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Lecture Notes on Chapter 7—Maternal and Infant Health (NOTE: Print in red is meant to help you answer questions left blank on the slides—things that you usually would fill in during the lecture.) Slide 1—Title slide Slide 2—In earlier generations, most families were made up of a mom and a dad and children all living under the same roof. But society has changed dramatically. We now have many different types of family structures: blended families, step families, same sex parents, extended families, and especially single-parent families. You can see the % of births to single women in 1980 was relatively low—about 18%, but by 2013 that had increased to about 40% (which is still true today). Often this comes with disadvantages which you see at the end of the slide. Statistically those single mothers tend to have fewer years of education, have jobs that pay less, and end up relying on social welfare programs to provide for their children. Slide 3—This graph shows you how dramatic the rise in single mothers has been in the US. I was born in the 50s (yes, I am that old!) and I can tell you that when I was in high school, there was only 1 student in my class who became pregnant—and there was a huge sense of shame about that. She was sent away to live with an aunt in another town and after having the baby (which was given up for adoption), she came back and finished school a year behind her peers. Why have we seen such an increase through the years? This is intended to be more of a discussion question rather than something with a definite right or wrong answer. But, among the reasons is that divorce started to become more acceptable, couples living together without being married became more common, and there was less stigma (no longer a sense of shame, disgrace, embarrassment) about being pregnant and single. Slide 4—This graph is also about single-mothers, but notice that it breaks the mothers down by their age. The first blue bar reflects what was already stated: about 40% of all births are to single-moms. Look at the 2nd and 3rd bars (very high)—these represent births to single-moms who are still in their teens. Very few of us marry in our teen years, so if you get pregnant as a teen and give birth, these are almost all going to be single-moms. Notice that the numbers of births to single moms begins to steadily drop after the age of 20, even more so after 25 (which is when most will begin to marry). Also notice that there is a little increase at age 40. That’s because some women will decide to have a child on their own because their “biological clock” is ticking and they are running out of time. Men can continue to become fathers in their later years, but women don’t have that option. Our fertility is declining significantly from our mid-30s until menopause. Slide 5—The previous slide illustrates a social problem that we have in the US: teen pregnancies. Let’s take a closer look at that on this slide. We know that pre-natal care (regular medical check-ups during pregnancy along with good self-care) will greatly improve the health of the pregnant mother and her developing fetus. But pregnant teens often don’t get that care. There can be several reasons for this, including that some actually don’t know they are pregnant until they are many weeks into the pregnancy; they aren’t educated to know that they need to see a doctor; they are trying to hide their pregnancy from others—including parents; they may be in denial and don’t want to believe that they are pregnant; they don’t have access to healthcare. Another problem with teen pregnancies is that teens are also more likely to smoke (and use alcohol and other drugs) as many young people do. When they engage in these behaviors, that puts them at risk of giving birth to a low-birth weight baby (one that weighs 5.5 lbs or less at birth). These low-birth weight babies have a 40x greater risk of dying in the first year of life. The rest of the slide shows you 5 other differences between teen moms and their peers. I think these points are self-explanatory. But one final note: many teen moms do very well, especially if they have support from partners and extended family and friends. They go on to be very capable and loving parents and provide stable homes for their children. We certainly do not want to ever go back to the old days (my days) of stigmatizing and shaming teen moms. Slide 6—Some very good public health news: the rates of teen pregnancies in the US have been declining—and we can link this to better community health campaigns and community services. You can see the 57% decline between 1991 and 2013 which is a huge success. (And by the way, the rate is still dropping—currently according to the CDC it is at an historically low rate of 18.8 births per 1000 teens in this age group. You can see that is much lower than the textbook info on the slide.) But the problem is NOT entirely solved. By the time girls reach the age of 20, 1 out of every 4 will become pregnant. That doesn’t mean they will actually give birth—many will opt to terminate the pregnancy instead (get an abortion). How does the teen birth rate compare to similar Western (developed) countries? It is far higher. See the quote from a recent study below: “Teens in the United States are far more likely to give birth than in any other industrialized country in the world. U.S. teens are two and a half times as likely to give birth as compared to teens in Canada, around four times as likely as teens in Germany or Norway, and almost 10 times as likely as teens in Switzerland.” (Note: don’t worry about memorizing any of these numbers—the important point is that we have far more teen pregnancies than other similar countries.) Slide 7—This slide shows the rapid decrease in teen pregnancies in the graph. Which answer would you choose to the question about the reason for the decline? The best choice is “B”—young women have been more likely to use birth control than in earlier times. This includes the more effective long-acting methods such as IUDS and implants, as well as condoms and oral contraceptives. Note: There is also evidence that teens today are having slightly less sex (answer “A”)—but that is not significant enough to explain the steep drop in the teen birth rate. Slide 8—How are we doing here in the Bronx compared to the rest of NYC? The good news is that we are also declining in the rates of teen pregnancies, but not as much as the rest of the city. Of the 5 boroughs of NYC, we see more teen pregnancies than the other boroughs (Manhattan, Brooklyn, Queens, Staten Island all have lower rates than the Bronx). Slide 9—Family Planning means that, ideally, we want all pregnancies to be planned (intentional pregnancies). That means you and your partner decide you are ready to become parents. You want to have a child and are ready to provide the emotional and financial resources necessary to raise that child. You are committed to educate yourself about good prenatal care and have access to medical providers to ensure the healthiest pregnancy possible for you and your developing fetus. Only about 50% of all pregnancies in the US are planned (intentional). That means, all too often, the pregnancy is a “surprise” and is occurring at a time when you are not at all ready to become a parent. Note that when we separate out younger women (teens and early 20s), almost all of those pregnancies (well over 80%) are unplanned or unintentional. A lot of the care around women’s reproductive health, especially in low-income communities, is provided by funds from a government grant program called Title X (the X is the Roman numeral 10—so this program is pronounced “Title Ten” not “Title EX”). It is the only federal grant program providing funding for comprehensive family planning and related health services to low-income women and their families. You can see from the slide that there are more than 4000 of these centers located across the US. Slide 10—Are the centers funded by Title X effective? YES!! The slide shows you that almost 4 million women receive services through this program each year. The research is clear that these programs have made a significant impact in the following ways: 1.) They have decreased teen pregnancies by about 30%. 2.) They have decreased unintended pregnancies (among all ages, not just teens) by about 30%. 3.) They have decreased abortions by about 30%. Slide 11—The graph here illustrates another important point about family planning clinics funded by Title X: They provide many health services to low income communities—not just reproductive care. That means if the federal government cuts the funding, those living in these communities will have less access to many health services including nutrition counseling, immunizations, cancer screenings, and even primary care. Remember when we talked about social factors that affect health? One of those social factors was “politics.” Politics plays a big role in the funding for Title X. Often when conservative politicians are elected to office, a debate follows about cutting funding for Title X because those politicians don’t think reproductive services should be paid for by tax dollars. Or they believe that these clinics are providing abortions paid for by tax dollars--which is not true. A separate federal law prohibits any tax dollars from funding abortions—that law was passed decades ago. If politicians are successful in cutting funding for Title X, then a low-income community may lose access to multiple health services, not just reproductive care. Slide 12—The definition of “maternal mortality” is on the slide. Notice that it does not just refer to the mother dying during pregnancy but also those who die during the 6-week period after giving birth. (Note: this would not include those who die from accidents, overdoses, homicide or other reasons that would be totally unrelated to the pregnancy). Globally, this is a much larger problem for women in poor countries. But, once again, we find the rates in the US are higher than in other wealthy countries. In spite of the fact that we spend more money on healthcare than any other country, we have worse health outcome for our mothers. And it is not yet getting better. We are not sure of all the reasons, but one that is often mentioned is that we see more women of child-bearing age with chronic diseases that may complicate their pregnancies. For example, as our obesity rate has