MATERNAL AND CHILD HEALTH

Maternal and child health (MCH) refers to the health of mothers, infants, children, and adolescents. It also refers to a profession within public health committed to promoting the health status and future challenges of this vulnerable population.

HISTORICAL DEVELOPMENT

One of the greatest achievements of public health in the twentieth century in the United States was the dramatic improvement in the health of mothers and babies: during this period infant mortality declined by greater than 90 percent, and maternal mortality declined by 99 percent. While improvements in living standards, educational levels, and environmental conditions have contributed most to these improvements, public health MCH programs have also played a role.

The development of these MCH programs occurred in the unique political and social landscape of the United States, where a reliance on individualism has shaped the attitude that caring for children is the parents' responsibility, and that government should step in to help only when families and communities are not able to care for their own. The concept of federalism has also played a role in dividing responsibility between the federal government and state and local authorities. Further, the dominance of the biomedical model in the United States has directed most of the monies spent on MCH to the provision of direct clinical services. Some of the major historical developments in MCH are highlighted in Table 1.

Maternal Health. At the beginning of the twentieth century, for every one thousand live births, six to nine women died of pregnancy-related complications. Sepsis was the leading cause of maternal death, with half of the cases following delivery (often performed without following the principles of asepsis), and half associated with illegally induced abortion. Hemorrhage and preeclampsia (convulsions) were other leading causes of mortality. In response to the high maternal and infant mortality rates, and to women's suffrage, Congress passed the Maternity and Infancy Act

Table 1

(also known as the Sheppard-Towner Act) in 1921. The Fetal, Newborn, and Maternal Mortality and Morbidity Report of the 1933 White House Conference on Child Health Protection called attention to the link between poor aseptic practice, excessive and inappropriate obstetrical interventions (induction of labor, use of forceps, episiotomy, and cesarean deliveries), and high maternal mortality. During the 1930s and 1940s, hospital and state maternal mortality review committees were established. At the same time, a shift from home to hospital deliveries was occurring. The proportion of infants born in hospitals increased from 55 percent in 1938 to 90 percent in 1948, which was accompanied by a 71 percent decrease in maternal mortality. Medical advances (including the use of antibiotics, the use of oxytocin to induce labor, safe blood transfusions, and better management of hypertensive disorders) accelerated the declines in maternal mortality. Liberalization of state abortion laws, beginning in the 1960s, contributed to an 89 percent decline in deaths from septic illegal abortions between 1950 and 1973. In 1979, the Centers for Disease Control and Prevention partnered with the American College of Obstetricians and Gynecologists in developing the Pregnancy-Related Mortality Surveillance System, and implementing maternal mortality review boards across the country. At the end of the twentieth century, for every 100,000 live births, only seven to eight women died of pregnancy-related complications—a 99 percent reduction of the rate at the beginning of the century.

Infant Health. At the beginning of the twentieth century, for every one thousand live births, one hundred infants died before age one. Infant mortality began to decline in the early part of the twentieth century, following improvements in urban environments (e.g., sewage and refuse disposal and safe drinking water), milk pasteurization, rising standards of living, and declining fertility rates. The Children's Bureau formed in 1912 called for the establishment of the National Birth Registry in 1915. The Children's Bureau became the primary government agency to work toward improving maternal and infant health and welfare for the next thirty years. In 1935, Congress enacted Title V of the Social Security Act, which authorized and appropriated funds for maternal and child health-services programs. Between 1930 and 1949, infant mortality declined by 52 percent, largely due to antibiotics, development of fluid and electrolyte replacement therapy, and safe blood transfusions. It declined further following the implementation of Medicaid, Community Health Centers, and other federal programs in the 1960s. The Special Supplemental Food Program for Women, Infants, and Children (WIC) was created in 1972. Infant survival continued to improve in the 1970s because of technologic advances in neonatal medicine and the regionalization of perinatal services. Medicaid eligibility for pregnant women and infants was significantly expanded in the 1980s to enhance access to, and utilization of, prenatal care. The development of artificial pulmonary surfactant in the late 1980s and the use of antenatal corticosteroids in the 1990s to prevent and treat respiratory distress syndrome in premature infants also contributed to a decline in infant mortality. Other improvements in infant health in the 1990s include a 50 percent decline in the rates of sudden infant death syndrome, advances in prenatal diagnosis and surgical treatment of birth defects; and national efforts to encourage reproductive-aged women to consume folic acid to reduce the incidence of neural tube defects.

Child Health. Industrialization in the late nineteenth century forced many children into hazardous labor in mills, mines, and factories. In 1909, President Theodore Roosevelt convened the first White House Conference on Care of Dependent Children, which called attention to the unacceptably high rate of infant deaths and the detrimental effects of child labor. This led to the creation of the Children's Bureau in 1912 to "serve all children, to try to work out standards of care and protection which shall give to every child his fair chance in the world." Both the establishment of the Children's Bureau and the passage of the Sheppard-Towner Act met with formidable resistance. They were seen by many as governmental intrusion into the relationship between children and their parents, and they were opposed by the American Medical Association (AMA) because of their potential for governmental interference or control over the practice of medicine—despite an endorsement from the Pediatric Section, which split off from the AMA in 1930 to form the American Academy of Pediatrics. The Sheppard-Towner Act was over-turned in 1929. The enactment of Title V in 1935, however, expanded health and social services to mothers and children.

Medicaid was enacted in 1965 as a federal-state partnership to fund health services for low-income families with children. The Head Start program, launched in 1965, provided an intellectually stimulating and healthful environment for preschool children. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program was created in 1967 to fund preventive health services for Medicaid-eligible children, including physical and developmental exams, vision and hearing screening, dental referrals, and immunizations. These advances were followed, however, by a downsizing of federal involvement and the return of power and responsibility for MCH policies to the states in the 1980s. The most significant change was the consolidation of seven categorical MCH programs into the MCH Services Block Grant. Health care coverage for children was re-expanded in 1997 with the creation of the State Children's Health Insurance Program.

Children with Special Health Care Needs. Title V of the 1935 Social Security Act created Crippled Children's Services (CCS), which became the only source of federal funding for the next thirty years for children with special health care needs. Enactment of Medicaid (Title XIX) in 1965 relieved CCS of many of its reimbursement and direct service provision responsibilities. In 1974, the Supplemental Security Income (SSI) Childhood Disability Program began to provide monthly cash payments to low-income children with disabilities and special health care needs. The Omnibus Budget Reconciliation Act of 1989 (OBRA89) directed state Children with Special Health Care Needs programs (CSHCN, formerly CCS) to develop community-based systems of services and to promote and provide family-centered, community-based, comprehensive, and culturally competent services for children with special health care needs. Thirty percent of the MCH Services Block Grant was to be directed toward this use. Alarmed by the rapidly increasing SSI enrollment, Congress redefined disability, restricted eligibility, and reduced cash assistance to children with disabilities in 1996.

CURRENT STATUS

Despite significant improvements in the health of mothers, infants, and children during the twentieth century, the United States compares poorly with other developed nations on most indicators of MCH. In 1997, the United States ranked twenty-fifth in infant mortality and twenty-first in maternal mortality among developed nations. Table 2 presents a report card of selected indicators of MCH in the United States, along with national goals set for the year 2010.

There are also significant disparities in MCH among racial, ethnic, and other sociodemographic categories. For example, African-American infants have twice the chance of dying, of low birth weight, and of being premature, as compared to white infants. Maternal mortality is five times higher among pregnant African–American women than among pregnant white women. The teen pregnancy rate is twice as high among Hispanic women, and three times as high among African-American women, than it is among white women aged fifteen

Table 2

to seventeen. Causes of these disparities have not been determined, but they have been attributed to differences in genetics, behavior, culture, socioeconomic class, and access to health care. Recent research on neighborhood and community factors, as well as cumulative life experiences and exposures, may shed light on the persisting disparities in MCH outcomes.

MCH PROGRAMS

A myriad of public health programs have been created over the years to improve the health of disadvantaged mothers, infants, and children, and to reduce disparities in health status and health care access. A few of the major programs are listed below.

MCH Block Grant Program. Title V of the Social Security Act (1935) authorized the use of federal monies for MCH programs. The biggest change to the Title V program came in 1981, when seven MCH programs were consolidated into the MCH block grant. Administration of MCH programs, which support direct delivery of MCH services in the public health setting, devolved to the state level, while state and federal governments share the costs.

Medicaid. Created by Title XIX of Social Security Act in 1965, the objective of Medicaid is to support the provision of health services to low-income Americans. The federal and state governments jointly administer the program and share its costs. Medicaid is really a financing program rather than a service delivery program. States are mandated to cover pregnant women and children six years of age and younger living at up to 133 percent of the federal poverty level, as well as all children up to age nineteen in families with incomes below the poverty level. Medicaid is by far the largest MCH program, funding prenatal and obstetrical care, the EPSDT program, and health services for children with special health care needs. Three out of four Medicaid recipients are women and children, though they consume only one-fourth of total Medicaid expenditures.

Community and Migrant Health Center Program. Created in 1965, the Community and Migrant Health Center Program provides basic primary care to medically underserved (largely rural) areas. It is funded by the federal government and administered at the community level. These centers place a high priority on reducing infant mortality and improving the health of mothers and children. One-third of individuals served by the program are children under age fifteen, and one in four are women of childbearing age.

The Special Supplemental Food Program for Women, Infants, and Children (WIC). Created in 1972, WIC provides supplemental food and nutritional education to low-income pregnant women, nursing mothers, and children diagnosed as being at nutritional risk. It is funded by the federal government and administered by the U.S. Department of Agriculture. Technically speaking, WIC is not a health care program, but evaluations have found WIC to be effective in reducing infant mortality, low birth weight, anemia, and other problems.

Head Start, Early Head Start, and Healthy Start. Project Head Start was created in 1965 to promote social and behavioral competence among preschool children from low-income families and to ensure that the children enter school with a similar foundation as their more economically advantaged peers. The program includes comprehensive health services, including preventive health services. Ten percent of Head Start enrollment is reserved for children with disabilities. Evaluations have shown reduced juvenile delinquency and increased school completion rates among children enrolled in the Head Start program. In 1994, Congress established the Early Head Start program for low-income families with infants and toddlers. Both programs are administered by the Head Start Bureau of the Department of Health and Human Services. The Healthy Start Initiative was created in 1991 to attack the causes of infant mortality and low birthweight using a broad range of community-based interventions in nearly one hundred communities across the United States. The Healthy Start Initiative is administered by the Maternal and Child Health Bureau.

Temporary Assistance for Needy Families (TANF) Program. In 1996, the U.S. Congress passed landmark welfare reform legislation (the Personal Responsibility and Work Opportunity Reconciliation Act) that replaced the Aid to Families with Dependent Children (AFDC) Program with the TANF Program. TANF was intended to give states new opportunities to develop and implement creative and innovative strategies and approaches to removing families from a cycle of dependency on public assistance and creating employment opportunities for them. While reviews of the impact of TANF on the health of women and children have been mixed, TANF has generated additional monies for MCH programs. For example, Los Angeles County created the Long-Term Family Self Sufficiency Plan with its TANF monies. The plan includes programs to help pregnant women gain access prenatal care, and to provide additional support services, such as parenting skills training.

State Children's Health Insurance Program (SCHIP). SCHIP was established in 1997 to provide insurance for children from families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. Of the over 10 million children in the United States who were uninsured in 1997, only 3 million were eligible for Medicaid prior to SCHIP. In its first three years, SCHIP has enrolled over 3 million children. Although enrollment was slow initially, states have responded with innovative strategies to reach out to uninsured children and families to increase enrollment. SCHIP is administered through the Health Care Financing Administration (HCFA).

State Programs. In addition to the programs described above, many state and local governments have developed additional MCH programs of their own. A notable example is the California Children and Families First Initiative, or Proposition 10. Passed in 1998, the initiative has raised approximately $700 million annually from a tobacco surtax to be used to improve early child development for children up to age five. The money will be used to support health care services for children and families, parental education and support services, and child-care programs. Because of the autonomy of its governance structure and its broadly defined goals, it is flexible enough to allow for different approaches that cross the traditional boundaries of MCH, a flexibility that is often not permitted under categorical funding and grant making. Proposition 10 has the potential for providing a model for the rest of the nation.

FUTURE CHALLENGES

At the beginning of the twenty-first century, many challenges in MCH remain. Some of the most important areas of concern are described below.

Maternal Mortality and Morbidity. The decline in maternal mortality in the United States has leveled off since 1982. This does not mean that it has reached an irreducible minimum, as one-third to one-half of the deaths that still occur are probably preventable. Maternal deaths are only the tip of the iceberg, however, as one in four women experience complications during pregnancy, many of which are preventable. An increased effort to assess and assure the quality of health care for pregnant women is needed. Likewise, the connection between maternal health and women's health needs to be better understood. Improving women's health over the life course, and not only during pregnancy, is likely to have the greatest impact on improving maternal and child health.

Infant Mortality and Morbidity. Birth defects are the leading cause of infant death, affecting approximately 3 percent of all live births. Because many birth defects occur in the first three months of pregnancy, they are best prevented by preconceptional and early prenatal care. The causes of most birth defects are still unknown and require further research. Low birthweight and prematurity contribute to most of the infant deaths and congenital neurological disabilities not related to birth defects. They are also the leading cause of infant deaths among African Americans. To date, most interventions during pregnancy designed to prevent low birthweight and prematurity have not been effective.

Prenatal and Preconceptional Care. Although widely accepted, the effectiveness of prenatal care in improving pregnancy outcomes, particularly in preventing low birthweight and prematurity, has not been conclusively demonstrated. While this may reflect methodological flaws in research on prenatal care, it could also suggest that prenatal care is not provided in the proper manner, and some researchers have begun to question the appropriateness of the content of prenatal care. Still others have argued that less than nine months of prenatal care is not enough to reverse the cumulative impact of lifelong habits and exposures on pregnancy outcomes. Most women do not obtain preconceptional care before getting pregnant, and many health care providers do not know how to provide preconceptional care, or they provide it only to women who are actively trying to get pregnant, thereby missing opportunities to improve the outcomes of pregnancies that are unintended.

Breast-Feeding. The benefits of breast-feeding to the health of mothers and infants have been well documented, including enhanced immunity against infections, improved cognitive development, and stronger maternal-infant bonding. Despite these benefits, the initiation and duration of breast-feeding in the United States remains low, particularly among disadvantaged women. Efforts to promote the WHO/UNICEF "Ten Steps to Successful Breast-feeding" in hospitals have met with little success. Changes in cultural norms, workplace practices, and social policy are also needed to encourage breast-feeding among American women.

Immunization. Although the up-to-date immunization rate of children in the United States has been steadily improving, it still falls short of the national goal of 90 percent by age two, particularly for poor children. There is no agreement among public health experts on a strategy to bring this up to the level at which "herd immunity" would protect those children who remain without immunization.

Child Care. Over half of U.S. mothers with children under six work outside the home, and 60 percent of these children receive care outside their homes. In addition to increased risk for infections and injuries, children cared for in day-care centers may receive less support for cognitive and social development than children cared for at home. Support for parents with child-care needs is low, particularly for low-income families.

Family Violence. A U.S. woman has a one-in-five chance of being physically abused at some point in her lifetime. Estimates of the prevalence of physical abuse by an intimate partner during pregnancy range from 4 to 8 percent, but it may be as high as 20 percent. Most communities have inadequate resources to help battered women. Many health care providers do not screen for, or cannot identify, domestic violence. Within communities, a shortage of shelter beds, social workers, and other basic services frequently exists, together with a lack of coordination among health care, social-service, and judicial systems. Children are abused in half of the families where women are abused. While little is known or done about primary prevention of family violence, what is clear is that family violence cannot be overcome without attention to the social and economic conditions that put children and families at risk.

Unintentional and Intentional Injury. Injury is the leading cause of death among children and adolescents, with motor-vehicle injury being the single leading cause. Other causes include fires/burns and drowning. Homicides and suicides account for one-fourth of injury-related deaths among adolescents. While progress has been made in preventing deaths related to motor-vehicle injury, largely attributable to a reduction in alcohol-related fatalities, little progress has been made in preventing deaths related to homicides and suicides.

Tobacco, Alcohol, and Other Drugs. Nearly one-third of teens are current smokers, and half have drunk alcohol within the last month. Nearly one-third have used marijuana, and 5 percent have used cocaine. Alcohol and other drugs contribute significantly to unintentional and intentional injuries among adolescents, including motor-vehicle accidents, homicide, suicide, as well as unintended pregnancies, sexually transmitted infections, and a host of other medical and social problems. Success of clinical interventions at the individual level is modest; and the effectiveness of neighborhoodand community-level interventions remains to be demonstrated.

Sexual Behavior and Unintended Pregnancy. One-third of girls and nearly one-half of boys in the United States have had sexual intercourse by the ninth grade, and 20 percent of all youth in grades nine through twelve have had four or more sexual partners. While these rates are similar to European rates, the rates of sexually transmitted infections and unintended pregnancies are much higher among U.S. teens. One in four sexually active adolescents will get a sexually transmitted infection by age twenty. Nearly one million adolescent women become pregnant each year in the United States, with half of these pregnancies resulting in live births. Teen mothers have lower educational attainment, lower future earnings, and higher welfare dependency. Two-thirds of these teen births occur outside of marriage.

CONCLUSION

Much of the advancement in maternal and child health has been made outside of public health. Progress in medicine, education, environment (both physical and social), gender and race relations, public policy, and many social areas have made, and will continue to make, important contributions to MCH. An important challenge for MCH as a profession is to promote change outside the traditional boundaries of MCH in order to improve the health of mothers, infants, children, and adolescents.

Michael C. Lu

J. Robert Bragonier

(see also: Alcohol Use and Abuse; Child Care, Daycare; Child Health Services; Domestic Violence; Head Start Program; Immunizations; Infant Mortality Rate; Perinatology; Pregnancy; Prenatal Care; Reproduction; Sexually Transmitted Diseases; Teenage Pregnancy; Title V; Tobacco Control; Women, Infants, and Children Program [WIC]; Women's Health )

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