The Role of Health Education in Maternal and Infant Health

BackgroundRates of preterm birth, low birth weight, and Neonatal Intensive Care Unit (NICU) admissions continue to rise in the United States (US). Social determinants of health (SDOH) are recognized as significant contributors to infant and maternal health, underscoring the need for use of research frameworks that incorporate SDOH concepts. The Restoring Our Own Through Transformation (ROOTT) theoretical framework is rooted in reproductive justice (i.e. reproductive rights and social justice-based framework) and emphasizes both structural and social determinants as root causes of health inequities. The impact of SDOH on maternal and infant mortality and morbidity can often be traced to structural determinants unique to the US, including slavery, Jim Crow laws, redlining, and the GI Bill.AimsUsing data from the Pregnancy Risk Assessment Monitoring System (PRAMS) 8 database, we aimed to evaluate relationships between SDOH (as guided by the ROOTT Framework) and maternal and infant health outcomes.MethodsData were analyzed from 11 states that included the SDOH supplement in their PRAMS 8 data collection. We used bivariate analyses to examine relationships between SDOH measures guided by the ROOTT framework (e.g. abuse during pregnancy, access to prenatal care, housing stability and education) and maternal morbidity (i.e., gestational hypertension and gestational diabetes) and infant outcomes (i.e., preterm birth, NICU admission, breastfeeding). Pre-identified covariates were controlled for in the logistic and linear regression models.ResultsPreterm birth, NICU admission, breastfeeding, and maternal morbidities were significantly associated with SDOH measures linked to structural determinants in the US. Abuse during pregnancy, access to prenatal care, housing, and education were all significantly associated with poorer infant health outcomes in the final regression models. Women who received prenatal care beginning in the 3rd trimester were twice as likely to develop gestational hypertension.ConclusionsSDOHs rooted in structural determinants are important predictors of poorer maternal and infant health outcomes. Evaluating health outcomes using a reproductive justice framework reveals modifiable risk factors, including access to stable healthcare, safety, and housing. Comprehensive healthcare provision must ensure early and consistent access to healthcare and resources for safety and housing stability to support maternal and infant health.

Housing quality, stability, and affordability have a direct relationship to socioemotional and physical health. Both city planning and public health have long recognized the role of housing in health, but the complexity of this relationship in regard to infant and maternal health is less understood. Focusing on literature specifically relevant to U.S. metropolitan areas, I conduct a multidisciplinary literature review to understand the influence of housing factors and interventions that impact infant and maternal health. The paper seeks to achieve three primary goals. First, to identify the primary “pathways” by which housing influences infant and maternal health. Second, the review focuses on the role and influence of historical housing discrimination on maternal health outcomes. Third, the review identifies emergent practice-based housing interventions in planning and public health practice to support infant and maternal health. The literature suggests that the impact of housing on infant health is complex, multifaceted, and intergenerational. Historical housing discrimination also directly impacts contemporary infant and maternal health outcomes. Policy interventions to support infant health through housing are just emerging but demonstrate promising outcomes. Structural barriers to housing affordability in the United States will require new resources to foster greater collaboration between the housing and the health sectors.

Preconception Women’s Health and Pediatrics: An Opportunity to Address Infant Mortality and Family Health

Home visiting: A lifeline for families during the COVID-19 pandemic

Prenatal Care Visits and Associated Costs for Treatment-Seeking Women With Depressive Disorders

This study aimed to determine whether a history of depressive disorders is associated with use and costs of prenatal care among pregnant women in Taiwan. Participants were mothers with singleton births between 2004 and 2006 (N=23,290), some of whom (N=614) had received care for depression in the year before conception but not during pregnancy. The mean number of prenatal care visits was 8.50 and associated costs were $NT 51,187 for pregnant women with a history of depressive disorders and 9.17 visits and $NT 27,998, respectively, for those without such a history. After adjustment for age, monthly income, medical conditions, and obstetric complications, mothers with a history of depression were significantly less likely to receive prenatal care (relative risk=.94, 95% confidence interval=.92-.97, p<.001). However, women with a history of depression had $NT 22,494 higher prenatal care costs than mothers without a history of depression. Pregnant women with a history of depressive disorders had fewer prenatal care visits but higher prenatal care costs. Physicians should consider screening to identify pregnant women with a history of depressive disorders.

To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Data from cross-sectional household-based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log-linear model. Between 2002 and 2007, having no any pre-natal visit decreased from 25% to 12% (difference 13%, 95% CI 10-17%); facility-based delivery increased from 45% to 80% (difference 35%, 95% CI 29-37%); and differences in using pre-natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre-natal and delivery care in 2007. The expenditure for facility-based delivery increased over the period, but the out-of-pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low-income group. NCMS participation was found positively correlated with lower out-of-pocket expenditure for facility-based delivery (coefficient -1.14 P < 0.05) in 2007. Facility-based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility-based delivery, although NCMS participation reduced the out-of-pocket expenditure on average.

BackgroundPregnancy is a critical developmental window in which optimal maternal nutrition and health are key for pregnancy and infant development. The COVID-19 pandemic is considered as a “natural experiment” in which maternal and infant nutrition and health challenges were faced especially in developing countries. Therefore, understanding the health consequences for mothers and infants living in the COVID-19 era is key to revisit public health measures focused on maternal and infant health. The current work aims to describe the design, methods, and descriptive information at recruitment and preliminary findings of the Chilean Maternal & Infant Cohort Study II (CHiMINCs-II) cohort.MethodsThe CHiMINCs-II is an ongoing cohort that is part of the Chilean Maternal and Infant Nutrition Observatory of the South-East area of Santiago, Chile. In total, 1954 pregnant women beneficiaries of the public health systems and their offspring were recruited before 15 weeks of gestation and are followed across pregnancy (<15, 26–28, and 35–37 weeks of gestation) and up to 2 years of age in their offspring. Two studies are currently nested within the CHiMINCs-II cohort: (1) Breast Cancer Risk Assessment in Mothers (BRECAM) study, and (2) the CHiMINCs-COVID study. The primary objective of BRECAM study is to test the association between maternal metabolic indicators (i.e., insulin, glucose, insulin growth factor 1, and hemoglobin A1c concentrations) at early pregnancy (i.e., <15 and 26–28 weeks of gestation) and breast density 3 months after the cessation of lactation. For this purpose, we collect maternal obstetric, lifestyle, dietary intake, anthropometric, and biochemical information. The aim of the CHiMINCs-COVID study is to assess maternal dietary intake and mental health problems derived from the COVID-19 pandemic and their association with maternal and infant's health and nutrition. Thus, we collected detailed information on dietary behaviors, mental health, and COVID-related information at each trimester, along with neonatal and infant nutritional information.DiscussionThe findings of this study will provide novel and critical information to better understand maternal nutritional status, mental health, as well as infant growth and nutrition during the COVID-19 era.Clinical Trial RegistrationBRECAM study registration number NCT03920098 and CHiMINCs-COVID study registration number NCT01916603.

Bihar ranks very low in terms of maternal health indicators mainly due to lack of utilization of maternal care services. Based on an extensive literature review and supported by our fieldwork, we contend that maternal health conditions in Bihar could be improved if health education is disseminated among women. Health informatics tools, such as mobile phones, could be used for channelizing health education and pioneer positive changes. Mobile phones have the ability to assist people anywhere, at any time, and that too at lower cost. Hence, the main objective of this paper is to explore the role of mobile phones as health informatics tool for improving maternal health conditions in Bihar. Using mixed method approach a study was conducted in Patna, the capital city of Bihar. The respondents included both service users, i.e., women, and service providers. The findings reiterated that there is lack of information available to women on maternal health so they have to rely on their immediate family members for suggestions and advice. Service providers also affirmed the crucial role of maternal health education to improve maternal health status and agreed that it could be more effective if generated through media tools, such as, mobile phones. Thus, the study empathizes the importance of mobile phone for propagating maternal health education among women in Bihar.

Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s. We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes. We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search. We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs. Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately. Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment). Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Breast milk is the optimal source of nutrition for infants, but exclusive breastfeeding rates in Indonesia and globally remain below target, largely due to maternal anxiety, insufficient milk production, and inadequate support systems. Innovative, integrative interventions that address both physiological and psychological barriers are urgently needed to support successful lactation outcomes. This study aimed to evaluate the effectiveness of the Stimulasi Pijat Endorphin, Oksitosin, dan Sugestif (SPEOS) method—an integrative technique combining oxytocin massage, endorphin massage, and positive suggestion—in increasing breast milk production among postpartum mothers at PMB Fatimah Bandungrejosari, Malang. A quasi-experimental posttest-only control group design was implemented, involving 36 postpartum mothers (days 1–40) who were divided equally into intervention and control groups. The intervention group received the SPEOS method (20-minute sessions for nine consecutive days), while the control group received only standard informational leaflets. Data on breast milk production were collected using validated observation sheets and baby scales, and analyzed using univariate and bivariate methods, including the Mann-Whitney test. The findings revealed that 66.7% of mothers in the SPEOS group achieved high breast milk production, compared to just 16.7% in the control group. Statistical analysis confirmed a significant difference between groups (p = 0.002). The SPEOS intervention demonstrated not only physiological benefits, through hormonal stimulation, but also psychological benefits, by improving maternal confidence and emotional well-being. The SPEOS method is an effective, holistic, and easily adopted intervention for enhancing breast milk production in postpartum mothers. Its integrative approach, targeting both hormonal and psychological pathways, makes it suitable for inclusion in maternal health education and practice. This research supports the integration of the SPEOS method into midwifery education and practice as a low-cost, evidence-based strategy to promote exclusive breastfeeding, maternal empowerment, and optimal infant health. The study provides a foundation for further research and broader implementation in diverse healthcare settings. Larger-scale and longer-term studies are recommended to confirm these findings, explore additional maternal and infant health outcomes, and refine SPEOS implementation protocols for various populations.

Provision of human milk is crucial for maternal and infant health. However, exclusive breastfeeding may exacerbate mood disorders in women unable to achieve this goal. A nuanced approach that considers all aspects of maternal and infant health is needed. In this paper, we bring attention to the potentially negative consequences on maternal and infant health that may be associated with exclusive breastfeeding in the setting of significant challenges. We discuss recent literature exploring the relationship between breastfeeding and maternal mental health, and contextualize it with our first-hand experiences as healthcare professionals who aimed to exclusively breastfeed and encountered difficulties. Given existing evidence and our collective anecdotal experience, we advocate for a balanced approach when supporting parents struggling to breastfeed. Timely recommendations are offered for healthcare providers, medical educators and hospital administrators seeking to balance maternal and infant child health considerations while continuing to promote breastfeeding.Précis statementExclusively promotion of breastfeeding impacts maternal mental health and consequently, infant health. We advocate for balanced considerations of maternal and infant child health while promoting breastfeeding.Clinical implications Singular promotion of exclusive breastfeeding may exacerbate adverse maternal mental health outcomes.A balanced consideration of maternal and infant child health is vital as breastfeeding is encouraged.Clinicians who provide front-line support to breastfeeding parents must be taught and expected to provide nuanced breastfeeding support that anticipates both physical and mental health challenges.

Objective We investigate gradients (i.e. differences) in infant health outcomes by maternal education in Argentina, Brazil, Chile, and Venezuela and explore channels related to father's education, household labor outcomes, and maternal health, fertility, and use of prenatal services and technology. Methods We employ secondary interview and birth record data similarly collected across a network of birth hospitals from the early 1980s through 2011 within the Latin American Collaborative Study of Congenital Anomalies (ECLAMC). Focusing on children without birth defects, we estimate gradients in several infant health outcomes including birth weight, gestational age, and hospital discharge status by maternal education using ordinary least squares regression models adjusting for several demographic factors. To explore channels, we add as covariates father's education, parental occupational activity, maternal health and fertility history, and use of prenatal services and technology and evaluate changes in the coefficient of maternal education. We use the same models for each country sample. Results We find important differences in gradients across countries. We find evidence for educational gradients in preterm birth in three countries but weaker evidence for gradients in fetal growth. The extent to which observed household and maternal factors explain these gradients based on changes in the regression coefficient of maternal education when controlling for these factors as covariates also varies between countries. In contrast, we generally find evidence across all countries that higher maternal education is associated with increased use of prenatal care services and technology. Conclusions Our findings suggest that differences in infant health by maternal education and their underlying mechanisms vary and are not necessarily generalizable across countries. However, the positive association between maternal education and use of prenatal services and technology is more consistent across examined countries.

This thesis consists of three essays in health economics, examining the effects of economic policies, mainly state-level earned income tax credits (EITC) on maternal health, access to healthcare services, and minimum wage and EITC on infant health using quasi-experimental designs. The first essay examines the effects of state EITC on general health outcomes of low-educated single mothers in the U.S. The second essay examines the effects of refundable state EITC on access to medical and dental care services and explores the interaction between state EITC and Medicaid parental eligibility. The last essay investigates the effects of minimum wage and state EITC on infant health. The innovation of the third essay is to provide new causal evidence of the effects on infant health accounting for local time-varying confounders.The first chapter highlights the significance, innovation, and the conceptual framework of effects from minimum wage and state EITC on maternal health and infant health. The second chapter examines the effects of refundable and non-refundable state EITC programs on health of single low-educated women of childbearing age with two or more children, the group receiving the highest credits on average. The data comes from the Behavioral Risk Factors Surveillance Survey (BRFSS). The research design accounts for time-invariant differences between states and national trends shared across states using a difference-in-difference model and adjusts for other state policies. Overall, findings suggest that an increase in refundable state EITC improves the health of single women of childbearing age with low income and two or more children; this may also lead to better preconception health. Estimates for non-refundable EITC programs are smaller and not statistically significant. As expected, there are small and statistically insignificant refundable EITC effects for single low-educated childless women, who receive low state EITC benefits on average. The third chapter examines the effects of refundable state EITC on access to medical and dental care services using a similar design and group to the first paper in chapter 2. This study examines the effects on access averaging across the 12 past months from the interview time but also focuses on the period closest to the disbursement of the EITC refund. The findings show a small albeit weak evidence of some increase in access to care including a reduction in forgone care due to cost and an increase in dental visit within the months immediately following disbursement of EITC refund during May to December and June to November. The estimates however are sensitive to specifications in that there is a negative association with some of the access measures when pooling across the 12 past months, suggesting recall bias and differences in effects of EITC on healthcare utilization relative to disbursement month. The fourth chapter examines the effects of minimum wage and refundable state EITC and explores their interaction on health of infants born to single low-educated mothers. The outcomes include birth weight, low birth weight, preterm birth, gestation weeks and fetal growth. The data comes from restricted use of Natality Birth Certificates from National Center for Health Statistics (NCHS). The empirical approaches are innovative in several ways. The first approach uses a general difference-in-difference model to examine the effects of the minimum wage and state EITC at the county level aggregated data both pooling and stratifying by birth order; the second approach addresses unobserved local time-varying confounders using a contiguous boarder county-pair approach at the county-level aggregated data. This approach allows to control for systematic differences between cross-border counties at local levels since counties sharing a state border provide better control groups than other randomly selected counties in the U.S, and they should have relatively similar economic condition and outcome trends. The identification relies on that changes in outcomes only come from within county-pairs variations in minimum wage increase or EITC policy change. The general difference-in-difference estimates show significant positive effects of both minimum wage and refundable state EITC on infant health outcomes. However, the state EITC effects are implausibly large. In contrast, the effects become much smaller and statistically insignificant in the contiguous county-pair design controlling for local time-varying confounders. Further, the estimate rules out large effects. Finally, there is overall no evidence of significant interactive effects between these two policies on infant health.

Prenatal and infant health care in a medium-sized community. E B GallagherCopyRight https://doi.org/10.2105/AJPH.57.12.2127 Published Online: August 29, 2011