Maternal Health Issues Barbara Parker R.N., M.P.H. Division of Women’s and Infants’ Health Virginia Department of Health October 25, 1999

Major Issues Regarding Maternal Health <Maternal Mortality <Infant Mortality <Low Birth Weight <Access to Care

The 3 leading causes of maternal death in the United States THemorrhage, including ectopic pregnancy TPregnancy-Induced Hypertension TPulmonary Embolism

Reasons for reduction in maternal mortality PSulfa and antibiotic drugs PDecrease infections secondary to illicit abortions PAvailability of banked blood PSafer surgical procedures, including Cesarean

The Year 2000 goal (3.3 maternal deaths per 100,000 live births) will not be reached nationally or in Virginia.

Most obstetric complications which lead to maternal deaths can neither be predicted nor prevented.

Maternal mortality is not reduced through general improvement in nutrition, education, or elevation in social status.

Maternal Deaths by Race Virginia Residents,

Components of maternal death reviews 3Investigation of individual maternal death 3Multidisciplinary discussion of each case 3Recommendations to prevent future deaths

Maternal mortality is reduced by: gQuality intrapartum care gAccess to emergency obstetric care

Infant mortality is a health status variable which is widely recognized as a measure of a nation’s, as well as a state’s, maternal and child health status.

The United States ranks 22nd in the world in infant mortality.

Countries with lower infant mortality rates than the U.S. have comprehensive medical care systems that provide virtually all pregnancy and infant health care visits.

African-American babies are more likely to die in America than their white counterparts when born with the same medical risks.

Social standing in a community is linked to favorable outcomes in perinatal care even when access to services is constant.

Role of men in pregnancy and childbirth: WEncourage reduction of risky behaviors such as smoking, drug and alcohol use WFollow healthy nutrition WPromote early and regular prenatal care WIncrease assistance with household chores WObserve for complications of pregnancy

Strategies to reduce infant mortality: RExpand Medicaid eligibility RSimplify and shorten eligibility requirements RProvide “wrap-around” services

The improvement in infant mortality rates is not an indicator that babies are healthier, but medical technology is enabling sicker babies to survive.

Resource Mothers - home visiting mentors for pregnant teens and their families Baby Care - case management services after completion of a “risk assessment” with coordination, follow-up and monitoring Virginia Healthy Start Initiative - mentoring services for pregnant women; nutrition services for prenatal patients and infants; male support services for fathers; and community-based death reviews.

Regionalization of perinatal care was successful in the 1970s and 1980s by concentrating the births of very low birth weight infants to the tertiary centers.

RPCC The Regional Perinatal Coordinating Councils (RPCCs) are public/private coalitions charged with the goal to improve the system by which perinatal health care is provided within Virginia.

Quality of Care  Guidelines for Perinatal Care - ACOG/AAP  Toward Improving the Outcomes of Pregnancy - March of Dimes  National Fetal and Infant Mortality Review

National Fetal-Infant Mortality Review (NFIMR) Program cEstablished in 1990 cPublic-private partnership American College of Obstetricians and Gynecologists (ACOG) Maternal and Child Health Bureau March of Dimes Birth Defects Foundation

FIMR is: 8Community-based, action-oriented process 8Early warning system that describes health care 8Method of continuous quality improvement 8Means to implement core public health functions

Objectives: 3Initiate an interdisciplinary review of fetal and infant death from medical and social records and maternal interview. 3Describe significant social, economic, cultural and systems factors that contribute to mortality. 3Design and participate in implementing community-based interventions determined from review findings.

Low Weight Births:  7.7% of all Virginia Births  Has not significantly changed since 1970s  Single most important contributor to infant death

The etiology of preterm labor and premature birth is unknown.

Low Birth Weight is associated with multiple factors: !Medical Risk Factors  High parity  Chronic diseases  Previous Low Birth Weight infant  Genetic factors  Multiple gestation  Poor weight gain  Infection  Placental problems  Premature rupture of membranes  Fetal anomalies  Maternal stress

Low Birth Weight (continued) !Demographic Risk Factors  Age 34 years  African-American race  Low socioeconomic status  Unmarried  Low education !Behavioral Risk Factors  Smoking  Poor nutrition  Toxic exposures  Inadequate prenatal care  Substance abuse

Long-term effects of Low Birth Weight uNeurologic disorders uLearning disabilities uDelayed development

Prevention of low birth weight infants is related to effective family planning.

Efforts to reduce Low Birth Weight are either: NPopulation-level activities NIndividual-level strategies

Early and regular use of prenatal care is a strong predictor of positive pregnancy outcomes.

In 1996, 15.3% of women were uninsured in Virginia

Conclusion aStudies of underlying factors that contribute to morbidity and mortality are needed aReview of quality of health care and access to care for all women and infants is needed. aRacial/ethnic disparities need to be eliminated.