Maternal and Child Health Health Article

FUTURE CHALLENGES

At the beginning of the twenty-first century, many challenges in MCH remain. Some of the most important areas of concern are described below.

Maternal Mortality and Morbidity. The decline in maternal mortality in the United States has leveled off since 1982. This does not mean that it has reached an irreducible minimum, as one-third to one-half of the deaths that still occur are probably preventable. Maternal deaths are only the tip of the iceberg, however, as one in four women experience complications during pregnancy, many of which are preventable. An increased effort to assess and assure the quality of health care for pregnant women is needed. Likewise, the connection between maternal health and women's health needs to be better understood. Improving women's health over the life course, and not only during pregnancy, is likely to have the greatest impact on improving maternal and child health.

Infant Mortality and Morbidity. Birth defects are the leading cause of infant death, affecting approximately 3 percent of all live births. Because many birth defects occur in the first three months of pregnancy, they are best prevented by preconceptional and early prenatal care. The causes of most birth defects are still unknown and require further research. Low birthweight and prematurity contribute to most of the infant deaths and congenital neurological disabilities not related to birth defects. They are also the leading cause of infant deaths among African Americans. To date, most interventions during pregnancy designed to prevent low birthweight and prematurity have not been effective.

Prenatal and Preconceptional Care. Although widely accepted, the effectiveness of prenatal care in improving pregnancy outcomes, particularly in preventing low birthweight and prematurity, has not been conclusively demonstrated. While this may reflect methodological flaws in research on prenatal care, it could also suggest that prenatal care is not provided in the proper manner, and some researchers have begun to question the appropriateness of the content of prenatal care. Still others have argued that less than nine months of prenatal care is not enough to reverse the cumulative impact of lifelong habits and exposures on pregnancy outcomes. Most women do not obtain preconceptional care before getting pregnant, and many health care providers do not know how to provide preconceptional care, or they provide it only to women who are actively trying to get pregnant, thereby missing opportunities to improve the outcomes of pregnancies that are unintended.

Breast-Feeding. The benefits of breast-feeding to the health of mothers and infants have been well documented, including enhanced immunity against infections, improved cognitive development, and stronger maternal-infant bonding. Despite these benefits, the initiation and duration of breast-feeding in the United States remains low, particularly among disadvantaged women. Efforts to promote the WHO/UNICEF "Ten Steps to Successful Breast-feeding" in hospitals have met with little success. Changes in cultural norms, workplace practices, and social policy are also needed to encourage breast-feeding among American women.

Immunization. Although the up-to-date immunization rate of children in the United States has been steadily improving, it still falls short of the national goal of 90 percent by age two, particularly for poor children. There is no agreement among public health experts on a strategy to bring this up to the level at which "herd immunity" would protect those children who remain without immunization.

Child Care. Over half of U.S. mothers with children under six work outside the home, and 60 percent of these children receive care outside their homes. In addition to increased risk for infections and injuries, children cared for in day-care centers may receive less support for cognitive and social development than children cared for at home. Support for parents with child-care needs is low, particularly for low-income families.

Family Violence. A U.S. woman has a one-in-five chance of being physically abused at some point in her lifetime. Estimates of the prevalence of physical abuse by an intimate partner during pregnancy range from 4 to 8 percent, but it may be as high as 20 percent. Most communities have inadequate resources to help battered women. Many health care providers do not screen for, or cannot identify, domestic violence. Within communities, a shortage of shelter beds, social workers, and other basic services frequently exists, together with a lack of coordination among health care, social-service, and judicial systems. Children are abused in half of the families where women are abused. While little is known or done about primary prevention of family violence, what is clear is that family violence cannot be overcome without attention to the social and economic conditions that put children and families at risk.

Unintentional and Intentional Injury. Injury is the leading cause of death among children and adolescents, with motor-vehicle injury being the single leading cause. Other causes include fires/burns and drowning. Homicides and suicides account for one-fourth of injury-related deaths among adolescents. While progress has been made in preventing deaths related to motor-vehicle injury, largely attributable to a reduction in alcohol-related fatalities, little progress has been made in preventing deaths related to homicides and suicides.

Tobacco, Alcohol, and Other Drugs. Nearly one-third of teens are current smokers, and half have drunk alcohol within the last month. Nearly one-third have used marijuana, and 5 percent have used cocaine. Alcohol and other drugs contribute significantly to unintentional and intentional injuries among adolescents, including motor-vehicle accidents, homicide, suicide, as well as unintended pregnancies, sexually transmitted infections, and a host of other medical and social problems. Success of clinical interventions at the individual level is modest; and the effectiveness of neighborhoodand community-level interventions remains to be demonstrated.

Sexual Behavior and Unintended Pregnancy. One-third of girls and nearly one-half of boys in the United States have had sexual intercourse by the ninth grade, and 20 percent of all youth in grades nine through twelve have had four or more sexual partners. While these rates are similar to European rates, the rates of sexually transmitted infections and unintended pregnancies are much higher among U.S. teens. One in four sexually active adolescents will get a sexually transmitted infection by age twenty. Nearly one million adolescent women become pregnant each year in the United States, with half of these pregnancies resulting in live births. Teen mothers have lower educational attainment, lower future earnings, and higher welfare dependency. Two-thirds of these teen births occur outside of marriage.