Nutrition 526 - 2009 A Framework for Maternal & Infant Nutrition

1. Nutrition 526 - 2009A Framework for Maternal & Infant Nutrition

2. 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

3. Preconception – Conception – Gestation – Birth - Infancy Sexual maturity - Childhood

4. 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

5. Social-Ecological Model for Determinants of Access to Resources & Nutrition Behaviors Structures, Policies, Systems Local, state, federal policies and laws Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs

6. 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,

7. Intrapersonal/Community • Social and cultural environments • Support from friends and family • Health and nutrition care providers

8. Institutional • Hospital breastfeeding & formula policies • Child Care policies • School policies for pregnant and parenting teens • Worksite lactation policies

9. Policy & Environment • Nutrition Assistance Programs for pregnancy, lactation and early childhood. • Insurance policies for lactation support

11. Maternal-infant dyad

12. A Public Health Approach to Maternal and Infant Health • Assessment • Policy Development • Assurance: Surveillance and monitoring progress towards goals

13. Assessment • Pregnancy population characteristics • Maternal health indicators • Infant health indicators

14. 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

17. National Vital Statistics Reports. 2009; 57:12

19. Percentage of all births to unmarried women by age of mother, 1980 and 2007 In 2007, 40% of all US births were to unmarried women National Center for Health Statistics, National Vital Statistics System.

20. 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

21. Population Indicators & Trends for Maternal Health • Pre-conceptual indicators • Weight gain • Diabetes in pregnancy • Pre-eclampsia • Cesarean delivery • Maternal death

22. Weight Gain During Pregnancy: Reexamining the Guidelines, IOM. 2009

25. Per birth certificate – includes all diabetes in pregnancy

26. Ferrara. A. Diabetes Care. Jul 2007

27. Ferrara. A. Diabetes Care. Jul 2007

30. 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.

31. 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.

32. Population Indicators of Infant Health • Infant mortality • Birthweight • Gestational age

33. 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.

35. http://www.chipublib.org/004chicago/disasters/infant_mortality.htmlhttp://www.chipublib.org/004chicago/disasters/infant_mortality.html

36. 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

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

39. http://mchb.hrsa.gov/mchirc/chusa_05/healthstat/infants/0307iimr.htmhttp://mchb.hrsa.gov/mchirc/chusa_05/healthstat/infants/0307iimr.htm

40. 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.”

41. Health Affairs, Vol 23, Issue 5, 2004

42. Birthweight

44. 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

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

48. Distribution of Births, by Gestational Age --- United States, 1990 and 2005 MMWR, April 2007

49. NGA Center for Best Practices, June 2004

50. 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