neonatal death
Mamas on Bedrest: Priorities for Maternal and Child Health Identified
December 21st, 2011
Click to take the postpartum depression survey conducted by Case Western Reserve University http://filer.case.edu/~axp335/postpartdep.htm Thank you very much for your consideration.
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On the heels of the 20/20 special segment, “Giving Life: A Risky Proposition” World Health Organization (WHO) has released Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health. This comprehensive document outlines the necessary steps and guidelines nations (developing low and mid income nations in particular) must adopt in order to further reduce maternal, infant and child mortality and to have a chance of reaching Millennium Development Goals .
Maternal, Infant and Child mortality is a global issue. According to the report,
Annually, 358,000 women die worldwide during pregnancy and childbirth. Approximately 7.6 million children die before the age of 5 years, and those in low-income countries are about 18 times more likely to die during that time than children in high-income countries. Under-5 mortality rates are highest in sub-Saharan Africa and Southern Asia.
Maternal, newborn, and under-5 mortality rates have declined in accordance with Millennium Development Goals 4 (reduce the under-5 mortality rate by two thirds between 1990 and 2015) and 5 (reduce the maternal mortality ratio by three quarters between 1990 and 2015). However, the improvements are not occurring quickly enough to reach the 2015 targets.
WHO and its partners The AGA Khan University (in Pakistan) and The Partnership for Maternal, Newborn and Child Health performed a survey of more than 50,000 review papers to determine what steps are necessary to critically impact maternal, newborn and child health. Their goal was to identify key interventions that low and middle income countries can implement that are cost effective, will maximize resources and maximize the health and mortality of women, infants and children and thus help these countries reach worldwide millennium health and development goals. Their research has revealed some 56 key evidence-based interventions that when implemented, will have a significant impact on maternal, newborn and child health.
Rather than try and list all the interventions here, I refer you to their report, Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.
For each intervention, the authors indicated whether they recommend the intervention be delivered,
- Through the community or in the home-These health care workers are often community volunteers and/or influential outreach workers who have knowledge of the local community and are trusted by the community.
- Via healthcare professionals, outreach workers, or community health workers-Health care providers at this level are skilled professionals as well as outreach workers.
- In hospitals-Either local hospitals or regional referral hospitals that can provide higher levels of intervention and care.
The interventions were classified broadly as adolescents/prepregnancy, pregnancy, childbirth, postnatal (mother), postnatal (newborn), infancy and childhood, and cross-cutting community strategies.
Researchers believe that the recommendations in this report will help low and middle income countries’ health care workers best utilize their resources in an effort to reduce Maternal, Newborn and Child deaths. These guidelines will also help countries develop policies and regulations that will not only benefit women and children’s health, but also take into consideration the health care and policy environments of the countries so that all citizens will benefit.
Mamas on Bedrest: Pregnancy Spacing Improves Long Term Health Of Mamas and Babies
September 23rd, 2011According to a February 1999 New England Journal of Medicine article, separating pregnancies by 18-23 months is optimum to ensure the health of both mamas and babies.
The authors, Bao-Ping Zhu and colleagues found that incidences of adverse pregnancy outcomes such as premature birth and low birth weight were less likely to occur in pregnancies in which conception occurred 18-23 months after a prior pregnancy and delivery. They also found that there were lower incidences of pregnancy complications, such as pre-eclampsia, in pregnancies which occurred 18-23 months after a previous pregnancy and delivery. Interestingly, rates of complications went up when the pregnancy intervals were longer than 23 months between pregnancy and subsequent conception. The authors admitted that while this was a first assessment, there may be likely confounding variables such as maternal age, socioeconomic status, reproductive history and others that may exert an influence on pregnancy outcome.
As you can imagine, this has not always been well received. Many people simply balk at the notion of “planning” pregnancies and feel like pregnancies occur when they are supposed to occur. Others contend that the failures of contraception account for most of the pregnancy failures and that this cannot be helped as not contraceptive method, except for abstinence, is 100% effective at preventing pregnancy.
At the 2011 Association of Reproductive Health Professions Annual Meeting, this topic was discussed and the position of the Reproductive Health professionals present is to recommend long acting contraception (LARC) to women, especially those in the highest risk groups. Robert Hatcher, MD, MPH reviewed the currently available forms of reversible contraception.
- Depro Provera Injection
- Paragard IUD
- Mirena IUS
- Implanon implants
The recommendation for LARC comes as unintended pregnancies in the United States account for approximately half of all pregnancies annually. 60% of unintended pregnancies are what is called “Mistimed Pregnancies” meaning women admit that they would have had (another) child, just not at the time of this particular pregnancy. Most women cited contraceptive failure as the primary reason for unintended pregnancy. But a closer look at contraceptive use habits revealed some interesting statistics.
James Trussell, PhD, Office of Population Research at Princeton University and The Hull York Medical School shared statistics that showed that while the rates of unintended pregnancy has dropped amongst teens, the rates have increased in women in their 20’s. Women of lower education and lower socioeconomic status account for the greatest numbers of unintended pregnancies and African American and Latina Women have the highest rates of unintended pregnancies.
What was even more alarming is that in 2001, 52% of unintended pregnancies were to women who were using no method of birth control. Further, when interviewed for a study between 2006 and 2008, 10.6% of women at risk for unintended pregnancy weren’t using any contraceptive method.
Contraceptive problems arise mostly from “typical use”. What this means is how women typically use the contraceptive method vs. “Perfect use” i.e. how the method is intended to be used. Below is a table taken from the 2011 Contraceptive Technology Handbook outlining the failure rates of contraceptives with “typical use” and “perfect use”.
Method Typical Use Perfect Use
Chance 85% 85% (Percentages are effective rates)
Condom 18% 2%
Pill, Patch, Ring 9% 0.3%
Depo Provera 6% 0.2%
Paragard IUD 0.8% 0.6%
Mirena IUS 0.2% 0.2%
Implanon 0.05% 0.05%
What this table shows is that methods that require consistent (daily) use have a significant failure rate and significant difference between “typical use” and “perfect use”. However, the more “reliable” methods provide no protection against sexually transmitted infections (STI’s).
Anita Nelson, MD, Professor at the David Geffen School of Medicine at Harbor-UCLA Medical Center in Manhattan Beach, CA looked specifically at the oral contraceptives or birth control pills. What she shared both from the research and from her years in clinical practice is that in a 12 month cycle, women rarely take their pills as prescribed. Women on average miss 3 pills a month and as many as 60 pills a year. Even if they take a pill when they remember, for many women, this is days later and they are already at risk for unintended pregnancy.
Nelson also reiterated a little known fact amongst many women. Pregnancy is more dangerous to a woman’s health than hypertension, blood clots in the legs or diabetes and yet pregnancy increases the risk of all of these conditions occurring and persisting throughout a woman’s life. Pregnancy related mortality (death) in the United States between 1998 and 2005 has been higher than at any other time in the previous 20 years. 14.5 women die annually for every 100, 00o births and the rates for African American women is 3-4 times higher. Unintended pregnancy also has a higher risk of “sicker babies”. Nelson and other researchers advocate continuous (or long acting) oral contraceptives and condoms as a way for,
- Women to control their fertility
- Pregnancy to occur when desired, lowering risk for complications
- Unwanted fertility to be eliminated
Family Planning is seen by the US Centers for Disease Control and Prevention as one of the top 10 most important contributions to public health in the 20th century.
Family Planning is also seen as an important global health issue asserts Willard Cates, Jr., MD, MPH of Family Health International and The UNC Gillings School of Global Public Health. Cates presented data and information from the United Nations Population Fund, an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. Sharing statistics from the Guttmacher Institute, family planning averts 187 million unintended pregnancies and in turn prevents:
• 54 million unplanned births
• 112 million induced abortions
• 1.2 million infant deaths
• 230,000 maternal deaths
• 71 million DALYs saved
(WHO Definition of DALY’s: DALYs = Disability Adjusted Life Years. The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability)
Cates reiterated that Family Planning contributes to the Millinium Development Goals for the world which are:
1. End Poverty and Hunger
2. Universal Education
3. Gender Equality
4. Child Health
5. Maternal Health
6. Combat HIV/AIDS
7. Environmental Sustainability
8. Global Partnerships
Cates makes the case that only with widely available, long acting reversible family planning will the world’s goals of economic equality for women, increased educational opportunities for women, improved health and mortality for women and babies, reduced unintended pregnancy rates, reduced abortion rates, increased economic growth and stability for all nations.
What are your thoughts on contraception and unintended pregnancy? Would you ever use a long acting reversible contraceptive (LARC)? Share your comments below.
Mamas on Bedrest: Why I Can’t Tolerate The US Infant Mortality Rate
September 14th, 2011
Mamas on Bedrest, I can’t tolerate the fact that more black babies die in infancy than babies of other racial backgrounds. It sickens me. It angers me! It makes me want to cry. As a mama of two beautiful black children, the thought that simply by being African American their lives were at risk in their infancy is horrifying. I am lucky, I know. I have a husband who has single handedly supported our family financially while I was pregnant and beyond. I had the best healthcare. We live in a wonderful residential area and I don’t smoke or do drugs. Yet I still lost 2 children and my daughter was a preterm infant of low birth weight. What’s up?
September is Infant Mortality Awareness Month. We define infant mortality rate (IMR) as the number of deaths of infants under one year old per 1,000 live births. This rate is often used as an indicator of the level of health in a country. According to Index Mundi, the current IMR for the United States is 6.06/1000 live births. The breakdown is male: 6.72 deaths/1,000 live births, female: 5.37 deaths/1,000 live births and these numbers, from the CIA World Factbook, are accurate as of July 12, 2011.
Infant Mortality is often used as an indicator of the overall health of a nation. Looking at these numbers, things look pretty good for the US. But once you start looking “behind the numbers” things get a little sketchier. The United Nations lists infant mortality rates of most of the world’s countries. On this list, the US ranks 34th among nations of the world, and amongst industrialized nations and many of our “western” allies, we rank dead last. Suddenly things aren’t looking quite so rosy.
But we’ve improved. According to the Department of Health and Human Services,
“Overall, the nation’s infant mortality rate has fallen from 20 deaths per 1,000 live births in 1970 to 6.9 deaths in 2003 (preliminary data). The 2002 rate of 7.0 deaths, based on complete data, was higher than the 2001 rate (6.8), but has fallen 8 percent since 1995 and 24 percent since 1990. In 2002, the leading causes of infant mortality were congenital anomalies, disorders related to immaturity (short gestation and unspecified low birthweight), SIDS, and maternal complications.”
The most discouraging fact about infant mortality in the US is that it varies tremendously across racial groups. African American infants have an infant mortality rate of more than twice that of Caucasian and Hispanic infants. African American women, especially teenagers, are more likely to start prenatal care late in the first trimester or beyond and this is a known risk factor for increased infant mortality. The DHHS reports that for mothers 15 to 19 years of age, 29 percent received no early prenatal care in 2004.
According to the DHHS, there are 3 steps that we can implement now to lower infant mortality in the US and to narrow the gap amongst the racial groups.
- Promoting Access to Prenatal and Infant Care – Babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care. They also support a number of programs designed to improve access to care including Healthy Start, Medicaid/SCHIP programs, Prenatal care hotlines and immunization programs.
- Promoting Healthy Choices of Known treatments and behaviors that will lower infant risk – DHHS has promoted and implemented many programs proven to increase infant mortality. In particular, DHHS has be a staunch supporter of Maternal and Child Health Services (MCH) Block Grant (Title V). HRSA provides block grants to states to develop service systems to meet critical challenges in maternal and child health, including reducing infant mortality. These state efforts are developed with careful attention to Health Status Indicators and National Performance Measures, among them those that emphasize the importance of adequate prenatal care in improving the health of pregnant women and reducing infant mortality. In an average year, about 60 percent of U.S. women who give birth receive services through MCH programs.
- Increasing Research into the causes and potential cures of infant mortality – In addition to a myriad of research projects addressing specific causes of infant mortality, The Centers for Disease Control and Prevention is examining sociocultural, behavioral and environmental factors, including stress and social support, related to preterm births among African-American women in Harlem, N.Y., and Los Angeles, CA to try to get to the root issue causing the racial disparities in IMR.
Mamas on Bedrest are always in my mind when I read such reports because your pregnancy complications put you and your babies at risk. I think we all have to ask the questions, are we doing absolutely everything to ensure that pregnant women receive all the support and resources that they need to gestate and give birth to healthy babies? In my opinion, the answer is “No”. When a mama on bed rest has to worry about her job, feels forced to leave her bed and risk her child’s life in order to keep her job, is unable to meet her financial obligations and/or cannot access or afford much needed medical care for herself and her baby then we as a nation have failed her and her baby.
The US can redeem itself and lower its infant mortality rate. But it will require that we place the health and well being of mamas and babies before grandstanding, posturing and “political games of chicken” in our legislature. We have to impress upon our legislative leaders that our infant mortality rate is unacceptable and that disparities in IMR amongst infants of different racial backgrounds is also unacceptable. Speak up mamas! Your voices need to be heard! Your stories need to be told! Change will only happen when we demand it and refuse to settle for anything less than the absolute best for ourselves and our children. I won’t tolerate it. Will you?
References:
Preventing Infant Mortality: Fact Sheet The Department of Health and Human Services
