

The same is often true of outcomes for parents. For example:

• Hispanic women with low incomes lack health insurance at twice the rate of all other women.
• The rate of inadequate prenatal care among births to Black women is nearly twice as high as those to White women.

State Investments in Effective Policies Translate to Better Child and Family Wellbeing

These outcomes matter a lot – to our children, their families and communities, and the overall wellbeing of our states. These outcomes are the consequence of state policy choices and larger investments in effective solutions can lead to better outcomes for our children and their parents. For example:

• Access to paid family and medical leave for parents with a new child leads to beneficial impacts on maternal labor force attachment, postneonatal infant mortality, parent and child health, and nurturing and responsive parenting.
• Higher state minimum wages increase parents’ earnings and family incomes with minimal or no adverse effects on employment and promote greater economic security for families with young children, contribute to healthier birth outcomes, and can reduce racial disparities in poverty.
• Community-based doulas are an effective strategy to increase attendance of health appointments; improve healthy birth outcomes such as preterm birth rate, low birthweight, and NICU admissions; foster nurturing and responsive parenting behaviors; and increase breastfeeding initiation.

The Prenatal-to-3 State Policy Roadmap Is a Guide for Evidence-Based State Policymaking

Comprehensive reviews of the most rigorous evidence available identified four state-level policies and eight strategies that positively impact at least one of the eight PN-3 policy goals. The 12 effective solutions are profiled throughout this and prior Prenatal-to-3 State Policy Roadmaps. When combined, the policies and strategies create a system of care that provides broad-based economic and family supports, as well as targeted interventions to address identified needs.

Each of the 12 effective solutions in the Roadmap are proven to impact at least one of the eight PN-3 policy goals. The framework below illustrates the alignment between goals and the evidence-based policies and strategies that impact each goal, as well as selected outcomes that illustrate the wellbeing of children and families. To improve outcomes within a policy goal area, state leaders can prioritize the effective solutions aligned with the goal that demonstrate beneficial impacts.