Where Is Women's Health in Maternal and Child Health?

Maternal and Child Health Journal -     

Women's Health in Maternal and Child Health: Time for a New Tradition?

Objectives. The status quo in maternal and child health (MCH) focuses on obstetric health. An emerging alternative is to broaden the notion to reproductive health. An inclusive perspective encompasses women's health issues in MCH. The purpose of this paper is to further the debate on the relationship of women's health to MCH. Specific aims are (1) to describe activities promoting women's health in MCH and (2) to examine consequences of alternative perspectives for MCH research, services, and training. Method. To achieve the first objective, I discuss developments in a state health agency and pertinent documents from the MCH Section of the American Public Health Association. To address the second aim, I follow the Bush Policy Analysis Model of weighing the three paradigms against the following evaluative criteria: equity, efficiency, satisfaction, stigma, indirect effects, feasibility, sensitivity to class and race, and social responsibility. Results. The obstetric approach meets most criteria in a positive fashion; reproductive health satisfies criteria more positively and less equivocally. A women's health perspective bears the most potential for improving reproductive outcomes at this time, since no area of women's general health has been definitively shown to be irrelevant to reproduction (or vice versa). Conclusions: This analysis suggests that women's health should be incorporated more fully into the MCH field, as well as other areas of public health and medicine. Once research deficits have been addressed and the scope of reproductive health delineated more clearly, the alignment of women's health with MCH may be reevaluated.     

Who Will Have Health Insurance in the Future? An Updated Projection

The passage of the 2010 Patient Protection and Affordable Care Act (PPACA) in the United States put the issues of health care reform and health care costs back in the national spotlight. DeVoe and colleagues previously estimated that the cost of a family health insurance premium would equal the median household income by the year 2025. A slowdown in health care spending tied to the recent economic downturn and the passage of the PPACA occurred after this model was published. In this updated model, we estimate that this threshold will be crossed in 2033, and under favorable assumptions the PPACA may extend this date only to 2037. Continuing to make incremental changes in US health policy will likely not bend the cost curve, which has eluded policy makers for the past 50 years. Private health insurance will become increasingly unaffordable to low-to-middle-income Americans unless major changes are made in the US health care system.     

What Does Attending Early Childhood Program Mean for Child Health in India?

The health impact of attending early childhood development programs in developing countries remains largely unknown. In this study, we focus on the health consequences of attending preschool programs in India. Using a unique longitudinal dataset, we allow for heterogeneity in the impact of preschool across the distribution of health outcomes while controlling for time‐invariant unobservables. We detect unique temporal variation in the effect of preschool attendance – growth of preschool attendees is slower than non‐attendees in various parts of the distributions of several anthropometric measures when evaluated in the early years between ages 1 and 5. This effect is likely to reverse in the longer term at age 8. The early years' adverse effect can be explained in part by over‐attendance in the form of long daily hours, excessive attendance days, and early entry. The findings are insensitive to nutritional incentives like free meals provided in public schools. The growth‐retarding effect remains robust for weight‐for‐age z‐scores, implying that the impact of preschool attendance is not only heterogeneous, but differs across dimensions of health status. Our study highlights the need for strengthening the delivery of childhood programs in developing countries in order to prevent adverse health effects in the critical years. Copyright © 2016 John Wiley & Sons, Ltd.     

Will Genomics Widen or Help Heal the Schism Between Medicine and Public Health?

We discuss the "schism" between medicine and public health in light of advances in genomics and the expected evolution of health care toward personalized treatment and prevention. Undoubtedly, genomics could deepen the divide between the two worlds, but it also represents an important and perhaps unique opportunity for healing the schism, given the volume of new scientific discoveries and their potential applications in all areas of health and disease. We argue that the integration of genomics into health care and disease prevention requires a strong medicine-public health partnership in the context of a population approach to a translational research agenda that includes four overlapping areas: (1) a joint focus on prevention-a traditional public health concern but now a promise of genomics in the realm of individualized primary prevention and early detection, (2) a population perspective, which requires a large amount of population-level data to validate gene discoveries for clinical applications, (3) commitment to evidence-based knowledge integration with thousands of potential genomic applications in practice, and (4) emphasis on health services research to evaluate outcomes, costs, and benefits in the real world. A strong medicine-public health partnership in the genomics era is needed for the translation of all scientific discoveries for the benefit of population health.     

Do Positive Parenting Practices Moderate Parental Mental Health and Child Behavior Among Homeless Families?

The social interaction learning framework was used to explore whether positive parenting practices (noncoercive discipline, clear expectations, and praise and incentives) mitigated any effects of parent mental health (psychological distress and parenting stress) on child externalizing behaviors in a predominantly African American sample of homeless parents residing in transitional housing (N = 52, 79.6% female). The results showed that the positive relationship between psychological distress and child behavior was attenuated when parents provided high levels of praise and incentives. In addition, a positive relationship between parenting stress and child behavior existed only when parents transmitted low levels of praise and incentives. No significant findings existed for noncoercive discipline and clear expectations. The results suggest the need to further understand the positive aspects of parenting in the context of homelessness that can promote child adjustment even if parental mental health is compromised.     

Bisphenol A and Child Vascular Health: A Preview of Future Heart Disease Risk?

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Exposures to phthalates and bisphenols have well-documented adverse effects on reproductive health and human development.¹ These endocrine-disrupting chemicals (EDCs) are also associated with obesity, hypertension, and blood vessel lesions in cross-sectional studies of adolescents and adults.^2–5 It is conceivable that processes leading to such damage start early in life and may be affected by prenatal chemical exposure.^6,7 A study recently published in Environmental Health Perspectives examined this question in children followed from gestation into childhood.⁸The authors measured phthalates and bisphenols in urine samples from 935 pregnant Generation R participants during their first, second, and third trimesters. The Generation R Study, based in Rotterdam, the Netherlands, comprises a population-based prospective cohort.⁹ At approximately 10 years of age, the women’s children underwent ultrasounds for two measurements of the common carotid artery: distensibility (elasticity) and intima-media thickness (the thickness between the intima and media layers of the vessel wall). Both distensibility and intima-media thickness reflect vascular health in the whole body^10–12; thicker vessel walls and reduced elasticity are considered distinct but overlapping risk factors for cardiovascular disease in adulthood, such as atherosclerosis.¹³Open in a separate windowThe intima layer of the artery (shown in black) is composed of endothelial cells, and the media layer (shown in pink) is made of smooth muscle and elastic fibers. Combined expansion (diastole) and contraction (systole) of the media layer pushes blood through the artery and controls blood pressure. In this transmission electron micrograph, the intima has accordioned due to contraction of the media. Image: © Steve Gschmeissner/Science Source.The authors analyzed the children’s vascular measurements in association with their mothers’ prenatal levels of three bisphenols [bisphenol A (BPA), bisphenol S (BPS), and bisphenol F (BPF)], low-molecular-weight phthalates as a group, high-molecular-weight phthalates, and three individual phthalates. They found no associations between any of the chemicals and distensibility. However, higher maternal urine concentrations of total bisphenols and of BPA alone were associated with thinner vessel walls in the children’s carotid artery. No associations were found for BPS, BPF, or any phthalate.The association of higher total bisphenol and BPA exposure with thinner—rather than thicker—vessel walls surprised the team initially but is biologically plausible, says first author Sophia Blaauwendraad. “Associations between higher BPA levels and atherosclerosis in adulthood [demonstrated in earlier studies¹⁴] could be due to oxidative stress that accelerates the formation of atherosclerotic plaques and thickens the vascular wall,” says Blaauwendraad, a physician and graduate student in epidemiology under senior coauthor Vincent Jaddoe at Rotterdam’s Erasmus University Medical Center. Fetal exposures, on the other hand, may be associated with an underdevelopment of the vasculature in childhood, the authors speculate. However, Blaauwendraad says, as yet no prospective studies have tracked intima-media thickness measures from childhood to adulthood.¹⁵Nikki Posnack, an assistant professor of pharmacology, physiology, and pediatrics at Children’s National Hospital in Washington, DC, says the study’s strengths include its large sample size and measurements of several subtypes of phthalates and bisphenols at three different time points during pregnancy. Posnack, who was not involved in the research, says, “This is a compelling study that opens up new opportunities for mechanistic follow-up studies in model systems.” Such studies could examine whether BPA disrupts development of blood vessels and alters their contractile properties,¹⁶ similar to the chemical’s disruption of hormonal regulation.According to Lars Lind, a professor of medicine at Uppsala University in Sweden, who also was not involved in the project, studying the effect of the chemicals on early vascular changes in animal models would be worthwhile and should be accompanied by replication efforts in other human birth cohorts. “Since the findings were unexpected, replication is critical to increase our faith in them,” says Lind. “But it is possible that these chemicals may have different effects at the fetal stage than later in life.”The association with total bisphenols appears to have been driven mainly by BPA; BPS and BPF were below the limit of detection in more than half the samples, possibly because they were collected in 2002–2006, when these chemicals were used less than today. However, human exposure to these BPA replacement chemicals has been increasing.¹⁷ “With that in mind,” Posnack says, “I think the study fills an important knowledge gap by exploring if exposure to any bisphenols in utero may affect subclinical indicators of vascular disease risk later in life.”