Nutrition 526 - 2009

A Framework for Maternal & Infant Nutrition

Learning Objectives for Today

• Integrate the science of maternal & infant nutrition into social-ecological framework

• Apply course learnings in the context of the maternal & infant population in the US and the nutrition-related concerns of this population

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

Questions to Consider…• Given individual variations in the physiology of

pregnancy and infancy, what ranges of nutrient intake best support optimal outcomes? (and what are those optimal outcomes?)

• What are the best indices of nutritional status in pregnancy and infancy? – individual– population

• What services & systems best promote nutritional health in pregnancy and infancy?– individual– population

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

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

National Vital Statistics Reports. 2009; 57:12

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

Percentage of Parents Who Were Married or Cohabiting at Birth of First Child, by Race/Ethnicity and Sex

MMWR; September 15, 2006 / 55(36);998

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

Ferrara. A. Diabetes Care. Jul 2007

Ferrara. A. Diabetes Care. Jul 2007

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.

Risk of Maternal Death

• The risk of death for African American women is almost four times that for white women.

• The risk of death for Asian and Pacific Islander women who immigrated to the United States is two times that for Asian and Pacific Islander women born in the United States.

• The risk of death is nearly three times greater for women 35–39 years old than for women 20–24 years old. The risk is five times greater for women over 40.

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

Infant Mortality

• Sensitive indicator of community health because reflects influences by various social factors– E.g. environment (housing, sanitation, safe food

and water)

• Historically decrease in infant mortality associated with improvements in living conditions and health services

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

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.”

Health Affairs, Vol 23, Issue 5, 2004

Birthweight

INDICATOR HEALTH1: PERCENTAGE OF INFANTS BORN WITH LOW BIRTHWEIGHT BY MOTHER'S RACE AND HISPANIC ORIGIN, 1980–2005

http://www.childstats.gov/americaschildren/health1.asp

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

Distribution of Births, by Gestational Age --- United States, 1990 and 2005

MMWR, April 2007

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

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.

Top Three “Best Practices” to Improve Birth Outcomes and Reduce High Risk Births

(NGA, June 2004)

• Improve access to medical care and health care services

• Encourage good nutrition and healthy lifestyles– Eating healthy foods– Taking folic acid– Harmful substances– Violence

• Reduce use of harmful substances

O’connor J et al. Health Promotion Practice, (1) 2005

Assurance: Healthy People 2010 Goals Related to

Maternal and Infant & Nutrition

Reduce low birth weight (LBW) and very low birth weight (VLBW).

1998Baseline

2010TargetReduction in Low and

Very Low Birth Weight Percent

Low birth weight (LBW) 7.6 5.0Very low birth weight(VLBW) 1.4 0.9

Reduce preterm births

Reduction inPreterm Births

1997Baseline (%)

2010Target (%)

Total preterm 11.4 7.6

Live births at 32 to 36weeks of gestation

9.4 6.4

Live births at lessthan 32 weeks ofgestation

1.9 1.1

Reduce the occurrence of spina bifida and other neural tube defects (NTDs)

• Target: 3 new cases per 10,000 live births.

• Baseline: 6 new cases of spina bifida or another NTD per 10,000 live births in 1996.

Increase the proportion of pregnancies begun with an optimum folic acid level.

Increase in PregnanciesBegun With OptimumFolic Acid Level

1991–94Baseline*

2010Target

Consumption of at least400 μg of folic acid eachday from fortified foods ordietary supplements bynonpregnant women aged15 to 44 years

21% 80%

Median RBC folate levelamong nonpregnantwomen aged 15 to 44years

161 ng/ml 220 ng/ml

Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant womenIncrease in ReportedAbstinence in PastMonth FromSubstances byPregnant Women*

1996–97Baseline %

2010Target %

Alcohol 86 94

Binge drinking 99 100

Cigarette smoking† 87 98

Illicit drugs 98 100

Smoking

Increase the proportion of mothers who breastfeed their babies

Increase in MothersWho Breastfeed

1998Baseline (%)

2010Target (%)

In early postpartumperiod

64 75

At 6 months 29 50

At 1 year 16 25

Increase smoking cessation during pregnancy• Target: 30 percent.

• Baseline: 12 percent smoking cessation during the first trimester of pregnancy in 1991 (age adjusted to the year 2000 standard population).

Reduce growth retardation among low income children under age 5 years

• Target: 5 percent.

• Baseline: 8 percent of low-income children under age 5 years were growth retarded in 1997 (defined as height-for-age below the fifth percentile in the age-gender appropriate population using the 1977 NCHS/CDC growth charts;31 preliminary data; not age adjusted).

Reduce iron deficiency among young children and females of childbearing age.

Reduction in IronDeficiency*

1988–94Baseline (%)

2010Target (%)

Children aged 1 to 2years

9 5

Children aged 3 to 4years

4 1

Nonpregnant femalesaged 12 to 49 years

11 7

Reduce anemia among low-income pregnant females in their third trimester

• Target: 20 percent.• Baseline: 29 percent of low-income

pregnant females in their third trimester were anemic (defined as hemoglobin < 11.0 g/dL) in 1996

Anemia Rates - 1996

African American, non-Hispanic 44%American Indian/Alaska Native 31%Asian/Pacific Islander 26%Hispanic 25%White, non-Hispanic 24%

Population vs.. individual