nutrition 526 - 2011 framing maternal & infant nutrition
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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
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