Advances in Maternal and Child Health

1. Advances in Maternal and Child Health http://profiles.nlm.nih.gov/QQ/B/C/Z/T/_/qqbczt.jpg Healthy Mothers Healthy Babies 1983http://profiles.nlm.nih.gov/QQ/B/C/Z/T/_/qqbczt.jpg Healthy Mothers Healthy Babies 1983

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 2

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 3

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 4

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 5

6. Advances in Maternal and Child Health Historical Perspective

7. Historical Perspective Remarkable advances in women’s health throughout the 20th century: Average life-span increased by more than 30 years 7

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 8

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 9 Women gained knowledge and access to health information Access to health care services expanded through both development of public health care infrastructure and increased access to private, employer-based health insurance Women slowly made in roads to male dominated medical schools and medical professions Female dominated health professions such as nursing and midwifery were formalized and Definition of women’s health issues were more specifically integrated into health care training, public policy debates, health education programs, medical research, and clinical practiceWomen gained knowledge and access to health information Access to health care services expanded through both development of public health care infrastructure and increased access to private, employer-based health insurance Women slowly made in roads to male dominated medical schools and medical professions Female dominated health professions such as nursing and midwifery were formalized and Definition of women’s health issues were more specifically integrated into health care training, public policy debates, health education programs, medical research, and clinical practice

10. 10 Additional milestones available at: http://www.mchb.hrsa.gov/timeline/Additional milestones available at: http://www.mchb.hrsa.gov/timeline/

11. 11 Additional milestones available at: http://www.mchb.hrsa.gov/timeline/Additional milestones available at: http://www.mchb.hrsa.gov/timeline/

12. 12 Additional milestones available at: http://www.mchb.hrsa.gov/timeline/Additional milestones available at: http://www.mchb.hrsa.gov/timeline/

13. 13 Additional milestones available at: http://www.mchb.hrsa.gov/timeline/Additional milestones available at: http://www.mchb.hrsa.gov/timeline/

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? 15

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 16

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 17

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 18

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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 woman’s pregnancy or its management, but not from accidental or incidental causes 22

23. 23 Up to half of all maternal deaths in this country could be prevented through a variety of interventions, including early diagnosis and appropriate medical care of pregnancy complications. At least 30% of women have a pregnancy-related complication before, during, or after delivery. These may cause long-term health problems even if they do not cause death. Up to half of all maternal deaths in this country could be prevented through a variety of interventions, including early diagnosis and appropriate medical care of pregnancy complications. At least 30% of women have a pregnancy-related complication before, during, or after delivery. These may cause long-term health problems even if they do not cause death.

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 24

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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 27

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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 30

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 31 About one in eight infants is born preterm – a rate that has risen 14 percent in the past decade (from 11.0 percent of births in 1994 to 12.5 percent in 2004). About one in eight infants is born preterm – a rate that has risen 14 percent in the past decade (from 11.0 percent of births in 1994 to 12.5 percent in 2004).

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 32

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 33 A rise in the rate of multiple births, associated with older age at childbearing and greater use of assisted reproductive technologies and fertility drugs, has contributed to the increase in the preterm birth rate.A rise in the rate of multiple births, associated with older age at childbearing and greater use of assisted reproductive technologies and fertility drugs, has contributed to the increase in the preterm birth rate.

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 34 A rise in the rate of multiple births, associated with older age at childbearing and greater use of assisted reproductive technologies and fertility drugs, has contributed to the increase in the preterm birth rate.A rise in the rate of multiple births, associated with older age at childbearing and greater use of assisted reproductive technologies and fertility drugs, has contributed to the increase in the preterm birth rate.

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) 35

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 36

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) 37

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) 38

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 39

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 41

42. Act of 1912 (P.L. 62-116) 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 42

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 nation’s women, infants, children, adolescents, and their families, including fathers and children with special health care needs 43

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 44

45. MCH Program Leadership Investigate and report Advocate Research and train Allocate funds Direct and redirect funds Assist as time and circumstance require 45

46. Health Insurance Topics 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 46

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) 47

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 48

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 49

50. Medicaid’s 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 50

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 states—at least 47 states cover children in families with incomes up to 200% of poverty 51

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 52

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? 54

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

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 56

57. Social Determinants of Child Health Poverty – never so concentrated in childhood as now Economic inequality 57

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 58

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) 59

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 60

61. Advances in Maternal and Child Health Conclusion

62. Wrap-Up Advances in women’s 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 62

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. 64

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/medicaid-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?ID=3013&sort<enu=102000&exp=11/8/2007+3:08:57+PM. 65

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/ecip053/2004026193.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. doi:10.1542/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/ 66

67. References and Resources 67