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Advances in Maternal and Child Health






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Milestones in Public Health: Chapter 8. Advances in Maternal and Child Health. Lectures for Graduate Public Health Education . January 2011. Learning Objectives. Describe the “continuum of care” concerns, linking maternal, newborn, and child health
Advances in Maternal and Child Health

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Slide 1

Milestones in Public Health: Chapter 8

Advances in Maternal and Child Health

Lectures for Graduate Public Health Education

January 2011

Slide 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

Slide 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

Slide 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

Slide 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

Slide 6

Advances in Maternal and Child Health

Historical Perspective

Slide 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

Slide 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 national public health practices

Slide 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

Slide 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

Slide 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.

Slide 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

Slide 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

Slide 14

Advances in Maternal and Child Health

The Milestone & Its Impact on Public Health

Slide 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?

Slide 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

Slide 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

Slide 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

Slide 19

March of Dimes (2008)

Slide 20

March of Dimes (2008)

Slide 21

March of Dimes (2008)

Slide 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

Slide 23

March of Dimes (2008)

Slide 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

Slide 25

March of Dimes (2008)

Slide 26

March of Dimes (2008)

Slide 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

Slide 28

www.healthypeople.gov

Slide 29

Advances in Maternal and Child Health

Biology, Behavior and Science

Slide 30

Preterm Births

National Center for Health Statistics (2004)

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

Slide 31

Preterm Births: Definitions

March of Dimes (2008)

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

Slide 32

Preterm Births: Stats

National Center for Health Statistics (2004)

March of Dimes (2008)

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

Slide 33

Risk of Preterm Births

March of Dimes (2008)

  • 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

Slide 34

Risk of Preterm Births (Cont.)

National Center for Health Statistics (2004)

Women with certain uterine or cervical abnormalities

Previous preterm delivery

Infections

Smoking

Illicit drug use

Extremes of maternal weight

Stress

Slide 35

Low Birthweight

March of Dimes (2008)

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)

Slide 36

Low Birthweight (Cont.)

March of Dimes (2008)

  • 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

Slide 37

Race/Ethnicity of Mother

March of Dimes (2008)

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)

Slide 38

Cost of Preterm and Low Birthweight Babies

March of Dimes (2008)

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)

Slide 39

Cost of Preterm and Low Birthweight Babies (Cont.)

March of Dimes (2008)

  • 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

Slide 40

Advances in Maternal and Child Health

Systems, Policies and Programs

Slide 41

Hutchins (2001)

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

Slide 42

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

Slide 43

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

Slide 44

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

Slide 45

MCH Program Leadership

Hutchins (2001)

Investigate and report

Advocate

Research and train

Allocate funds

Direct and redirect funds

Assist as time and circumstance require

Slide 46

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

Slide 47

Access to Care:Having Insurance Affects Health Care Utilization

Hutchins (2001)

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)

Slide 48

Coverage for Women of Childbearing Age

Hutchins (2001)

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

Slide 49

Coverage for Children

Hutchins (2001)

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

Slide 50

Medicaid’s Role

National Governors Association (2006)

Centers for Medicare and Medicaid Services (2007a)

Agency for Healthcare Research and Quality (2007)

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

Slide 51

State Children's Health Insurance Program (S-CHIP)

Centers for Medicare and Medicaid Services (2007b)

Georgetown University Center for Children and Families (2010)

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

Slide 52

Medicaid and S-CHIP: Eligibility and Enrollment

National Governors Association (2007)

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

Slide 53

Advances in Maternal and Child Health

Looking Ahead

Slide 54

What is the Status of Child Health Today in the U.S.?

What are the opportunities for improvement in the future?

Slide 55

What Are the New (and Old) Threats?

Chronic illness in children

Impact of social determinants of health

Striking prevalence of disparities

Slide 56

Challenges

Wise (2004)

  • 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

Slide 57

Social Determinants of Child Health

Wise (2004)

Poverty – never so concentrated in childhood as now

Economic inequality

Slide 58

Technical Determinants of Child Health

Wise (2004)

  • 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

Slide 59

Trends in Child Health Outcomes

Wise (2004)

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)

Slide 60

The Cumulative Effect of Social Risks on Child Health

Wise (2004)

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

Slide 61

Advances in Maternal and Child Health

Conclusion

Slide 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

Slide 63

Advances in Maternal and Child Health

References and Resources

Slide 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.

Slide 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.

Slide 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/

Slide 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.PDF

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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