Institutional Violence and the Effect on the Unborn Child

1. Institutional Violence and the Effect on the Unborn Child National Perinatal Association 2008 Annual Conference Loma Linda University Children’s Hospital Kim Carter Founder & Executive Director Time for Change Foundation November 19, 2008

2. Financial Disclosure Neither I, nor my significant other/spouse, have any financial interest/arrangements or affiliation with one or more of the corporate organizations offering financial support or educational grants for this continuing medical education program.

3. Definitions • Institutional– a standard practice, relationship, or organization in a society or culture. • Violence – intense, turbulent, or furious and often destructive action or force. • “Institutional Violence” (for this presentation) – a standard practice in society that has become a destructive force and has a negative impact on the unborn child.

4. Presentation Objectives • To identify risk factors associated with highly stressful pregnancies • To identify external factors that play key roles in perpetuating violence during pregnancy • To identify barriers to accessing risk appropriate care and prenatal care

5. Institutional Practices • Denial of Cash Aid Welfare • Lack of Health Insurance • Lack of Prenatal Care • Underutilization of Referrals & Transport • Minimal Promotion of Breastfeeding • Racism

6. Institutional Violence: Denial of Cash Aid Welfare • CalWORKS cash aid can be used for housing, food, utilities, transportation, and other living expenses. Not being able to pay for these basic necessities has harmful effects on the unborn child. • A Pregnant Woman Only (PWO) who is an adult (age 18+ years) and has no children living with her is not eligible to receive CalWORKS until she is in her third trimester of pregnancy. • Not being able to afford housing and transportation are also barriers for accessing prenatal care. (Source: TANF, 2006)

7. Critical Periods in Human Development1 Red areas indicate highly sensitive periods when teratogens may induce major anomalies

8. Institutional Violence:Lack of Health Insurance2,3 Percent of females (age 18-64 years) who reported not having current health insurance coverage, 2005 Source: CHIS, 2005 Women’s Health, 2007

9. Institutional Violence:Lack of Health Insurance (cont.) • Even among those who have health insurance coverage, many health insurance companies have limitations on coverage for pregnant women in terms of location of delivery. • Therefore, adequacy of health insurance coverage also contributes to institutional violence on the unborn child. • Lack of adequate health insurance is a barrier for accessing prenatal care services.

10. Institutional Violence:Lack of Health Insurance (cont.) AB 1962 (De La Torre) – Insurance Code relating to health care coverage: AB 1962 would have required all health insurance policies to provide coverage for maternity services including prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and post partum care. AB 1962 was vetoed by Governor Schwarzenegger in 2008. Source: CA Legislative info 2008

11. Institutional Violence:Lack of Prenatal Care4 Source: Women’s Health, 1999 Prenatal care consists of much more than just monitoring the mother's diet and weight. Keep in mind that during pregnancy it is not just the health of the pregnant woman that must be watched, but also the health of the unborn baby. Maternal difficulties such as diabetes (which can develop as a result of being pregnant even if diabetes was not present before), insufficient weight gain, and high blood pressure, if gone untreated, can be harmful to the fetus. A doctor can also monitor the baby's well being directly by listening to the fetal heartbeat, checking the size and positioning of the uterus and fetus, and testing for various abnormalities. Some conditions, if detected prenatally, can be treated before the baby is born. In other instances, early detection can allow the proper medical facilities to be present at the time of birth to allow the baby full access to the help it needs.

12. Institutional Violence:Lack of Prenatal Care5 (cont.) According to the March of Dimes, women who see a health care provider regularly during pregnancy have healthier babies, are less likely to deliver prematurely, and are less likely to have other serious problems related to pregnancy. (Source: March of Dimes, 2008)

13. Institutional Violence:Lack of Prenatal Care6,7 (cont.) Percent of live births with late or no prenatal care, 2005 “Late prenatal care” defined as care beginning in the third trimester. Source : (CA Dept of Public Health, 2006) Source: NCHS, 2005

14. Institutional Violence:Underutilization of Referrals & Transport8 • Risk appropriate care refers to an organized and coordinated system that provides services based on need for mothers and newborns during pregnancy, labor, birth, and the newborn period. • In addition, California Children’s Services (CCS) has defined four levels of NICU care for birthing hospitals. Source: (Inland Counties Regional Perinatal Program)

15. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) The four levels (from lowest to highest) are: • Primary: A nursery designed to provide care for healthy mothers and newborns. • Intermediate Neonatal Intensive Care Unit (NICU): A nursery that has the capability of providing neonatal services for sick neonates and infants who do not require intensive care but do require care at a higher level than provided in a general nursery.

16. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) • Community NICU: Having the capability of providing a full range of neonatal care services – or intensive, intermediate, and continuing care – for severely ill neonates and infants. In addition, Community NICUs provide support to Intermediate NICUs. A Community NICU may not have a full range of sub-specialties or provide certain pediatric surgeries.

17. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) • Regional NICU: Has the capability of providing a full range of neonatal care services encompassing intensive, intermediate, and continuing care. This includes neonatal surgery for severely ill neonates and infants. In addition, Regional NICUs provide support to Community and Intermediate NICUs. A Regional center provides a full range of sub-specialties, such as cardiology and neurology.

18. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) Region 7 birthing facilities that currently have NICUs defined as Community and Regional level (n = 14; 7 in Riverside County and 7 in San Bernardino County):

19. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) Healthy People 2010 Goal: 9.0 per 1,000 live births as the annual rate of very low birthweight births (VLBW). VLBW defined as less than 1,500 grams.

20. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) Healthy People 2010 Goal: 90% of very low birthweight (VLBW) births born at Level III hospitals or subspecialty perinatal centers. VLBW defined as less than 1,500 grams.

21. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) • California Perinatal Transport System (CPeTS) established by California Assembly Bill 4439 in 1976 • to facilitate transports of critically ill infants and mothers with high risk conditions to Neonatal Intensive Care Units (NICUs) and Perinatal High Risk Units • to collect and analyze perinatal and neonatal transport data for regional planning, outreach program development, and outcome analysis • CPeTS has engaged the California Quality Care Collaborative (CPQCC) to manage the data system

22. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) CORE CPETS Acute Inter-Facility Neonatal Transport Form

23. Institutional Violence:Underutilization of Referrals & Transport8 (cont.) • Perceived underutilization of maternal transport • Perceived delay in decision to transport infant • Difficulty obtaining transport placement/acceptance • Delay in effecting transport following decision • Consistent referring facility competency regarding infant stabilization prior to transport team’s arrival, as well as transport team competency Barriers and key transport issues:

24. Institutional Violence:Minimal Promotion of Breastfeeding9 • In California, only 43% of newborns were exclusively breastfed in the early post-partum period in 2006. In 2007, the rate was 42.7%. • In San Bernardino County, 34.6% of newborns were exclusively breastfed in the early post-partum period in 2006. This increased to 38.4% in 2007. • Healthy People 2010 goal is 75%. Source: Ca Department of Public Health, 2006, 2007

25. Institutional Violence:Minimal Promotion of Breastfeeding9 (cont.) • Very few health care professionals have received training or kept current about the science of lactation despite new published research on anatomy, maternal and infant assessment, effective breastfeeding interventions and the development of new community resources for referrals. • Some hospitals hinder exclusive breastfeeding practices by providing new mothers with complimentary diaper bags that contain baby formula and pacifiers, which undermines the intrinsic desire of the baby to latch on. Barriers to exclusive breastfeeding practices:

26. Institutional Violence:Minimal Promotion of Breastfeeding9 (cont.) • Few hospitals have policies that effectively promote and protect breastfeeding. • Few workplaces, educational sites, and childcare centers support breastfeeding mothers. • Due to the lack of social and professional support, many mothers have little confidence and fear attempting to breastfeed.

27. Institutional Violence:Minimal Promotion of Breastfeeding (cont.) • In the United States, social norms do not support or embrace breastfeeding practices, as demonstrated by: • Lack of portrayal in mainstream media • Minimal funding for breastfeeding promotion compared with advertising of baby formula • Lack of accommodations for breastfeeding mothers in social settings • There is no glamour or appeal associated with breastfeeding

28. Institutional Violence:Minimal Promotion of Breastfeeding8,10 (cont.) • The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation. The BFHI assists hospitals in giving breastfeeding mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies and gives special recognition to hospitals that have done so. • Currently, 10 out of the 31 birthing facilities in Region 7 have been designated as Baby-Friendly Hospitals and Birth Centers. Source: Baby-Friendly USA, 2006

29. Institutional Violence:Racism11 • According to the Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes, racism is another form of chronic stress that may contribute to premature birth. • Maternal stress may cause the release of certain hormones, which may cause premature contractions and preterm delivery. • Black women may experience stress from racism throughout their lifetime. This may help explain why Black women are more likely to deliver prematurely than women from other racial/ethnic groups. Source: March of Dimes, 2006

30. Institutional Violence:Racism15 (cont.) Source: CA – Newsreel, 2008

31. Institutional Violence:Racism12 (cont.) • Kure Walters (a SIDS fundraiser and educator in Riverview, Florida) hears women say they’re deterred from preconception and perinatal care because of racism in physicians’ offices and hospitals. • Based on her own experience, she recalls when “on my first visit to a new gynecologist, the staff assumed I was on Medicaid and were very dismissive. When they asked for my Medicaid card and got my card from an excellent insurer, their attitude was much more positive.” Source: Nursing Spectrum, 2008

32. Institutional Violence:Racism12 (cont.) • According to Versie Johnson-Mallard, PhD, WHNP-bc (a clinical researcher and assistant professor at the University of South Florida College of Nursing, Tampa), “the women who show up in their second trimester may not have known they were pregnant, or they waited weeks for Medicaid before they could request an appointment. The woman who didn’t get an ultrasound may have had difficulty getting an appointment due to work or lack of transportation. If they’re told or it’s implied that they’re lazy or irresponsible, it’s a deterrent to going back.”

33. Institutional Violence:Racism12 (cont.) • Barbara Cottrell, ARNP, MSN (an associate professor at the Florida State University College of Nursing, Tallahassee) studied 272 black women on perinatal care preferences. According to Cottrell, “don’t make them feel rushed, explain as much as possible, ask how they’re doing, show warmth, and be conversational instead of authoritarian.” • It’s hard for women on the receiving end to tell if providers are rude or rushed, rather than racist. Regardless, unless providers attain and maintain rapport, patients may not disclose life circumstances interfering with proper care and compliance.

34. Outcomes:Infant Mortality Rates13,14 • According to the Centers for Disease Control and Prevention (CDC), infant mortality is one of the most important indicators of the health of a nation, as it is associated with a variety of factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices. • In 1960, the U.S. had the 12th lowest infant mortality rate and by 2004, the U.S. was ranked 29th. The most recent study, published in July 2008 titled “The Measure of America” estimates that the U.S. is now in 34th place. Source: (13) CDC, 2008 (14) World Socialist, 2008

35. Outcomes:Infant Mortality Rates15 (cont.) Source: Ca Newsreel, 2008 In 33 other countries, a baby has a better chance of living until the age of one than here in the United States. • Iceland • Finland • Singapore • Spain • Sweden • Japan • Czech Republic • Norway • Belgium • Denmark • France • Italy • Germany • 14. Greece • Slovenia • Portugal • 17. Korea • 18. Australia • 19. New Zealand • 20. Cyprus • 21. Canada • 22. Netherlands • 23. Switzerland • 24. Luxemburg • 25. Israel • 26. Austria • 27. Malta • 28. Ireland • 29. United Kingdom • 30. Croatia • 31. Estonia • 32. Slovakia • 33. Cuba • 34. United States

36. Outcomes:Infant Mortality Rates16 (cont.) • According to a 20/20 documentary entitled “Babyland”, the United States has the highest rate of infant mortality amongst the richest countries in the world. • Tennessee has the highest rate where every 43 hours, a baby dies in Memphis.

37. Outcomes:Infant Mortality Rates16 (cont.)

38. Source: (13) CDC,2008 (17) CA Dept of Public Health, Outcomes:Infant Mortality Rates13,17 (cont.) Overall infant mortality rates (per 1,000 live births) among San Bernardino County, California, and United States residents, 2001-2006

39. Outcomes:Infant Mortality Rates13,17 (cont.) Infant mortality rates (per 1,000 live births) by race/ethnicity among San Bernardino County, California, and United States residents, 2005 Black infants die at a rate three times higher than that of White infants.

40. Outcomes:Infant Mortality Rates15 (cont.) Source: CA Newsreel • Assumption: Higher education improves birth outcomes. • United States infant mortality data, 2005: • Data suggests that White non-educated women have better birth outcomes than Black educated women.

41. Outcomes:Infant Mortality Rates15 (cont.) • Question: Is this a “genetic factor” pre-disposed by DNA? • Study conducted using three different cohorts revealed that while African American women born in the United States had poor birth outcomes, immigrant Africans had birth outcomes equal to that of White women born in the United States. However, after one generation in the United States, those immigrant Africans were exhibiting the same dismal birth outcomes as the United States-born African American women.

42. Outcomes:Infant Mortality Rates15 (cont.) • Infant mortality is not just a problem for African Americans. When we remove the data for African Americans, we find that White babies still have a death rate that ranks the United States 23rd. This means that there are at least 22 other countries in the world that have better birth outcomes than White babies in the United States. • During the 1960’s, the infant mortality gap was closing due to effective social policies and programs. During the 1980’s, however, these programs were eliminated and infant mortality increased.

43. Outcomes:Prematurity (Preterm Births)18 Most pregnancies last around 40 weeks. Babies born between 37 and 42 completed weeks of pregnancy are called full term. Babies born before 37 completed weeks of pregnancy are called premature or preterm. Source: March of Dimes (2008)

44. Outcomes:Prematurity (Preterm Births)17,19 (cont.) Percent of births that were preterm among San Bernardino County, California, and United States residents, 2005 Source: (17) CA Dept. of Public Health, 2001, (19) CDC, 2005

45. Outcomes:Prematurity (Preterm Births)17,18,20 (cont.) • Premature birth is a serious health problem. Premature babies are at increased risk for newborn health complications, as well as lasting disabilities, such as mental retardation, cerebral palsy, lung and gastrointestinal problems, vision and hearing loss, and even death. • Disorders related to short gestation (prematurity) and low birthweight were the 2nd leading cause of death among resident infants in San Bernardino County (2005), California (2005), and the United States (2004). Source: (17) CA Dept of Public Health, 2004 (18) March of Dimes, 2008 (20) CDC, 2008

46. Outcomes:Low Birthweight Births21 • Babies born weighing less than 5 pounds, 8 ounces (2,500 grams) are considered low birthweight. • Low birthweight babies are at increased risk for serious health problems as newborns, lasting disabilities and even death. Source: March of Dimes, 2008

47. Outcomes:Low Birthweight Births17,19 (cont.) Percent of births with low birthweight among San Bernardino County, California, and United States residents, 2005 Source: (17) CA Dept. of Public Health, (19) CDC, 2005

48. Outcomes:Low Birthweight Births21 (cont.) Advances in newborn medical care have greatly reduced the number of deaths associated with low birthweight. However, a small percentage of survivors develop mental retardation, learning problems, cerebral palsy and vision and hearing loss. Source: March of Dimes, 2008

49. Outcomes:Health Risks of Not Breastfeeding22 • Babies who are not exclusively breastfed for 6 months are more likely to develop a wide range of infectious diseases including ear infections, diarrhea, respiratory illnesses and have more hospitalizations. • Infants who are not breastfed have a 21% higher postneonatal infant mortality rate in the United States. Source: US Dept of Health & Human Svcs.,2005

50. Outcomes:Health Risks of Not Breastfeeding22 (cont.) • Higher rates of SIDS in the first year of life • Higher rates of Type 1 and Type 2 Diabetes • Lymphoma • Leukemia • Hodgkin’s Disease • Overweight & obesity • High cholesterol • Asthma Babies who are not breastfed are sick more often and have more doctor visits. Source: US Dept of Health & Human Svcs.,2005