Advances in Maternal and Child Health

1. Milestones in Public Health: Chapter 8 Advances in Maternal and Child Health Lectures for Undergraduate Education January 2011

2. Learning Objectives Describe the “continuum of care” concerns, linking maternal, newborn, and child health List interventions delivered at specific timeframes which result in multiple benefits Describe the significant disparities by race and ethnicity that persist today Discuss the association among family, poverty and children’s health Assess achievement of benchmark objectives for MCH in Healthy People 2010 thus far

3. Learning Objectives (Cont.) Analyze the Annual Survey of Vital Statistics for Children (2006) Discuss the historical foundations of maternal and child health Describe how federal, state, local health and educational agencies, legal entities and universities and community-based organizations can work together to improve health outcomes and leverage resources to implement successful and preventive interventions

4. Learning Objectives (Cont.) Describe the physiology of breast feeding Discuss the links among breast feeding, the immune response and the long-term health of children Describe the long-term benefits of breast feeding for the infant and the mother Discuss the implications of biology upon policy

5. Lecture Outline Historical Perspective The Milestone & its Impact on Public Health Biology, Behavior and Science Systems, Policies & Programs Looking Ahead Conclusion References and Resources

6. Advances in Maternal and Child Health Historical Perspective

7. Historical Perspective Arias et. al. (2010) Remarkable advances in women’s health throughout the 20th century: • Average life-span increased by more than 30 years

8. Historical Perspective (Cont.) Century of Women’s Health (2002) • Significant reduction in death, disease and disability due to: • Improvements in sanitation practices • Health care training • Public health information • Preventive health practices • Medical treatments • Implementation of nation public health practices

9. Historical Perspective (Cont.) Century of Women’s Health (2002) • Significant reduction in death, disease and disability due to: • Expanded access to health care services through both development of public health care infrastructure and increased access to private, employer-based health insurance • Education and entry into male-dominated medical professions • Formalization of female dominated health professions such as nursing and midwifery

10. HRSA-MCH Timeline, 2010 1800 1840 1860 1880 1900 1800: Smallpox vaccination begins in the U.S. 1840s: Public school movement 1850: First children’s hospital 1860: First children’s clinic 1874: Society for the prevention of cruelty to children established 1881: Abolition of child labor becomes top priority for AFL 1893: First milk stations 1907: First Bureau of Child Hygiene

11. HRSA-MCH Timeline, 2010 (Cont.) 1910 1920 1930 1940 1950 1960 1909: Prevention of infant mortality and prenatal care organized 1912: Children’s Bureau established 1914: Pamphlet on infant care published 1930: Prevention of rickets through milk fortification 1938: March of Dimes 1939: Food stamp program 1946: Hill-Burton Act, UNICEF and CDC established 1949: Apgar score developed 1954: Polio vaccine developed 1962: Child abuse formally recognized in the U.S.

12. HRSA-MCH Timeline, 2010 (Cont.) 1970 1980 1990 1970: Developmental Disabilities Service Act Passed 1972: Special Supplemental Food Program for WIC Created 1975: Education for All Handicapped Children Act Passed 1978: Smallpox Eradicated 1981: AIDS 1981: Title V of the Social Security Act Amended 1984: Child Safety Seats 1985: Preventing Low Birth Weight IOM Report Published 1990: NIH Office of Research on Women's Health Established 1994: Violence Against Women Act 1997: State Children's Health Insurance Program (SCHIP) Title XXI was added to Social Security Act

13. HRSA-MCH Timeline, 2010 (Cont.) 2000 2000: Oral Health in America: A Report of the Surgeon General Released 2000: New Regulations Added to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 2002: Childhood Obesity Tripled since 1980 2002: No Child Left Behind Act Signed into Law 2006: Increase in Autism Awareness and Funding 2007: WIC Food Package Revised 2009: Children's Health Insurance Program Reauthorization Act 2009: American Recovery and Reinvestment Act Passed

14. Advances in Maternal and Child Health The Milestone & Its Impact on Public Health

15. “The Challenge” CDC (1999) • What is the greatest public health achievement in the 20th century? • Sanitation? • Vaccinations? • Maternal and child health? • What do you think?

16. Then and Now • 1900 • for every 1,000 live births: • 6-9 women died of pregnancy-related complications • 100 infants died before age 1 year At the beginning of the 20th century in the U.S., maternal and infant mortality were fearsome. . . 2000 for every 1,000 live births: • 0.1 maternal deaths • 7.2 infants died before age 1 year

17. What Were the Main Reasons for This Amazing Achievement? • Improvements in medical care and public health interventions both played important roles: • Environmental interventions • Nutrition improvements • Advances in clinical medicine • Improvements in access to health care • Improvements in surveillance and monitoring of disease • Higher education levels • However, significant health disparities still exist

18. Milestone Overview: Five Snapshots March of Dimes (2008) On an average day in the U.S. Quick stats for the U.S. Maternal mortality Infant mortality Healthy People 2010

19. March of Dimes (2008)

20. March of Dimes (2008)

21. March of Dimes (2008)

22. Maternal Mortality March of Dimes (2008) A maternal death is defined as one that occurs during pregnancy or within 42 days of the end of a pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by a woman’s pregnancy or its management, but not from accidental or incidental causes

23. March of Dimes (2008)

24. Infant Mortality March of Dimes (2008) Infant mortality refers to deaths under age one The infant mortality rate is the number of infant deaths per 1,000 live births

25. March of Dimes (2008)

26. March of Dimes (2008)

27. Healthy People 2010 www.healthypeople.gov A series of national health objectives, released by the U.S. Department of Health and Human Services, in January 2000 These objectives are being used as a benchmark for measuring progress in health promotion and disease prevention Broad goals of this initiative are to increase the quality and years of healthy life and eliminate racial and ethnic disparities in health status

28. www.healthypeople.gov

29. Advances in Maternal and Child Health Biology, Behavior and Science

30. Breastfeeding Physiology of breastfeeding Links among breastfeeding, immune system and long-term health of a child Benefits to infant, benefits to mother From biology to policy

31. Physiology of Breastfeeding Chiras (2005) Breast milk is better… multiple studies have demonstrated the benefits of breast milk: • In general, breastfed babies are healthier and have fewer infections, gastroenteritis, otitis and URIs • In general, breastfed babies have fewer cancers in childhood than infants fed formula for at least 6 months – particularly incidence of lymphoma in childhood • Breast milk proteins may stimulate development of immune system • Breast milk is more digestible and more easily absorbed

32. Physiology of Breast Milk Chiras (2005) • Composition of Breast Milk • Immunoglobulins present • Secretory IgA – high quantities in colostrum which coat lining of intestines – protective in preventing bacteria from adhering to epithelium • Lysozyme – enzyme which breaks down cell walls of bacteria

33. Benefits of Breastfeeding Kotch (2005) Increasing evidence for benefits of breastfeeding for any length of time Prevalence in the U.S. inadequate Practice has declined in the U.S.

34. At Birth Chiras (2005) At birth, newborns have poorly developed immune systems however, they are protected by their passive immunity (antibodies passed directly to them in the mother’s blood or in breast milk)

35. Benefits to Infant Chiras (2005) There are numerous immunological and nutritional benefits of breast milk for the infant •  incidence of infection • Fewer hospitalizations • Breast milk adjusts to the baby’s appetite within each feeding which maximizes contentment and helps to prevent obesity

36. Benefits to Mother Chiras (2005) • Immediate benefits: causes release of oxytocin during milk let-down • increased uterine contractions • aids in uterine involution • decreased maternal blood loss • Later benefits: • rest • weight loss •  menstruation and PMS • risk of breast cancer (premenopausal) • mobility • saves time, trouble, expense(?)

37. Barriers to Breastfeeding Kotch (2005) • Not encouraged by health care provider or her partner • Inconsistent information • Hospital policies and protocols: • Separation of mother and child • Regular feeding intervals • Routine sporadic supplementation with artificial feeds, satisfying hunger and causing nipple confusion • Exclusion of lay support staff • Free formula gifts on discharge • Societal and political influences

38. From Biology to Policy Kotch (2005) U.S. value placed on breastfeeding reflected in workplace policies and state legislation

39. From Biology to Policy (Cont.) Kotch (2005) • Women in the workplace: • Since 1960 ,more women with children in workforce • For married women with children under age 1, this rate increased from 32% in 1977 to 52% in 1989 and 59% in 1998 • Black women more likely to work than white or Hispanic women with children – over half of all black families with children are maintained by the mother only (compared with 18% of white families with children) • Studies show some work interferes more than others…professional women breast feed longer than women in sales or technical jobs • Lack of refrigerators, on-site health care professionals, electric breast pumps, day care, breast stations at work place discourage breast feeding

40. Thus, in the U.S. there is… Kotch (2005) • Not generalized support for breastfeeding • Nor is there a national parental leave policy for this purpose • In fact, there is no standard procedure for maternity leave • More research is needed to measure the effectiveness of breastfeeding programs

41. The Law National Conference of State Legislatures (2010) • 44 states have laws that allow women to breastfeed in public or private locations • 28 states exempt breastfeeding from public indecency laws • 24 states have laws related to breastfeeding in the workplace • The federal government provides free infant formula to needy mothers

42. Contraindications to Breastfeeding Kotch (2005) Mother addicted to drugs Mother drinks more than minimum Mother receiving certain therapeutic or diagnostic agents Mother infected with HIV

43. Birth Defects Monitoring Programs CDC (2007b) CDC is working with the National Birth Defects Prevention Network to compile state data where they have developed national estimates for 21 birth defects CDC funds 8 Centers for Birth Defects Research and Prevention to collaborate on the largest multi-state study of birth defects Researchers at these centers have a unique opportunity to look at the effects of genetics and the environment on birth defects

44. Advances in Maternal and Child Health Systems, Policies and Programs

45. Hutchins (2001) How the Federal Maternal and Child Health Program Advanced the Field of Maternal and Child Health

46. Act of 1912 (P.L. 62-116) Hutchins (2001) Congress established The Children’s Bureau to help states and local groups take appropriate action to improve the care of pregnant women and children • Defined responsibility to cover all the nation’s children • Investigated and reported on the status of children regarding common as well as special needs • Established evidence for the purpose of stimulating actions in support of children

47. Maternal and Child Health Bureau (MCHB) Hutchins (2001) The mission of the Maternal and Child Health Bureau (MCHB) is to provide national leadership, in partnership with key stakeholders, to improve the physical and mental health, safety and well-being of the maternal and child health (MCH) population which includes all of the nation’s women, infants, children, adolescents, and their families, including fathers and children with special health care needs

48. Maternal and Child Health Bureau Goals (2007) Hutchins (2001) Goal 1:  Provide National Leadership for Maternal and Child Health Goal 2:  Promote an Environment that Supports Maternal and Child Health Goal 3:  Eliminate Health Barriers and Disparities Goal 4:  Improve the Health Infrastructure and Systems of Care Goal 5:  Assure Quality of Care

49. MCH Program Leadership Hutchins (2001) Investigate and report Advocate Research and train Allocate funds Direct and redirect funds Assist as time and circumstance require

50. Health Insurance Topics Hutchins (2001) Access to care Coverage for women of childbearing age Coverage for children Medicaid’s role in maternal and child health State Children’s Health Insurance Program (S-CHIP) Medicaid and S-CHIP: Eligibility and enrollment