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Advances in Maternal and Child Health

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Title: Advances in Maternal and Child Health


1
Advances in Maternal and Child Health
Milestones in Public Health Chapter 8
Lectures for Graduate Public Health 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
    childrens 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.)
  • Define categories of pre-term birth and low
    birthweight babies
  • Describe data on pre-term birth and its risks
  • Explore determinants for escalating prematurity
  • Discuss pre-term birth health disparities
  • Analyze economic impact of pre-term and low
    birthweight babies

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
  • Remarkable advances in womens health throughout
    the 20th century
  • Average life-span increased by more than 30
    years

Arias et. al. (2010)
8
Historical Perspective (Cont.)
  • 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 national public health
    practices

Century of Womens Health (2002)
9
Historical Perspective (Cont.)
  • 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

Century of Womens Health (2002)
10
HRSA-MCH Timeline, 2010
1800
1840
1860
1880
1900
1800 Smallpox vaccination begins in the U.S.
1840s Public school movement
1850 First childrens hospital
1860 First childrens 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 Childrens 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
  • What is the greatest public health achievement in
    the 20th century?
  • Sanitation?
  • Vaccinations?
  • Maternal and child health?
  • What do you think?

CDC (1999)
16
Then and Now
  • 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
  • 1900
  • for every 1,000 live births
  • 6-9 women died of pregnancy-related
    complications
  • 100 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
  • On an average day in the U.S.
  • Quick stats for the U.S.
  • Maternal mortality
  • Infant mortality
  • Healthy People 2010

March of Dimes (2008)
19
March of Dimes (2008)
20
March of Dimes (2008)
21
March of Dimes (2008)
22
Maternal Mortality
  • 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 womans pregnancy or its
    management, but not from accidental or incidental
    causes

March of Dimes (2008)
23
March of Dimes (2008)
24
Infant Mortality
  • Infant mortality refers to deaths under age one
  • The infant mortality rate is the number of infant
    deaths per 1,000 live births

March of Dimes (2008)
25
March of Dimes (2008)
26
March of Dimes (2008)
27
Healthy People 2010
  • 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

www.healthypeople.gov
28
www.healthypeople.gov
29
Advances in Maternal and Child Health
  • Biology, Behavior and Science

30
Preterm Births
  • More than 500,000 babies were born
    prematurely (preterm) in 2004, facing a much
    higher risk of health problems and death than
    other newborns
  • Premature infants are more than 15 times as
    likely as those not born preterm to die in the
    first year of life
  • Premature babies who survive may suffer lifelong
    consequences, such as mental retardation,
    blindness, chronic lung disease, and cerebral
    palsy

National Center for Health Statistics (2004)
31
Preterm Births Definitions
  • A preterm birth occurs before 37 completed weeks
    gestation
  • A very preterm birth occurs before 32 completed
    weeks gestation
  • A late preterm birth occurs between 34 and 36
    completed weeks gestation

March of Dimes (2008)
32
Preterm Births Stats
  • Nearly 82,000 babies were born very preterm in
    2004
  • These babies were more than 75 times as likely as
    those not born preterm to die in the first year
    of life
  • Late preterm infants comprised 71.2 percent of
    all preterm births in 2004 and account for the
    majority of the increase in preterm birth rates
    over the past two decades

National Center for Health Statistics
(2004) March of Dimes (2008)
33
Risk of Preterm Births
  • While specific causes of preterm births are
    largely unknown, certain factors are associated
    with increased risk
  • Maternal age higher preterm birth rates found
    among the youngest and oldest mothers (16 of
    births to teens under 18 and nearly 17 of births
    to women 40 and older in 2004)
  • Multiple births nearly 60 of twins and about
    93 of triplets and higher-order births were
    preterm in 2004

March of Dimes (2008)
34
Risk of Preterm Births (Cont.)
  • Women with certain uterine or cervical
    abnormalities
  • Previous preterm delivery
  • Infections
  • Smoking
  • Illicit drug use
  • Extremes of maternal weight
  • Stress

National Center for Health Statistics (2004)
35
Low Birthweight
  • A low birthweight baby weighs less than 5.5
    pounds (2,500 grams)
  • A very low birthweight baby weighs less than 3.5
    pounds (1,500 grams)

March of Dimes (2008)
36
Low Birthweight (Cont.)
  • Many infants born too soon are born too small
  • More than 43 percent of babies born preterm in
    2004 were also born low birth weight, while more
    than 67 percent of low birthweight babies were
    preterm
  • About one in 12 infants is born low birthweight
    a rate that has risen nearly 11 percent in the
    past decade (from 7.3 percent in 1994 to 8.1
    percent in 2004
  • More than 60,000 babies were born very low
    birthweight in 2004 1.5 percent of live births

March of Dimes (2008)
37
Race/Ethnicity of Mother
  • Prematurity/low birth weight is the leading cause
    of death for African-American infants
  • In 2004, nearly 18 percent of infants born to
    non-Hispanic black mothers were preterm, compared
    with more than 11 percent of infants born to
    non-Hispanic white mothers
  • Infants born to non-Hispanic black mothers were
    more than two times as likely as those born to
    non-Hispanic white mothers to be very preterm
    4.1 percent of births, compared with 1.6 percent
  • Of infants born to Hispanics, 12 percent were
    preterm and the rate was highest for babies born
    to Puerto Rican mothers (14 percent)

March of Dimes (2008)
38
Cost of Preterm and Low Birthweight Babies
  • In 2005, the annual societal economic cost
    (medical, educational, and lost productivity)
    associated with preterm birth in the United
    States was at least 26.2 billion
  • During that same year, the average first year
    medical costs, including both inpatient and
    outpatient care, were about 10 times greater for
    preterm (32,325) than for term infants (3,325)
  • The average length of hospital stays in 2005 was
    nearly nine times as long for a preterm infant
    (13 days) compared with an infant born at term
    (1.5 days)

March of Dimes (2008)
39
Cost of Preterm and Low Birthweight Babies (Cont.)
  • Four of the ten most expensive hospital stays,
    regardless of age, are related to infant care
    infant respiratory distress syndrome,
    prematurity/low birthweight, cardiac/circulatory
    birth defects, and lack of oxygen in infants
  • Costs associated with prematurity and low
    birthweight are not limited to the hospital stay
    at birth
  • Low birthweight accounts for 10 percent of all
    health care costs for children
  • Prematurity may result in long-term physical and
    mental disabilities, which generate additional
    costs
  • Children born prematurely are at greater risk of
    lower cognitive test scores and behavioral
    problems, and are more likely to be enrolled in
    special education classes than children born full
    term

March of Dimes (2008)
40
Advances in Maternal and Child Health
  • Systems, Policies and Programs

41
  • How the Federal Maternal and Child Health
    Program Advanced the Field of Maternal and Child
    Health

Hutchins (2001)
42
Act of 1912 (P.L. 62-116)
  • Congress established The Childrens 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 nations
    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

Hutchins (2001)
43
Maternal and Child Health Bureau (MCHB)
  • 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 nations
    women, infants, children, adolescents, and their
    families, including fathers and children with
    special health care needs

Hutchins (2001)
44
Maternal and Child Health Bureau Goals (2007)
  • 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

Hutchins (2001)
45
MCH Program Leadership
  • Investigate and report
  • Advocate
  • Research and train
  • Allocate funds
  • Direct and redirect funds
  • Assist as time and circumstance require

Hutchins (2001)
46
Health Insurance Topics
  • Access to care
  • Coverage for women of childbearing age
  • Coverage for children
  • Medicaids role in maternal and child health
  • State Childrens Health Insurance Program
    (S-CHIP)
  • Medicaid and S-CHIP Eligibility and enrollment

Hutchins (2001)
47
Access to Care Having Insurance Affects Health
Care Utilization
  • Uninsured women
  • Receive fewer prenatal visits and have more
    trouble obtaining services
  • In 1996, 18.1 reported NOT using medical
    services the year they gave birth (compared with
    7.6 for private insurance and 8.1 for those
    with Medicaid)
  • Uninsured Children
  • Insurance status is the most important factor in
    determining accessibility to care
  • Though uninsured newborns are more likely to be
    sick, they receive fewer hospital services
  • Are most likely to have no usual source of
    medical care (28, compared with 2.3 and 4.6
    for private and public insurance)

Hutchins (2001)
48
Coverage for Women of Childbearing Age
  • One in five women of childbearing age is
    uninsured
  • Hispanics in this group are three times as likely
    as whites to be uninsured
  • Pregnant women are less likely to be uninsured
    (about 8 at delivery)
  • In 2000, 7 of insurance plans offered by small
    employers did not cover prenatal care
  • Individual health plans usually exclude, or add
    additional premiums, for prenatal care

Hutchins (2001)
49
Coverage for Children
  • In 2006, 12 of children under 19 in the U.S. did
    not have health insurance
  • 61 of these children were from families with
    incomes below 200 of poverty and may have been
    eligible for public coverage
  • Native American children are three times as
    likely as white children to be uninsured
  • In 2004, 4.8 of infants born in hospitals were
    uninsured

Hutchins (2001)
50
Medicaids Role
  • Medicaid is the major public source of financing
    for health services for pregnant women, infants,
    and children
  • Medicaid financed 41 of hospital births in 2002
    and covered nearly 30 million children in 2004
  • 48 of hospital stays for preterm births were
    financed by Medicaid in 2004 (Approx 30,700 per
    birth)
  • 46 of infant and child hospital stays due to
    birth defect were covered by Medicaid in 2006
  • Although women and children make up about 70 of
    Medicaid enrollees, they account for only 32 of
    spending

National Governors Association (2006) Centers for
Medicare and Medicaid Services (2007a) Agency for
Healthcare Research and Quality (2007)
51
State Children's Health Insurance Program (S-CHIP)
  • Enacted in 1997 to cover uninsured children. Has
    been extended to March 2009
  • 6.6 million children were enrolled in 2006
  • 40 billion in federal matching funds were
    available to S-CHIP between 1988-2007
  • In 2010, nine states plus DC were using S-CHIP to
    expand Medicaid, 18 states used a separate
    program and 23 states used a combination
  • S-CHIP eligibility varies among statesat least
    47 states cover children in families with incomes
    up to 200 of poverty

Centers for Medicare and Medicaid Services
(2007b) Georgetown University Center for Children
and Families (2010)
52
Medicaid and S-CHIP Eligibility and Enrollment
  • States can determine eligibility for Medicaid and
    S-CHIP to prevent delays in enrollment for
    eligible pregnant women and children
  • Presumptive eligibility allows states to cover
    applicants temporarily, until eligibility is
    determined
  • Continuous eligibility allows states to provide
    coverage to children for up to 12 months,
    regardless of changes to the family income or
    eligibility

National Governors Association (2007)
53
Advances in Maternal and Child Health
  • Looking Ahead

54
What is the Status of Child Health Today in the
U.S.?
  • What are the opportunities for improvement in
    the future?

55
What Are the New (and Old) Threats?
  • Chronic illness in children
  • Impact of social determinants of health
  • Striking prevalence of disparities

56
Challenges
  • Paul Wise has illustrated the challenge of
    transforming child health in the U.S. by
    addressing
  • Social determinants of health
  • Technical determinants of health
  • Trends in child health outcomes

Wise (2004)
57
Social Determinants of Child Health
  • Poverty never so concentrated in childhood as
    now
  • Economic inequality

Wise (2004)
58
Technical Determinants of Child Health
  • Technical innovation and access
  • The legacy of birth
  • Trends in infant outcomes
  • Prematurity dropped over past four decades
  • Disparities in infant outcomes mortality rates
    for black newborns remains more than twice the
    rate for whites

Wise (2004)
59
Trends in Child Health Outcomes
  • Acute illness little change
  • Chronic illness increase in prevalence
  • Severity of pediatric illness and hospitalization
    reduced
  • Disparities in child mortality fell
    dramatically except for African Americans (15-19
    yrs)

Wise (2004)
60
The Cumulative Effect of Social Risks on Child
Health
  • It has been clearly recognized that social risk
    factors such as
  • growing up in poverty
  • racial/ethnic minority status
  • maternal depression
  • have been associated with poorer health outcomes
    for children

Wise (2004)
61
Advances in Maternal and Child Health
  • Conclusion

62
Wrap-Up
  • Advances in womens health have led to increased
    lifespan and reduction in death, disease, and
    disability
  • Link among maternal, newborn, and child health
  • Breastfeeding
  • Advances in maternal and child health depend on
    federal, state, and local agencies
  • Link between biology and policy

63
Advances in Maternal and Child Health
  • References and Resources

64
References and Resources
  • Agency for Healthcare Research and Quality.
    (2007). March of Dimes HCUPnet tabulations using
    the 2004 Nationwide Inpatient Sample. Retrieved
    from http//hcupnet.ahrq.gov
  • American College of Medical Genetics. (2004).
    Newborn screening Toward a uniform screening
    panel and system. Retrieved from
    ftp//ftp.hrsa.gov/mchb
  • Arias, E., Rostron, B. L., Tejada-Vera, B.
    (2010). Unites States life tables, 2005. National
    Vital Statistics Reports. Hyattsville, MD
    National Center for Health Statistics.
  • A century of women's health 1900-2000.
    Washington, D.C. Office on Women's Health, U.S.
    Department of Health and Human Services.
    Retrieved from http//www.womenshealth.gov/archive
    /owh/pub/century/century.pdf
  • Centers for Disease Control and Prevention.
    (2007b). Information on state activities in
    birth defects and surveillance. Retrieved from
    http//www.cdc.gov/ncbddd/bd/state.htm
  • Centers for Disease Control and Prevention.
    (1999). Ten great public health achievements
    United States, 1900-1999. Morbidity and
    Mortality Weekly Report, 48(12) 241-243.

65
References and Resources
  • Centers for Medicare and Medicaid Services.
    (2007a). Medicaid Statistical Information System
    State Summary Datamart. Fiscal Year 2004
    Quarterly Cube. Data prepared for the March of
    Dimes.
  • Centers for Medicare and Medicaid Services.
    (2007b) SCHIP Enrollment Reports.
    www.cms.hhs.gov/schip/enrollment
  • Chiras, D. D. (2005). Human biology (5th ed.).
    Boston, MA Jones and Bartlett Publishers.
  • Georgetown University Center for Children and
    Families. (2010). Medicaid and CHIP programs.
    Retrieved from http//ccf.georgetown.edu/index/me
    dicaid-and-schip-programs
  • Healthy people 2010 home page. Retrieved
    5/14/2010, from http//www.healthypeople.gov/
  • Heckman, J. (2007). Investing in disadvantaged
    young children is good economics and good public
    policy (keynote address). AAP 2007 national
    conference exhibition. San Francisco. Retrieved
    5/13/2010, from http//s23.a2zinc.net/clients/aap/
    nce2007/public/Content.aspx?ID3013sortltenu10200
    0exp11/8/200730857PM.

66
References and Resources
  • Hutchins, V. L. (2001). Maternal and child health
    at the millennium. Rockville, MD
  • Kotch, J. (2005). Maternal and child health
    Programs, problems, and policy in public health
    (2nd ed.). Sudbury, MA. Jones and Bartlett.
    Retrieved from http//www.loc.gov/catdir/toc/ecip0
    53/2004026193.html
  • Larson, K., Russ, S. A., Crall, J. J., Halfon,
    N. (2008). Influence of multiple social risks on
    children's health. Pediatrics, 121(2), 337-344.
    doi10.1542/peds.2007-0447
  • Maiese, D. R., United States Health Resources
    and Services Administration. Office of Women's
    Health. (2002). Healthy people 2010 Leading
    health indicators for women. Rockville, MD
    Office of Women's Health, Health Resources and
    Services Administration, U.S. Department of
    Health and Human Services. Retrieved from
    http//www.healthypeople.gov/
  • March of Dimes. (2008). Data book for policy
    makers Maternal, infant, and child health in the
    United States, 2008. Washington, D.C. Office of
    Government Affairs, March of Dimes.
  • Maternal and Child Health Bureau. (n.d.). HRSA -
    MCH timeline History, legacy and resources for
    education and practice. Retrieved 5/14/2010 from
    http//www.mchb.hrsa.gov/timeline/

67
References and Resources
  • National Center for Health Statistics. (2007).
    1994-2004 final natality data. Data prepared by
    the March of Dimes Perinatal Data Center.
  • National Center for Health Statistics. (2007).
    1995-2004 period linked birth/infant death data.
    Data prepared by the March of Dimes Perinatal
    Data Center.
  • National Governors Association. (2006). MCH
    Update 2005 States Make Modest Expansions to
    Health Care Coverage. Issue Brief. Retrieved
    from http//www.nga.org/Files/pdf/0609MCHUPDATE.PD
    F
  • National Governors Association. (2007). MCH
    Update 2006. Issue Brief.
  • National Newborn Screening and Genetics Resource
    Center, (2007). U.S. National Screening Status
    Report, November 30, 2007. Retrieved from
    http//genes-r-us.uthscsa.edu/
  • Reiser, S., Russo, C. A., Elixhauser, A.
    (2007). Hospitalizations for birth defects.
    Statistical Brief, 24.
  • United States Department of Labor. (2007).
    Employment and earnings, 2007 annual averages and
    the monthly labor review. Retrieved 5/14/2010
    from http//www.dol.gov/wb/stats/main.htm
  • Wise, P. H. (2004). The transformation of child
    health in the United States. Health Affairs
    (Project Hope), 23(5), 9-25.
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