Nutrition 526 - 2011

Framing Maternal & Infant Nutrition

A Life Course Framework: T2 – E2

• Timeline: today’s exposures influence tomorrow’s health

• Timing: health trajectories are particularly affected during critical periods

• Environment: the broader community environment strongly affects the capacity to be healthy

• Equity: inequality in health reflects more than genetics and personal choice

Resources& Biology

Adaptive Mechanisms

Goals of Reproduction

DNA & metabolic programming

Access to Food

Knowledge & Skills

Support: basic needs, health care, cultural/social

Physiologic responses to reproduction & growth

Behavioral responses

Healthy mother who can nourish infant & produce further offspring

Optimal growth & development of offspring

Maternal-infant dyad

A Public Health Approach to Maternal and Infant Health

• Assessment• Policy Development• Assurance: Surveillance and monitoring

progress towards goals

Assessment

• Pregnancy population characteristics• Maternal health indicators• Infant health indicators

National Vital Statistics Reports. 2009; 57:12

In 2007• 4,317,119 births - highest number ever registered for the US• general fertility rate increased by 1 percent in 2007, to 69.5 births per 1,000 women aged 15–44 years, the highest level since 1990

In 2008 births and birth rate were ~ 2% less than 2007; in 2009 they were ~ 3% less than 2008. http://www.cdc.gov/nchs/products/nvsr.htm

http://www.cdc.gov/nchs/products/nvsr.htm

http://www.cdc.gov/nchs/products/nvsr.htm

Percentage of all births to unmarried women by age of mother, 1980 and 2007

National Center for Health Statistics, National Vital Statistics System.

In 2007, 40% of all US births were to unmarried women

Population Indicators & Trends for Maternal Health

• Pre-conceptual indicators• Weight gain• Diabetes in pregnancy• Pre-eclampsia• Cesarean delivery• Maternal death

Weight Gain During Pregnancy: Reexamining the Guidelines, IOM. 2009

Per birth certificate – includes all diabetes in pregnancy

African American and White Women Who Died of Pregnancy Complications,* United States

* Annual number of deaths during pregnancy or within 42 days after delivery, per 100,000 live births. † The apparent increase in the number of maternal deaths between 1998 and 1999 is the result of changes in how maternal deaths are classified and coded. Source: CDC, National Center for Health Statistics.

Population Indicators of Infant Health

• Infant mortality• Birthweight• Gestational age

Infant Mortality

• Infant mortality rate – Deaths of infants aged under 1 year per 1,000 or 100,000 live births. The infant mortality rate is the sum of the neonatal and postneonatal mortality rates.

• Neonatal mortality rate – Deaths of infants aged 0-27 days per 1,000 live births. The neonatal mortality rate is the sum of the early neonatal and late neonatal mortality rates

• Postneonatal mortality rate – Deaths to infants aged 28 days-1 year per 1,000 live births.

http://www.chipublib.org/004chicago/disasters/infant_mortality.html

INDICATOR HEALTH2: DEATH RATES AMONG INFANTS BY RACE AND HISPANIC ORIGIN OF MOTHER, 1983–2004

QuickStats: Infant Mortality Rates, by Mother's Place of Birth and Race/Ethnicity --- United States,* 2007MMWR July 8, 2011 / 60(26);891

http://mchb.hrsa.gov/mchirc/chusa_05/healthstat/infants/0307iimr.htm

Muntaner, C et al. ECONOMIC INEQUALITY, WORKING-CLASS POWER,SOCIAL CAPITAL, AND CAUSE-SPECIFICMORTALITY IN WEALTHY COUNTRIES. International Journal of Health Services, Volume 32, Number 4, Pages 629–656, 2002

• “In summary, the rates of low birth weight and infant deaths from all causes were lower in those countries with more voter turnout, more left votes, more left members of parliament, more years of social democratic government, more women in government, a stronger social pact and various aspects of the welfare state, and low income inequality, as measured in a variety of ways.”

Birthweight & Gestational Age

Defining Small for Gestational Age (SGA) and Large for Gestational Age (LGA)

National Vital Statistics Reports. 2010; 58:16

LBW Rate (%)

Premature Birth Rate

(%)

Infant Mortality

Rate(%)

African Americans

13.4 17.7 13.5

Asians 7.8 10.4 4.6

Native Americans

7.2 13 9.7

Whites 6.9 11 5.7

Hispanics 6.5 11.6 5.4

NGA Center for Best Practices, June 2004

Structures, Policies, SystemsLocal, state, federal policies and laws

InstitutionsRules, regulations, policies &

informal structures

CommunitySocial Networks, Norms, Standards

InterpersonalFamily, peers, social networks,

associations

IndividualKnowledge, attitudes,

beliefs

Social-Ecological Model for Determinants of Access to Resources & Nutrition Behaviors

Individual - Pregnancy• Physiology and Psychology of Pregnancy• Maternal Preconceptual status

– Inter-generational programming• Diet in pregnancy: energy/weight gain, macro

& micronutrients• Behaviors that impact nutritional status

– Substances: alcohol, caffeine, tobacco, drugs– Physical activity– Oral health– Pregnancy intendedness

• Stage of development: adolescence• High risk situations: GDM, PIH,

Intrapersonal/Community

• Social and cultural environments• Support from friends and family• Health and nutrition care providers

Institutional

• Hospital breastfeeding & formula policies

• Child Care policies• School policies for pregnant and

parenting teens• Worksite lactation policies

Policy & Environment

• Nutrition Assistance Programs for pregnancy, lactation and early childhood.

• Insurance policies for lactation support• Parental leave policies

Policy approach

• Access to food – Individual maternal-infant

dyad– Community based– Public health and health

services

• Knowledge and beliefs– individual– Family, community– Public health and health

services

Determinants of infant feeding practices

• Maternal employment• Health sector activities• Commercial availability and promotion

of processed milks and cereals• Urbanization vs.. modernization• Poverty and maternal nutrition• Perceived insufficiency of breast milk

History

• Child welfare movements became noticeable in industrialized countries (U.S. and Western Europe– “Political, economic, and humanitarian

motivations all converged to reduce the large wastage of child life”

History

• World War 1 and 2– Recruits unfit for service– “weaklings”

History

• Child welfare movements directed toward general hygiene for disease prevention, dietary improvements, and antepartum care– Infant Stations: to provide clean milk, instruct

new mothers on child/infant care, encourage breastfeed

– Innovative approach in 1908 establishment of Division of Child Hygiene in NYC

Child Hygiene Bureau NYC

• Tracked from register of live births• Home nursing visits• Education on infant care• Milk stations

– “there were 1200 fewer deaths when comparable to previous summer”

Policy Development: Poor Pregnancy Outcomes are Costly

• Medicaid finances 40% of annual births in the US and pays for 50% of hospital stays for premature and LBW.– Medicaid-funded deliveries represented

45.6% of births in WA in 2003.• The care cost for children with one of 17

common birth defects is $8 billion per year in the US.

Population vs.. individual