Nutrition 526 - 9/29/2006 A Public Health Approach to Maternal and Infant Health

1. Nutrition 526 - 9/29/2006A Public Health Approach to Maternal and Infant Health

2. Topics • Who is having babies in the US? How many babies? What are the outcomes? • Why is nutrition important for pregnant women and babies? • What population based approaches to improve nutrition might improve outcomes?

3. Topic 1 • How many babies? • Who is having babies in the US? • Race/ethnicity • Age • Marital status • What are the nutrition-related outcomes we are concerned about for population health?

4. Health, United States, 2005: www.cdc.gov/nchs/hus.htm

14. Percentage of Parents Who Were Married or Cohabiting at Birth of First Child, by Race/Ethnicity and Sex MMWR; September 15, 2006 / 55(36);998

15. Infant Mortality • Infant mortality rate – Deaths of infants aged under 1 year per 1,000 or 100,000 live births. The infant mortality rate is the sum of the neonatal and postneonatal mortality rates. • Neonatal mortality rate – Deaths of infants aged 0-27 days per 1,000 live births. The neonatal mortality rate is the sum of the early neonatal and late neonatal mortality rates • Postneonatal mortality rate – Deaths to infants aged 28 days-1 year per 1,000 live births.

16. http://www.chipublib.org/004chicago/disasters/infant_mortality.htmlhttp://www.chipublib.org/004chicago/disasters/infant_mortality.html

17. Infant Deaths Per Thousand Live Births, by Race and Hispanic Origin 1960-1995  National Center for Health Statistics. Health, United States, 1995

18. Racial/Ethnic Disparities in Infant Mortality --- United States, 1995--2002 MMWR; June 10, 2005 / 54(22);553-556

19. MMWR, April 19, 2002 / 51(15);329-332, 343

20. Figure 2.  Rates of infant mortality, low birthweight, and preterm birth, 1990-2002 Supplemental Analyses of Recent Trends in Infant Mortality, CDC February 11, 2004

21. Health Affairs, Vol 23, Issue 5, 2004

22. Causes of Infant Death

24. Health Affairs, Vol 23, Issue 5, 2004

25. NGA Center for Best Practices, June 2004

26. Reported Stressful Life Events During Year Before DeliveryKing County, 1999-2001Pregnancy Risk Assessment Monitoring System (PRAMS)

27. * stat. sig compared to whites

28. Maternal Mortality

29. African American and White Women Who Died of Pregnancy Complications,* United States * Annual number of deaths during pregnancy or within 42 days after delivery, per 100,000 live births. † The apparent increase in the number of maternal deaths between 1998 and 1999 is the result of changes in how maternal deaths are classified and coded. Source: CDC, National Center for Health Statistics.

30. Risk of Maternal Death • Race/ethnicity • The risk of death for African American women is almost four times that for white women. • The risk of death for Asian and Pacific Islander women who immigrated to the United States is two times that for Asian and Pacific Islander women born in the United States. • Age • The risk of death is nearly three times greater for women 35–39 years old than for women 20–24 years old. • The risk is five times greater for women over 40.

31. The most common serious pregnancy complications • Ectopic pregnancy • Depression • High blood pressure • Infection • Complicated delivery • Diabetes • Premature labor • Hemorrhage

32. Topic 2 • Why is nutrition important for pregnant women and babies?

33. Poor Pregnancy Outcomes are Costly • Medicaid finances 40% of annual births in the US and pays for 50% of hospital stays for premature and LBW. • The care cost for children with one of 17 common birth defects is $8 billion per year in the US.

34. Top Three “Best Practices” to Improve Birth Outcomes and Reduce High Risk Births (NGA, June 2004) • Improve access to medical care and health care services • Encourage good nutrition and healthy lifestyles • Eating healthy foods • Taking folic acid • Reduce use of harmful substances

35. Emerging Understandings about Nutrition in Pregnancy: • Fetal nutritional status is affected by the intrauterine and childhood nutritional experiences of the mother • Maternal nutritional status at time of conception is an important determinant of outcomes • Intrauterine nutritional environment affects health and development of the fetus throughout life

36. Emerging Understandings about Nutrition in Pregnancy • Periods of critical development are key when considering effects of nutrition in pregnancy. • Undernutrition has different effects at different times of life. • Societies transitioning from chronic malnutrition to access to high calorie foods are at high risk of chronic disease due to lasting effects of early nutritional status.

37. Effect of Women’s own Intrauterine Nutritional Experience her Offspring

38. Two Studies of Effects of Maternal Birthweight on Infant Birthweight

39. Classic Definitions of Birth weight

40. Godfrey KM, Barker DJP, Robinson S, Osmond C. Mother's birthweight and diet in pregnancy in relation to the baby's thinness at birth. Br J Obstet Gynaecol 1997;104:663–7

42. Illinois StudyCoutinho et al. Am J Epi, 1997 146:804-809 • N=15,287 Black and 117,708 white matched pairs of infants and mothers. • Mothers were born between 1956-75, infants between 1989-1991

44. Results • Father’s birthweight had effect on infant birthweight but not as strong as mothers. • In multiple linear regression for infants who weighed more than 2500 g, parental birthweight accounted for 5% of variance among black infants and 4% among white infants. • (adjusted for parental age, years of schooling, marital status and adequacy of prenatal care)

45. Results, cont. • Each 100 g increase in maternal birthweight was associated with 24-27 g increase in infant birthweight

46. Influence of Maternal Intrauterine & Childhood Nutrition on Outcomes of Pregnancy

47. Reproductive performance and nutrition during childhood Nutrition Reviews; Washington; Apr 1996; Martorell, Reynaldo; Ramakrishnan, Usha; Schroeder, Dirk G; Ruel, Marie;

48. Longitudinal Supplementation Trial (1969-1977) • Guatemala, 4 Villages, one pair of villages had about 900 people each and the other about 500 each. • 2 each randomized to: • Atole (Incaparina, a vegetable protein mix developed by INCAP*, dry skim milk, sugar, and flavoring, 163 kcal/cup, 11/5 g protein) • Fresco (flavored drink with sugar, vitamins and minerals, 59 kcal/cup) *Institute of Nutrition of Central America and Panama

49. Feeding center was open daily for over 7 years, from 1969 to 1977. • Anyone in the village could attend, but careful recording of consumption, including of additional servings as well as of leftovers, was done only for women who were pregnant or breastfeeding and for children 7 years or younger. • Supplements were available twice daily, in midmorning and midafternoon, so as not to interfere with meal times.

50. Conceptual framework “Malnutrition in early childhood constrains the future capacity of women to bear healthy newborns and their ability to feed and care for them, and through these mechanisms the growth and development of the next generation.”