Maternal And Child Health Midterm

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Maternal and Child Health Goal

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To improve the health and well-being of women, infants, children, and families.

Reflection of current health status (lrg segment of pop). Predictor of health of next generation.
Infant mortality: measure of nation's health and indicator of social well-being and health status.

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Public Health: Science and Art of...

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Prevention, prolonging life, reducing disease and premature death, promoting health and efficiency thru organized community effort. Development of social machinery to insure everyone a standard of living adequate for the maintenance of health. Enable every citizen to realize his birthright of health and longevity.

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Core Functions of Public Health

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Assessment
Policy Development
Assurance

Assessment: monitor health status to identify probs, diagnose and investigate these probs and health hazards. Collects, analyzes info about community health

Policy Development: knowledge and info gathered utilized in development of ph policies and specific strats. Inform, educate, and empower ppl. Mobilize partnerships to identify and solve probs, and develop plans and policies

Assurance: ensures that services needed are available and accessible to all persons. Enforce regulations, assure competent health care workforce, evaluate effectiveness, accessibility, and quality.

Also, research for new insights and innovative solutions to health problems.

Prevention is the essence of Public Health!

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Rights

Theories of Justice

Advocacy

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privilege that one is justly entitled. Serves as rules of interaction between ppl. Standards.

Negative right: proscribe action.
Not be subjected to an action of another human (usually abuse or coercion).

Positive right: prescribe action.
Right to be provided with something.

Children cannot speak for themselves.

Satisfying rights required the expenditure of resources (ie public education), so we need rules for the fair allocation of resources..
Rules are called Principles of Distributive Justice:
-Principle of utility
-Principle of rules or duties

Advocacy: urging action to effect change toward a desired end for a cause. Attempting to persuade someone of your point of view.
Assessment of prob, scientific data to prove, development of strategic plan

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Healthy People 2010

2 Overarching Goals:

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1. Eliminate disparities
2. Increase quality and years of healthy life

PH doc that is part strategic plan and part textbook on PH priorities. National health objectives for the decade.

Also: 28 focus areas (2 relate directly to MCH), 468 specific objectives (also show numerical presentation), 10 leading health indicators.

Huge national resource and intellectual investment (lrg consortium of organizations). Part of a national action plan.

-Use Healthy Ppl as a data resource, vehicle to involve the public, media, officials.
-Basis to form coalitions, define common ground, common template
-use to form basis of agreements and interactions with government

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Healthy People 2010:

*Ten Major Health Indicators

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Used to measure the health of the nation

1. Physical activity
2. Overweight and obesity
3. Tobacco use
4. Substance abuse
5. Responsible sexual behavior
6. Mental health
7. Injury and violence
8. Environmental quality
9. Immunization
10. Access to health care

POTSRMIEIA

(Please observe the sticky rice mom is eating in august)

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*Forces that impacted the development of MCH services at end of 19th-early 20th century.

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1. Social action for the welfare of children
2. Advances in medicine
3. State and local health organization

Social action: Child labor was a big concern, national child labor committee, fair labor standards act.

Advances in Medicine: 1st children's hospital/clinic established, AMA, Pediatrics (Jacobi, father of)/special section of medicine, thru bacteriology and observation realization that children's medical needs differed (recall contaminated milk)!

Organization of State and Local Health Agencies: provided governmental framework for action of behalf of moms and kids. State Board of Health in MA and many health departments.

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More child health influences...

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Private sectors and actions usually happen first (milk stations, mary ellen-child cruelty), then state picks up; State board of health, School inspections, Henry Street Settlement (Wald, met needs of local community), school nurses.

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Progressive Period

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First 15 years of 1900s. Federal government expressing greater concern for the welfare of its citizens; more direct interest esp. children.

Crusade for Children: improve child health and labor conditions.

First Bureau of Child Hygiene in NY: Josephine Baker-move from private charity to public responsibility. Visits to tenement homes (rundown, slums, projects). Provided instruction and assistance to moms about infant care, school children, clinics, midwives, etc.

Then White House Conference..federal level! Federal US Children's Bureau (IM, maternal death, MCH care, standards, gave results to professionals and public)

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Flexner Report

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(1910) Survey of US medical education. He was an educator not a doctor. Schools to: enact higher admission and graduation standards; adhere to protocols of mainstream science in teaching and research. Many schools closed.

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*Sheppard-Towner Act

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1921 The First Maternity and Infancy Act!
(Support was created beforehand with an increased awareness of the importance of MCH issues, 1920 women get right to vote)
Happened at federal level, act of congress, provide services.

$$/Grants to states to develop MCH services.
Principle of public responsibility established (but many opposed)

People concerned about socialism and Shep-town collapsed in 1929--also stock market crashed in '29 = reduced resources but greater need

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*Social Security Act

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1935. Big milestone!
FDR signed into effect

-Title V of legislation provided programs for maternity, infant, and child care, as well as full range of medical services for children.

-Funds allocated to states to pay for MCH and Crippled Children's services; physicians, dentists, nurses, social workers, nutritionists

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More White House Conferences...

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Child health protection and development, investigate maternal deaths, importance of nutrition, malnutrition, no discrimination ('40), maternity care

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1940's and 1950's

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WWII: services developed to help fams of enlisted, strong support for these programs

National School Lunch Act: well-being of children and consumption of local foods. National security issue also bc many ppl after depression not physically up to par, so wanted to feed young children to they can fight later on.

Progress happening! Major advances in medicine, technology, knowledge of vitamins and nutrition, antibiotics

Mental well-being taken into account.

Racially segregated public schools, 'prejudice and your child' (Ken Clark 1st AA to get PhD). No differences b/t mental abilities of blk and white--important role in desegregation of American schools!

1951-ACOG

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*Oral Contraceptives

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Approved in 1960 for use in the US. After the Golden Anniversary WH Conference

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1962 Milestone

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Creation of the National Institute of Child Health and Human Development (NICHD).
Supports and conducts research on health of kids, adults, fams, and populations.

First time institute to promote studies directed at the entire life process rather than toward specific diseases or illnesses.

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1960's and 1970's

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A lot of mental health stuff going on.

MIC (maternity and infant care projects) Prevent mental retardation and reduce IM in poor areas)and C&Y (Health care) projects.

Screening procedures at birth.

All in all, major expansion of federal programs for poor and children, however growing disillusionment with the gov.

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Social Milestone (in the 60's)

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War on Poverty Jan 7th, 1964.

President Johnson declares "unconditional war on poverty"
=> Economic Opportunity Act: citizens have opportunity to work and for education

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Title XVIII and XIX of Social Security Act

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Medicare (XVIII): health insurance for the elderly (over 65)

Medicaid (XIX): coverage for poor women and children

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Family

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U.S. Census Def: 2 or more persons living together who are related by blood, marriage, or adoption.
vs. postmodern definition; fictive kin

Primary social context
Provide $ support, nurturing and socialization, protection

Trends. Always disparities

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Society/Government's Responsibility

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-Children living in poverty
-Public education concerns
-No access to health care
-No adequate health education programs
-Neighborhood degeneration
-Domestic violence and abuse
-Substance abuse
-Unemployment for adults and youth

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Children Living in Poverty

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lack of a usual or socially acceptable amount of money or material possessions; lack of the means to satisfy people's basic needs (food, shelter, prevailing standard of living).
Economic and noneconomic connotations (poor health, bad behavior, low education/skills)

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Public Education Concerns

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Funding
Performance standards.

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No Access to Health Care

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Availability-Medically underserved areas
Ability to pay
Knowledge to seek out
User friendly
Culturally sensitive

70% of uninsured live in fams above poverty level. Nat'l health insurance?

FL has KidCare: under 19, low cost health insurance. But now, enrollment in the system is capped

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Neighborhood Degeneration

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enviornment can affect health. No safe haven. Community stressors: Physical and psychosocial.

Physical: noise, temp, light vs. Psychosocial: crowding, discrimination, fear, economic deprivation. All can contribute to poor health!

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10 Great PH Achievements, 1900-1999

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Vaccination
Healthier Mothers and Babies
Family Planning (desired birth spacing and fam size)

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Pregnancy

Intended vs. Unintended

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Intended: wanted at time of conception or sooner

Unintended: (common). Not wanted. Either mistimed (wanted at some time, but occurred sooner than they were wanted) or unwanted (woman did not want to have pregnancy or any more at all)
Consequences of unintended (see lecture 1/30 #1 pg4). Healthy Ppl 2010 wants decrease to 30%.

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Family Planning

(clinics)

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Recall Margaret Sanger: nurse, she challenged the legal and cultural obstacles that made controlling fertility difficult and illegal.

Fam Planning clinics funded through Title X of Public Health Service Act (federal). Title X awards grants to pub and private non-prof agencies to provide voluntary fam planning services.

Clinics may be only contact ppl have with healthcare system

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ART

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Assisted Reproductive Technology: ART includes all fertility treatments (cycle) in which both eggs and sperm are handled:

IVF (in vitro)
GIFT (gamete intrafallopian transfer)
ZIFT (zygote intrafallopian transfer)

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*Causes of Maternal Mortality in the Developed World

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-Embolism
-Hemorrhage
-Pregnancy induced hypertension (PIH--> toxemia, eclampsia)
-Infection
-Ectopic pregnancy

EHPIE
(everyone hates peas including ed)

50 to 75% of all maternal deaths are preventable! Racial disparities...trend reversal

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*Causes of Maternal Mortality in the Developing World

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-Hemorrhage
-Indirect cause (ex. anemia, malaria)
-Infection
-Unsafe abortion (!)
-PIH (eclampsia/toxemia)
-Obstructed labor

HIIUPO
(hiigh-up-o)

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Maternal Mortality

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Underestimated, prob 1.3 to 3 times higher: underreporting and different definitions (6wks vs. 1 yr)

Racial disparities; blk women dying way more often (3.5 times higher than white women).

The US has not reached an irreducible minimum of maternal mortality

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Recall PMSS
PRAMS

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preg mortality surveillance system: gather info on preg related deaths

preg risk assessment monitoring system: population based data, state specific on maternal behaviors and experiences before, during, and shortly after pregnancy.

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march of dimes

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"fight to save babies!"
improve the health of babies by preventing LBW, defects, prematurity, and IM

Fight against prematurity: increase awareness of growing problem; decrease the rate of premature births
-fund research; educate fams; expand access; help healthcare providers

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Preconception Care important!

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risk assessment
education and health promotion
medical and psychosocial interventions.

Since PCP is usually the first person to see mother to be, certain cares should be integrated into these services

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(what is) Prenatal Care?

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One of the best examples of preventative care

-risk assessment
-serial surveillance
-health education
-psychosocial support

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Healthy Start

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A National Program

Many organizations (at local level) whose objective is to IMPROVE PREGNANCY OUTCOMES!

Adequate prenatalcare
positive behaviors
meet basic health needs
reduce barriers to access
Require provider participation in pre- and postnatal screening of all preg women

"Enhanced Services" (psychosocial support)

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Katherine's Law

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issuance of birth certificate of Birth Resulting in Stillbirth. Meant a lot to fams who lost a child, but not used to establish identity

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Low Birthweight and Prematurity

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contribute to IM and play major role in both short and long term morbidity.

Slight increase!
(because of multiple births with fertility treatments?).
# preterm babies increased

racial disparities.

Consequences of preterm: immediate, long-term, cost (pg 4, 2/6 #1)

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*Principle Risk Factors for Low Birthweight

Demographic Risks*

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-Age (less than 17, over 34)
-Race (black)
-Low socioeconomic status (hand in hand with race)
-Unmarried
-Low level of education

ARSUE
(Amber Runs Slow Under Evergreens)

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*Principle Risk Factors for Low Birthweight

*Behavioral and Environmental Risks

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-Smoking
-Poor nutritional status
-Alcohol and other substance abuse
-DES exposure and other toxic exposures, including occupational hazards
-High altitude

SNADH
(Study nothing and die hard)

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*Principle Risk Factors for Low Birthweight

*Healthcare Risks

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-Absent or inadequate prenatal care
-Iatrogenic prematurity (doctor caused it; induced the pregnancy)

AI
(artificial intelligence)

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*Infant Mortality

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Not a health problem--infant mortality is a social problem with health consequences!

IM Related to:
fam socioeconomic stat
parents education level
maternal age
maternal health stat and nutrition
maternal behavior
availability and utilization of health services

IM rate:
2004= 6.78
2007 = 6.34
2010 goal= 4.5

mortality is a social problem with health consequences!

Important measure of a nation's health
Indicator of health status and social well-being

racial disparities--blk infants deaths way higher

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Leading Causes of IM

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1. Congenital anomalies
2. Disorders related to short gestation (preterm) and low birthweight
3. Sudden infant death syndrome (SIDS)
4. Respiratory distress syndrome
5. Maternal complications of pregnancy

These 5 account for more than half of all infant deaths.

Majority of infant deaths during neonatal period (first 4wks of life)
SIDS doesn't usually happen in neonatal period.
Postneonatal SIDS in #1 (accounts for about 1/3 of all deaths)

Racial disparities
county and state/national differences--> hispanic population decreases IM rate?; new comers seek care and learn the system.
But Usually, IM higher in cities-> increased poverty, crime etc.

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CityMatCH

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nongovernmental
Organization of many health departments representing urban communities

Improve urban wmn and children by strengthing PH organzations and leaders in community.

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IMR

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Our ranking keeps getting worse (#41 on list of countries with lowest IM)

Wealthiest country. Out of 7 richest countries, US has the highest IMR (G7).

Why?
Racial and ethnic diversity, but all countries are melting pot
Income distribution-extreme poverty levels-country cant afford equitable distribution of resources
We do not have acceptable HC insurance coverage.
Prenatal care
Availability of resources

Adverse conditions experienced in mother's childhood?

Reduction of IM saves $$

(recall FL healthy start program-objective is to improve pregnancy outcomes)

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FIMR

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(part of healthy start)

Community based reviews of fetal and infant deaths to look at trends, issues in service delivery system

Provide continuous quality improvement-medical aspects, psychosocial, environmental etc aspects of prenatal care
Counseling available
Data that can be used for planning initiatives and incorporated into policies.

CRT: multi-disciplinary panel reviews data to determine trends and barriers; will develop recommendations for improving local system of care to reduce deaths

CAG: composed of leaders in the comunity who can affect change; non technical expertise in community and included ppl outside of health care; reviews CRT recommendations and implements into community to improve local services.

Review of cases should:
Describe health of commun
Share strengths and weakness
Improve coordination among providers
identify gaps
build collaborative improvemetns to service delivery system
Implement solutions
*what can we learn from the death of this baby?

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SIDS

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Sudden death of an infant under one year which remains unexplained

A diagnosis of exclusion!

Rates have declined 50% in US in last 20yrs (now.54)

Cause unknown! Predisposition to something or maybe a stressor in environment provoked whatever wrong with baby?

Most commonly occurs between 2-4 months. Sexual and racial disparities

Risk factors, but NOT causes!

American SIDS Institute

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Center for Birth Defects Research and Prevention

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enabled by CDC

congential #1 cause of infant mortality
causes of 75% of birth defects are unknown!

Possible environmental and genetic factors..?

In FL, the FL Birth Defects Registry (FBDR): statewide surveillance.

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Environmental Exposure in Pregnancy

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Environmental: all factors external to the individual-occupational hazards; use of meds; substance abuse; food-borne risks; infections

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Thalidomide

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used to treat morning sickness!

More than 10,000 children born w/major malformations.
FDA did not approve in US.

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DES (Diethylstilbestrol)

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synthetic estrogen drug.
Thought to prevent miscariage and ensure healthy pregnancy.

Wmn have higher risk for breast cancer
Offspring have increased risks for health probs
-girls: cancer; infertility; preg probs; changes in reproductive organs

-males: probs with reproduc organs, but third generation males have urethra opening on side of penis (hypospadias)

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Substance Abuse in Women

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Abuse = improper of excessive use

True prevalence is unknown

Meconium (1st stool baby has after born).

Major medical and obstetric complications associated with maternal substance abuse.

Direct and Indirect probs of substance abuse (non medical vs. medical)
Pregnancy may be incentive to stop using drugs

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Alcohol

Back 54

Most common
Diagnosis depends upon interview and what they tell you...

Can cause: spontaneous abortion; still birth; FAS (FAE); enters breast milk and can decrease lactation all together.

FAS: leading cause of mental deficiency in US
CNS dysfunction; growth deficiency; facial characteristics; malformations. Also, long term effects (mental, social)

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Substances to Avoid

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Tobacco
Mercury (certain game fish)
Listeriosis (found in deli meats and pates and soft cheeses)=microorganism
Raw or undercooked foods
Liver (high Vit A)

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Violence

Back 56

Intentional use of force against oneself, another person or group or community, that results in injury, death, psychological harm, maldevelopment, or deprivation.

Can occur anywhere from a personal level within the home to global proportions i.e. war.
Children define as 0-18 (all of 18 but not including 19)

Most violent deaths are suicidal 1/3 are children, but homicide 2/3rd are children!

Over 50% of violent deaths are due to firearms.

Racial disparities across the board.

With rates, recall that many injuries resulting from domestic disputes are not hospitalized!

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ACE Studies

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Adverse Childhood Events

(9 different recall event topics, then follow up patients for health outcomes)

Only about 12% of people have none of this going on, and 12% have more than 4.

Higher risk of adverse health with greater #s of ACE
(strongest event is violence against mother)

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Violence Impacts on Life

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Individual factors within context/culture (fam disorganization, poor opportunities, peers); cumulation of social factors vs. moderation effects (live in the hood and police wont come to your house, builds up); repetition of violence; developmental stages (young and impressionable)

=> the more positive things/prevention methods you have going for you, the better off you'll be in response to violence

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Solutions to violence (?)

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What works:
early start
prevention over intervention
multi-focused approach
macro-level influences
cultural/community resonance

-nurse/fam partnerships
-social capital and collective efficacy

Doesn't work:
Don't touch
scared straight
aggregation of offenders
gun buy-backs (very expensive and not getting criminal guns off street)

May or May Not Work:
Peer counseling
Child access prevention laws

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Current policies that are bad (violence lecture)

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Concealed carry
one gun a month
mental health
background check
castle law - you feel threatened in your house, you can shoot someone.
Zero-tolerance
preschool expulsion
prenatal drug exposure

Home visitation
Alternatives for young offenders

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Child well-being

Back 61

True measure of nation's standing.

Based on 6 things:
Material well-being
health and safety
education
peer and fam relations
behavior and risks
Own sense of well-being

MHEPBO

(My, he excels. Pretty bobby onward!)

Most children are healthy! But always racial disparities

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Unintentional Injuries

Back 62

#1 cause of death for children over the age of 1

=> Although overall rates have declined, 1/3 of injury deaths are preventable using known strategies! (most common: car crashes, drowning, fire)

Suffer directly and indirectly from UIs (i.e. can lose a parent, income reduced bc of disabled family member, etc.

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10 Great Pubic Health Achievements 1900-1999

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Motor vehicle safety

Reduction in childhood injuries not just a coincidence.
Changes have occurred thru concerted efforts by many people shaping injury prevention as a public health discipline
Esp in areas of:
-surveillance
-intervention
-evaluation

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Injury Prevention and Control

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Public Health Approach:
Assessment-> Policy Development-> Assurance

(In this case: surveillance, risk factor identification, implementation evaluation (i.e. what works?), implementation)

Historically, Haddon is the founding father of modern-day injury prevention

Accident- unforeseen happening
Injury- intentional or unintentional damage to the body

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Haddon Matrix

Back 65

For any injury, there's a...

Injury Host
Injury Agent
Injury Environment
(can be analyzed temporally in terms of:)
Pre-injury phase
Injury Phase
Post injury phase

Matrix looks like tic tac toe grid
Columns: Factors (human, agent & carrier, environmental: physical and social)
Rows: Phases (pre, event, post).

In first row, you reduce the probability of injury
2nd, the severity of injury
3rd, the consequence of injury

(see page 10, lecture 2/20 #2)

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Risk Factors for UI

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Demographic characteristics
-age
-gender
-location of residence
-race/ethnicity
-fam income
Prevalence of threat in commun
Access to and use of environmental countermeasures (i.e. prevent initial creation of hazard, make what is to be protected more resistant, stabilize and repair object of damage)
Importance of supervision in avoiding the threat

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Approached to Injury Prevention

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Governmental involvement, creation of services and laws
educational strats
environmental and product design
human behav
enforcement of regulation
need for coordinated efforts