Infant Mortality: How Problem Identification has Lead to Ineffective Interventions-Natalie MacDonald

Interventions to reduce infant mortality have historically been focused on prenatal care of high risk mothers and low weight or preterm babies. Infant mortality interventions have been medicalized into a narrow window of time for risk assessment and treatment among expecting women. This approach has not been effective because it has focused its primary concern on the pregnant woman and health of the baby, ignoring women’s health before conception and her health habits that begin much earlier than pregnancy. A more effective approach to the problem of infant mortality would be to identify infant mortality as a symptom of the larger problem of unhealthy women in our society.

Infant mortality is recognized as a significant problem in the US despite our superior technological ability. Our national infant mortality rate is 6.7 per 1000 births placing us 13th in developed nations (Starfield 2000). While there has been some progress in reducing infant mortality over the last two decades, public health professionals have recognized the limitations of prenatal care and recently there has been a policy shift to promote pre-conception counseling among women who want to conceive (Johnson 2006). Preconception counseling broadens the perspective of women’s health by adding an additional window of time for intervention. However, I am suggesting that this expansion is not sufficient. We should be broadening the problem of infant mortality one more step to encompass women’s health over a continuum of time that begins in adolescence.

Defining infant mortality as a women’s health issue and not simply as a defined period in their child-bearing years, public health can identify the root cause of infant mortality; such as women’s health and health behaviors that then lead to infant mortality. To demonstrate the importance of a new identification of the infant mortality problem I describe some of the failed solutions under current problem identification. I then consider three areas of women’s health under which current problem identification does not allow for effective interventions.

Current problem identification has led to failed solutions
Epidemiology of high risk babies has been successful in identifying several high risk populations including babies of teenage mothers, immigrant mothers and black mothers. However, identification of these high risk groups has not been sufficient to developing effective interventions or completely understanding the risk factors. The percent of low birth weight babies is 15.4% for women under 15 versus 3.6% for women 25-29 (Reichman 1997). The number of teenage pregnancies has dropped by a third since 1991 (Martin 2005). Yet, as teen pregnancies have dropped there has not been a parallel drop in rates of low birth weight and preterm babies. The preterm birth rate has increased by 16% since 1990 and the percentage of low birth weight babies is the highest it has been since 1970(Martin 2005).

While it has been known for many years that black infants have had persistently worse outcomes than white infants there is yet to be a complete explanation of the risk difference (Lu 2003). Explanations considered have been contextual and biologic. However even with these variables in a model, risk cannot be explained. Differences in mortality persist. Between 1989 and 2002 the disparity widened between non-Hispanic whites and non-Hispanic blacks in post neonatal death attributable to birth defects (Yang 2006).

Over the last 20 years significant efforts have been made to increase access to pre-natal care through increased Medicaid eligibility for pregnant women. Programs have been designed to include groups such as undocumented immigrants who may not access the healthcare system otherwise. Yet, despite increased access the rates of low birth weight babies and premature live births have been increasing.

Framing infant mortality as a women’s health issue provides new ways to consider why increased access to Medicaid and attempts to identify risk factors may have failed to reduce infant mortality in the last two decades. The programs to increase access through Medicaid allowed for limited intervention on woman’s health. Medicaid has strict criteria for eligibility and women are only eligible for Medicaid after they become pregnant or have already had one child. The program structure restricts women to having their health needs addressed in the narrow and precious pre-natal period. For women who have chronic illnesses such as diabetes or mental illness the prenatal period is not the optimal time to treat their chronic condition. The medications they can take may be restricted by their pregnancy, and experimentation of treatment regimens is difficult with the simultaneous hormonal changes of pregnancy.

For women whose babies are at risk not due to chronic illness, but as a result of their health behaviors, Medicaid also fails. Medicaid eligibility restricts her to being educated of healthy behaviors for herself and her baby only after conception. The most damaging lifestyle and health behaviors may already have had their impact on the fetus at this point.

Areas of women’s health affecting infant mortality that can be better addressed under new problem identification
To illustrate the importance of re-framing infant mortality I discuss three areas of women’s health that require a broader conception of health for appropriate intervention. Two areas focus on health behaviors, and the third is mental health. Health behaviors are ingrained into daily life and are difficult to change after a woman’s conception. Changing health behaviors during pregnancy may not be sufficient to reduce infant mortality. Mental health is included as a third argument for a new problem identification because it is an area of women’s health that requires the advocacy of public health professionals to reduce stigma. In addition, certain chronic health conditions such as depression cannot be addressed and treated exclusively during the prenatal period.

NUTRITION
One argument for a more community wide approach to increasing the health of women is in the area of nutrition. Poor nutrition is health risk for all women and it has a potential to affect the pregnancy of women regardless of their age of childbirth. Gidden et al discovered that high risk pregnant teenagers and older mothers had no significant differences in their diets. They were equally deficient in iron, zinc, calcium, magnesium, foliate and vitamins D and E (Gidden 2000). Gidden demonstrates that poor nutrition is a health behavior that needs intervention targeted at many groups, not just teens. It is also an indicator that there is a persistent and widespread lack of proper nutrition in women across a spectrum of age.

SMOKING AND ALCOHOL USE
Children that are born to mothers who have engaged in binge drinking experience longer hospitalizations and higher rates of fetal alcohol syndrome (Ockene 2002). Tobacco use is associated with higher rates of pre-term births, stillbirth, and spontaneous abortions (Cnattingius S 2004) Despite the known risks of both alcohol and tobacco use many pregnant mothers continue to use these substances. Ockene et al found that only 28% of women were able to spontaneously stop smoking during pregnancy. In contrast, 80% of women stopped drinking alcohol while pregnant (Ockene J 2002). To reduce the risks of substance abuse for babies we need to think about how to prevent women from starting these behaviors in early adulthood.

MENTAL HEALTH
By considering women’s health more generally and its potential impact on infant mortality, mental health of mothers can begin to be investigated as a contributing factor to healthy babies. Understanding the prevalence of mental health problems and monitoring stress and demands on women of childbearing age provides new solutions to the problem. Today’s women have a broader gender role and thus enhanced expectations to be successful in their careers. How has this broader responsibility of women affected their mental health in relation to pregnancy? This type of question would not be considered by a narrow intervention and focus on prenatal care. Weisman et al are beginning to look at this question and have found that younger women between the ages of 18 and 34 have significantly more stress in their lives than women in later stages of life (Weisman et al. 2006).

The timing of the intervention shifts
Current interventions focused on preconception counseling is further confounded by the fact 50% of pregnancies are not planned. The current approach does not consider that the timing of educational interventions is too late. If a woman becomes pregnant in her teen years she is unlikely to seek prenatal care until late into the pregnancy shrinking the window for providers to ensure a healthy pregnancy. These two facts make it critical to consider the timing of the intervention as preventative rather than reactive. By re-framing the problem of high infant mortality as a women’s health problem, the time frame for intervention is shifted and expanded. There is now room to consider interventions that occur before a woman conceives, before she starts planning her pregnancy, and even before she reaches the child bearing stage of her life.

Changing the education message
Recognizing that prenatal care is too late to change healthy habits of women and educate them on how their current and past behavior will affect the health of their child, public health professionals need to consider when health messages about pregnancy and healthy behaviors can be disseminated. One potential venue is the existing educational system.. Sexual education could expand beyond a discussion of STD’s and methods of birth control to a discussion of when you decide you do want to have a child, what are the conditions to in your life and health that will help your baby be healthy? This turns the sexual education classes from the negative, (here’s how not to have a baby) to the positive (when you do want to have a baby this is what you want to do). The high school years are one of the few opportunities to reach all young women in a uniform way about how their health and habits are important to the health of their children, knowing that children will be part of the lives of most women. Further, by emphasizing to young women that 50% of pregnancies are not planned, the importance of both using safe contraception and beginning their health habits early is reinforced.

Conclusion
Changing high school educational curriculums is just one example of how re-identification of the issue of infant mortality can change our approaches and interventions. The reframing of the issue also opens up new research questions and new perspectives on current policy. The issue of infant mortality is a clear example of how the identification of an issue frames the intervention options.

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