Changes in Socio-Economic Inequality in Neonatal Mortality in Iran Between 1995-2000 and 2005-2010: An Oaxaca Decomposition Analysis

BACKGROUND

Exploring changes in health inequality and its determinants over time is of policy interest. Accordingly, this study aimed to decompose inequality in neonatal mortality into its contributing factors and then explore changes from 1995-2000 to 2005-2010 in Iran.

METHODS

Required data were drawn from two Iran's demographic and health survey (DHS) conducted in 2000 and 2010. Normalized concentration index (CI) was used to measure the magnitude of inequality in neonatal mortality. The contribution of various determinants to inequality was estimated by decomposing concentration indices in 1995-2000 and 2005-2010. Finally, changes in inequality were investigated using Oaxaca-type decomposition technique.

RESULTS

Pro-rich inequality in neonatal mortality was declined by 16%, ie, the normalized CI dropped from -0.1490 in 1995-2000 to -0.1254 in 2005-2010. The largest contribution to inequality was attributable to mother's education (32%) and household's economic status (49%) in 1995-2000 and 2005-2010, respectively. Changes in mother's educational level (121%), use of skilled birth attendants (79%), mother's age at the delivery time (25-34 years old) (54%) and using modern contraceptive (29%) were mainly accountable for the decrease in inequality in neonatal mortality.

CONCLUSION

Policy actions on improving households' economic status and maternal education, especially in rural areas, may have led to the reduction in neonatal mortality inequality in Iran.

Mapping for maternal and newborn health: the distributions of women of childbearing age, pregnancies and births

BACKGROUND

The health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed.

METHODS

This paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies.

RESULTS AND CONCLUSIONS

These estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project.

A rollercoaster of policy shifts: global trends and reproductive health policy in The Gambia

Global trends influence strategies for health-care delivery in low- and middle-income countries. A drive towards uniformity in the design and delivery of healthcare interventions, rather than solid local adaptations, has come to dominate global health policies. This study is a participatory longitudinal study of how one country in West Africa, The Gambia, has responded to global health policy trends in maternal and reproductive health, based on the authors' experience working as a public health researcher within The Gambia over two decades. The paper demonstrates that though the health system is built largely upon the principles of a decentralised and governed primary care system, as delineated in the Alma-Ata Declaration, the more recent policies of The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria and the GAVI Alliance have had a major influence on local policies. Vertically designed health programmes have not been easily integrated with the existing system, and priorities have been shifted according to shifting donor streams. Local absorptive capacity has been undermined and inequalities exacerbated within the system. This paper problematises national actors' lack of ability to manoeuvre within this policy context. The authors' observations of the consequences in the field over time evoke many questions that warrant discussion, especially regarding the tension between local state autonomy and the donor-driven trend towards uniformity and top-down priority setting.

Improving the New Zealand dairy industry's contribution to local and global wellbeing: the case of infant formula exports

On narrow economic measures of wellbeing, New Zealand's dairy industry is a huge success. Infant formula, in particular, is New Zealand's 'export superstar'. However, using a broader wellbeing lens, there is some public disquiet about environmental, human and animal wellbeing associated with the dairy industry. This article questions whether New Zealand's dairy industry is also undermining global 'best practice' infant feeding. It argues that while there is support for increased trade and exports, there are few voices promoting global infant health and that discussion is needed on this issue by the New Zealand public health community.

Reasons for earlier than desired cessation of breastfeeding

OBJECTIVE

To describe the prevalence and factors associated with not meeting desired breastfeeding duration.

METHODS

Data were analyzed from 1177 mothers aged ≥18 years who responded to monthly surveys from pregnancy until their child was 1 year old. When breastfeeding stopped, mothers were asked whether they breastfed as long as they wanted (yes or no) and to rate the importance of 32 reasons for stopping on a 4-point Likert scale. Multiple logistic regressions were used to examine the association between the importance of each reason and the likelihood of mothers not meeting their desired breastfeeding duration.

RESULTS

Approximately 60% of mothers who stopped breastfeeding did so earlier than desired. Early termination was positively associated with mothers' concerns regarding: (1) difficulties with lactation; (2) infant nutrition and weight; (3) illness or need to take medicine; and (4) the effort associated with pumping milk.

CONCLUSIONS

Our findings indicate that the major reasons why mothers stop breastfeeding before they desire include concerns about maternal or child health (infant nutrition, maternal illness or the need for medicine, and infant illness) and processes associated with breastfeeding (lactation and milk-pumping problems). Continued professional support may be necessary to address these challenges and help mothers meet their desired breastfeeding duration.

Meningococcal vaccine evolution

Neisseria meningitidis is a leading cause of bacterial sepsis and meningitis worldwide. Invasive meningococcal disease (IMD) can develop rapidly and is associated with high mortality and morbidity. Case fatality in developed countries averages 10% and higher rates are reported in less prosperous regions. The incidence of invasive disease due to Neisseria meningitidis is highly variable according to geographical area and serogroup distribution. The major disease burden is in developing countries; in industrialized countries meningococcal disease occurs sporadically and most IMD is caused by serogroups B and C. In the US serogroup Y is a major cause of meningococcal disease, accounting for more than one third of cases. Polysaccharide vaccines against serogroups A, C, W-135, and Y were developed but they were not so effective in protecting infants, who are at particularly high risk from invasive meningococcal infections. Conjugation of bacterial capsular polysaccharide to a carrier protein generates a T cell dependent immune response and immunological memory from infancy. After the introduction of serogroup C meningococcal conjugate vaccines since 1999, the incidence of serogroup C disease fell dramatically in countries in which they have been used. The first quadrivalent meningococcal conjugate vaccine (MenACWY-D) was licensed in the US in 2005. More recently, another tetravalent meningococcal conjugate vaccine (MenACWY-CRM, Menveo) was licensed in Europe and the US. Although polysaccharide and glycoconjugate vaccines have been developed for serogroups A, C, Y and W-135, currently there are no broadly effective vaccines available for the prevention of meningococcal B disease.

From papers to practices: district level priority setting processes and criteria for family planning, maternal, newborn and child health interventions in Tanzania

BACKGROUND

Successful priority setting is increasingly known to be an important aspect in achieving better family planning, maternal, newborn and child health (FMNCH) outcomes in developing countries. However, far too little attention has been paid to capturing and analysing the priority setting processes and criteria for FMNCH at district level. This paper seeks to capture and analyse the priority setting processes and criteria for FMNCH at district level in Tanzania. Specifically, we assess the FMNCH actor's engagement and understanding, the criteria used in decision making and the way criteria are identified, the information or evidence and tools used to prioritize FMNCH interventions at district level in Tanzania.

METHODS

We conducted an exploratory study mixing both qualitative and quantitative methods to capture and analyse the priority setting for FMNCH at district level, and identify the criteria for priority setting. We purposively sampled the participants to be included in the study. We collected the data using the nominal group technique (NGT), in-depth interviews (IDIs) with key informants and documentary review. We analysed the collected data using both content analysis for qualitative data and correlation analysis for quantitative data.

RESULTS

We found a number of shortfalls in the district's priority setting processes and criteria which may lead to inefficient and unfair priority setting decisions in FMNCH. In addition, participants identified the priority setting criteria and established the perceived relative importance of the identified criteria. However, we noted differences exist in judging the relative importance attached to the criteria by different stakeholders in the districts.

CONCLUSIONS

In Tanzania, FMNCH contents in both general development policies and sector policies are well articulated. However, the current priority setting process for FMNCH at district levels are wanting in several aspects rendering the priority setting process for FMNCH inefficient and unfair (or unsuccessful). To improve district level priority setting process for the FMNCH interventions, we recommend a fundamental revision of the current FMNCH interventions priority setting process. The improvement strategy should utilize rigorous research methods combining both normative and empirical methods to further analyze and correct past problems at the same time use the good practices to improve the current priority setting process for FMNCH interventions. The suggested improvements might give room for efficient and fair (or successful) priority setting process for FMNCH interventions.

Factors associated with outcomes for looked-after children and young people: a correlates review of the literature

In 2008, the Department of Health made a referral to the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence to develop joint public health guidance on improving the physical and emotional health and well-being of children and young people looked after by the local authority/state. To help inform the decision-making process by identifying potential research questions pertinent to the outcomes of looked-after children and young people (LACYP), a correlates review was undertaken. Iterative searches of health and social science databases were undertaken; searches of reference lists and citation searches were conducted and all included studies were critically appraised. The correlates review is a mapping review conducted using systematic and transparent methodology. Interventions and factors that are associated (or correlated) with outcomes for LACYP were identified and presented as conceptual maps. This review maps the breadth (rather than depth) of the evidence and represents an attempt to use the existing evidence base to map associations between potential risk factors, protective factors, interventions and outcomes for LACYP. Ninety-two studies were included: four systematic reviews, five non-systematic reviews, eight randomized controlled trials, 66 cohort studies and nine cross-sectional studies. The conceptual maps provide an overview of the key relationships addressed in the current literature, in particular, placement stability and emotional and behavioural factors in mediating outcomes. From the maps, there appear to be some key factors that are associated with a range of outcomes, in particular, number of placements, behavioural problems and age at first placement. Placement stability seems to be a key mediator of directional associations. The correlates review identified key areas where sufficient evidence to conduct a systematic review might exist. These were: transition support, training and support for carers and access to services.

Centers for Disease Control and Prevention (CDC). Ten great public health achievements--United States, 2001-2010

During the 20th century, life expectancy at birth among U.S. residents increased by 62%, from 47.3 years in 1900 to 76.8 in 2000, and unprecedented improvements in population health status were observed at every stage of life. In 1999, MMWR published a series of reports highlighting 10 public health achievements that contributed to those improvements. This report assesses advances in public health during the first 10 years of the 21st century. Public health scientists at CDC were asked to nominate noteworthy public health achievements that occurred in the United States during 2001-2010. From those nominations, 10 achievements, not ranked in any order, have been summarized in this report.

Rekindling of Nurse‐Midwifery in Brazil: Public Policy and Childbirth Trends

In the last decade, nurse-midwifery in Brazil has experienced many changes both professionally and politically. In the 1990s, Brazil's Ministry of Health generated policies to improve childbirth services. Included in these policy initiatives was legislation for the reimbursement of nurse-midwifery services and a substantial increase in financing of nurse-midwifery schools throughout the country. It was during this period that the Brazilian National Nurse-Midwifery Organization was formed to provide professional leadership and an alternative model of childbirth care. The future is hopeful, but the nurse-midwifery profession will need collective determination to succeed in changing practices and improving services to women and families.

Regional collaborations as a way forward for maternal, newborn and child health: the South Asian healthcare professional workshop

This article reviews the importance of regional initiatives in the context of global efforts to achieve the Millennium Development Goal 4 and 5 and describes the action-oriented multi-country healthcare professional association (HCPA) workshops organized by the Partnership for Maternal, Newborn and Child Health. The South Asian HCPA workshop served as a catalyst for strengthening the ability of HCPAs in South Asian countries to organize and coordinate their activities effectively, play a larger role in national planning, and collaborate with other key stakeholders in maternal, newborn and child health.

The state of South Dakota's child: 2009

A confluence of variables led to South Dakota's 2008 infant mortality rising to its highest rate per 1000 live births (8.3) since 1999 and above the 6.5 per 1000 rate for the United States. The number of live births in the state decreased for the first time since 2000. In 2008, one hundred infants died, more in any one year since 1995. The increase in the infant mortality rate occurred for both white and minority infants in both the neonatal and post-neonatal periods of the first year of life. Analyzes show that in 2008, there was an increase in the percent of all births that were very low birth weight (VLBW) and that multiple births accounted for this increase. Further, survival in the VLBW category for infants decreased in 2008 compared to recent years. Accounting for the largest increase in the rate of death, however, were those attributed to causes "other" than perinatal causes, sudden infant death syndrome (SIDS), congenital anomalies or accidents. The possibility is discussed that a potential diagnostic shift in how deaths are certified may be reflected by the 2008 data, with increasing numbers of deaths occurring sleep now being certified as having an "undetermined" cause rather than SIDS.

Why has the health inequality among infants in the US declined? Accounting for the shrinking gap

Given that wealthier people are healthier, the increase in income inequality over the past two decades has led to fears that inequalities in health have also increased. Indeed, some papers have found that health disparities have become more salient among some adult populations. Using the US Vital Statistics 1983-2000, this paper presents a new stylized fact: the infant health disparity, as measured by Apgar score, neonatal mortality and infant mortality, has been narrowing over the past two decades. This is in sharp contrast to the increasing disparities in health among adults of different educational backgrounds. Using a decomposition method, I find that the most important factor in explaining the closing gap is an increase in access to medical care. All else being equal, access to proper medical care is the most important factor in explaining the narrowing infant health gap. Demographic shifts and maternal behavior changes are also significant factors, together explaining 42.2% of the closing gap in low Apgar score, 41.4% of the closing gap in neonatal death, and 45.6% of the closing gap in infant death.

The state of South Dakota's child: 2007

The year 2006 brought a 4 percent increase in births to the state that was almost entirely attributed to an increase in white newborns. The rate of low birth weight births decreased for newborns weighing less than 1,500 grams but increased for those weighing 1,500 to 2,500 grams. The state's rate of low birth weight, however, remained less than the persistently climbing U.S. rate. The incidence of prenatal care beginning in the last trimester of pregnancy, or no prenatal care, increased and is of concern in light of recent findings from a South Dakota report that shows how failure to receive this care is related to infant mortality. The state's overall infant mortality rate decreased from its 2005 rate. This decrease is attributable to a decrease in the rate of neonatal deaths for the state's white population. Rates of neonatal death increased for the minority population and post-neonatal mortality increased for both the white and minority population. How these findings are related to social and economic disparities is discussed.

Trends in maternal health/healthcare in low-income countries and the implications on neonatal health

Maternal health in low-income countries has received increasing attention over the last 15-20 years. Maternal mortality ratios in these countries are mainly still modelled estimates and one cannot discern trends. The introduction of registration systems-giving reliable causes of death-is essential both for monitoring maternal health and fuelling action. Countries with documented success in reducing maternal mortality have used systematic, incremental approaches, often tied to multi-sectoral efforts, including roads, communication links, education, water and sanitation. Improving maternal health requires a reasonably well-functioning health system and this typically requires the reduction of poverty and consistent investment in the health system. Increasingly, policies to improve maternal and newborn health are being implemented, but in the poorest countries the impact is still not discernible. New clinical interventions, such as effective treatment of (pre)eclampsia and post-partum haemorrhage, are often beyond reach of the majority in low-income countries. In summary, progress in maternal health, and the intimately linked perinatal and newborn health, is too slow and requires urgent efforts in poverty reduction and health system strengthening in low-income countries.

Trends in maternal and infant health in poor urban neighborhoods: good news from the 1990s, but challenges remain

OBJECTIVES

During the 1990s, numerous public policy changes occurred that may have affected the health of mothers and infants in low-income neighborhoods. This article examines trends in key maternal and child health indicators to determine whether disparities between high-poverty neighborhoods and other neighborhoods have declined.

METHODS

Using neighborhood-level vital statistics and U.S. Census data, we categorized "neighborhoods" (Census tracts) as being high poverty (greater than 30% of population below the federal poverty level in 1990) or not. We compared trends in four key indicators--births to teenagers, late prenatal care, low birth-weight; and infant mortality--over the 1990s among high-poverty and other neighborhoods in Cuyahoga County, Ohio; Denver, Colorado; Marion County, Indiana; and Oakland, California.

RESULTS

In all four metropolitan areas, trends in high-poverty neighborhoods were more favorable than in other neighborhoods. The most consistently positive trend was the reduction in the rate of teen births. The metropolitan areas with the most intensive programs to improve maternal and child health--Cuyahoga County and Oakland-saw the most consistent improvement across all indicators. Still, great disparities between high-poverty and other neighborhoods remain, and only Oakland shows promise of achieving some of the Healthy People 2010 maternal and child health goals in its high-poverty neighborhoods.

CONCLUSIONS

While there has been a reduction in maternal and infant health disparities between high-poverty and other neighborhoods, much work remains to eliminate disparities and achieve the 2010 goals. Small area data are useful in isolating the neighborhoods that should be targeted. Experience from the 1990s suggests that a combination of several intensive interventions can be effective at reducing disparities.

The health and social environment of uninfected infants born to HIV-infected women

Against a background of increasing numbers of uninfected children born to HIV-infected women in Europe, we describe the social environment and occurrence of infectious disease in 1,667 infants enrolled in the European Collaborative Study (ECS) and followed prospectively. In the ECS, the proportion of children born to black women from Sub-Saharan Africa who acquired their HIV infection heterosexually has increased since the mid-1980s, while the proportion of those born to white women with a history of illicit drug use has decreased, in both northern and southern Europe. The percentage of children who had been in alternative (non-parental) care decreased from 17% (82/469) in 1985-1989 to 5% (23/436) in 1999-2002. A total of 135 infants (with 1,475 child-years of follow-up) experienced at least one moderate/severe infective or febrile episode requiring medical attention in the first year of life; there was little correlation with recorded sociodemographic and child characteristics. The rate of hospitalization remained relatively stable over the study period at between 243-299 admissions per 1,000 child-years. Description of disease burden and social circumstances of uninfected children is needed, not only because of their increasing numbers but also because they are often used as controls in studies addressing vertically-acquired HIV infection.

Examination of the communication practices between state newborn screening programs and the medical home

BACKGROUND

As outlined in the Newborn Screening Task Force report published in August 2000, the newborn screening system is more than just testing, but also involves follow-up, diagnosis, treatment, and evaluation. As such, multiple professional and public partners need to be adequately involved in the system to help ensure success. In addition, newborn screening programs are state-based; therefore, policies and procedures vary from state to state. Historically, there has been little uniformity between state newborn screening programs.

OBJECTIVE

To examine the communication practices of state newborn screening programs in the United States, particularly in relation to the medical home.

METHODS

A facsimile survey of program staff in all US newborn screening programs. Survey data were collected in August 2000.

RESULTS

All 51 programs participated. States were questioned about whether or not they had a procedure to identify the infant's medical home before the child's birth. Twelve states (24%) indicated that there was a procedure in place, whereas 39 states (76%) indicated that either no procedure existed or that they were unsure. In contrast, all state programs (except 1) indicated they notified the primary care physician about abnormal results and the need for follow-up. In addition, state programs reported that primary care physicians have responsibilities within the newborn screening system, particularly related to communicating with parents about screen-positive results and coordinating the collection of a second specimen. Thirty states reported that they directly notified parents of screen-positive infants of results and the need for follow-up as well. In regard to informing parents about newborn screening, 45% of states indicated that primary care physicians had some responsibility in informing parents about newborn screening. Most often, parents were informed about newborn screening just before specimen collection, and the most commonly used techniques to educate parents were informational brochures and conversation. Thirty-five states reported that they engaged in long-term tracking of infants after diagnosis confirmation. Only about half of these states provided long-term tracking of all of the conditions included in their state's newborn screening test panel. Of these 35 states that engaged in long-term tracking, 25 reported that they requested patient information from the primary care physician and/or subspecialist about ongoing treatment and follow-up.

CONCLUSIONS

Newborn screening roles and responsibilities vary tremendously between states. Improvements in communication and better-defined protocols are needed, particularly between state newborn screening programs and the medical home. Many states identified the medical home as having significant responsibilities related to the short-term follow-up of screen-positive infants. Identification of the correct medical home before testing would help to reduce unnecessary time and frustration for state newborn screening programs, especially in the follow-up of infants that are difficult to locate. In addition, primary care physicians (ie, the medical home) need to have appropriate and ongoing involvement, including a mechanism to provide feedback to their state newborn screening program. This is particularly important given the adoption of tandem mass spectrometry by an increasing number of states, and the likely expansion of newborn screening in the future. Recommendations include the following: Primary care physicians should have appropriate and ongoing involvement in the newborn screening system and should be appropriately represented on state newborn screening advisory committees. States should develop protocols to identify the medical home before heelstick screening. States should work with families, primary care physicians, and prenatal health care professionals to develop well-defined systems for pretesting education of parents. All newborn screening results (both positive and negative) should be sent to the infant's medical home. If results are not received by the medical home, efforts should be made to obtain results. Medical homes and subspecialists should submit follow-up information on screen-positive infants and infants with confirmed diagnoses to the state newborn screening program, regardless of the existence of state requirements to do so, and efforts to build enhanced direct communication systems, linking state newborn screening programs to community-based medical homes, should continue.

Why are babies getting bigger? Temporal trends in fetal growth and its determinants

OBJECTIVES

To describe temporal trends in fetal "growth" and to examine the roles of sociodemographic, anthropometric, and other determinants.

STUDY DESIGN

Hospital-based cohort study of 61,437 nonmalformed singleton live births at 22 to 43 weeks' gestational age. Four main measures were examined: (1) birth weight, (2) birth weight-for-gestational-age Z score, (3) small-for-gestational-age (SGA), and (4) large-for-gestational age (LGA), with the latter 3 measures based on a recently developed population-based Canadian reference. Gestational age was based on the last normal menstrual period if confirmed (+/- 1 week) by early ultrasonogram.

RESULTS

The mean birth weight and Z score increased significantly (P <.0001) among infants > or =37 weeks, with a corresponding reduction in % SGA and a rise in % LGA. No consistent trends were seen among births 34 to 36 or < or =33 weeks. When simultaneous changes in maternal prepregnancy body mass index, gestational weight gain, height, cigarette smoking, and other clinical and sociodemographic factors were controlled by using multiple logistic regression, the temporal trends for term infants were no longer evident.

CONCLUSIONS

Increases in maternal anthropometry, reduced cigarette smoking, and changes in sociodemographic factors have led to an increase in the weight of infants born at or after term.

Severe traumatic brain injury in children--are the results improving?

QUESTIONS UNDER STUDY

Traumatic brain injury (TBI) remains an important cause of mortality and morbidity in children. Medical management is constantly being refined, and thus results should improve. The aim of the present study was to analyse our data of recent years and to compare them with previous series (1978-83 and 1988-92).

PATIENTS AND METHODS

The data of 51 children (1 month to 16 years old) with severe blunt TBI treated in our unit from 1994 to 1998 were analyzed retrospectively. Severe TBI was defined by immediate loss of consciousness and an admission Glasgow coma scale (GCS) <8. Outcome was classified by using the Glasgow outcome scale (GOS) 6 to 12 months after injury.

RESULTS

35 patients (69%) showed a good outcome (GOS 4 and 5), 14 died (GOS 1), one survived in a permanent vegetative state (GOS 2), and another was severely disabled (GOS 3) (GOS 1-3 = bad outcome, 31%). Bad outcome was associated with low GCS (i.e. 3 and 4), fixed and dilated pupils at admission, invisible basal cisterns on first computerized tomography, and presence of coagulopathy. Moderate to severe intracranial hypertension was also significantly related to bad outcome in the 26 patients with intracranial pressure monitoring. Compared to our first series severity of TBI was unchanged, and the incidence of multiple injury and consumption coagulopathy was less frequent. Intubation rate prior to admission to the centre increased from 35% to 94%. Intensive care measures (duration of mechanical ventilation, use of hypothermia, mannitol, thiopentone etc.) were less aggressive. The rate of good outcome remained unchanged (69% vs. 60%).

CONCLUSIONS

Despite changing management policies, results were comparable with those of our former series. This fact underlines the importance of primary injury and the secondary role of intensive care management on final outcome.

[1901-2001: 100 years of physicians of infant and toddler welfare centers in the Netherlands]

This year marks the centenary of infant welfare centres in the Netherlands. In 1901, Plantenga opened the first infant welfare centre in The Hague, the Netherlands. Initially, only advice about feeding was given and the growth of the infant was monitored. To support mothers, extra milk was supplied in so-called 'milk kitchens'. Over the years the tasks have been extended to include a wide range of preventive measures. At first the doctors in infant welfare clinics were predominantly paediatricians but later general practitioners and doctors specialised in infant primary health care followed. In their 100-years existence, infant welfare clinics have grown into an intricate network which sees 98% of Dutch infants.

Is birthweight an appropriate health-outcome measure for Torres Strait Islander babies?

BACKGROUND

Although Torres Strait Islanders (TSIs) are often combined with Aborigines, they are a distinct group and would prefer to be considered separately. The Queensland Perinatal Data Collection (QPDC) has been the only population-based, perinatal collection in Australia that has distinguished between Aboriginal and TSI mothers. It provided a unique opportunity to compare outcome measures based on birthweight in the TSI, Aboriginal and white populations. TSIs were of particular interest because recent research from overseas suggests that in groups with high rates of obesity and diabetes, birthweight is not a valid outcome measure. This is of concern because outcome measures based on birthweight have been proposed as a way of monitoring the neonatal health of Indigenous Australians.

METHODS

Retrospective analysis of 10 years of routine data from the QPDC.

RESULTS

TSIs had a birthweight distribution similar to that of whites, but mortality rates similar to those of Aborigines. For birthweights between 2500 g and 4000 g, TSIs had mortality rates that were 2.5 times higher than those for whites (95% CI: 1.3 to 4.2).

CONCLUSIONS

Although birthweight is widely used, it is not necessarily a valid outcome measure in all populations. For TSIs, maternal conditions such as obesity and diabetes might cause changes in the uterine environment that produce heavier, but not healthier babies.

Diagnostic clusters in infants as child health outcomes. Variation among socioeconomic areas in one community

Objectives were to examine geographic variation in rates of infant hospitalization for diagnostic clusters in Monroe County (Rochester), New York and to assess these clusters as indexes of child health. ICD-9 codes were used to cluster all 7,883 hospitalizations of infants (< 24 months) between 1985 and 1991 on the basis of their avoidability. Environmentally sensitive clusters accounted for 63% of admissions. These clusters included environmental, environmental/constitutional, and other infectious disease. Disparities in morbidity between inner city and suburbs were greatest for the environmental cluster, followed by the environmental/constitutional, and other infectious disease clusters. For the constitutional and quality indicator clusters, differences between inner-city and suburban risk were minimal. Environmental interventions may be more important than improved health services to reducing racial and economic disparities in child health. Analysis of morbidity clusters, ascertained from available administrative data bases and aggregated for small geographic areas, may guide child health policy well.

Returns on investment in public health: effect of public health expenditures on infant health, 1983-1990

In this study, we developed a broad conceptual framework focusing on how public health expenditures impact the nation's health. We then applied this framework to infant health outcomes and, using an eight-year state panel database, empirically analyzed how state public health expenditures, ceteris paribus, impact a state's level of teenage births and the receipt of prenatal care. Two hypotheses were tested. Hypothesis 1 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease births to mothers less than 20 years of age. Hypothesis 2 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease the number of infants whose mothers received late or no prenatal care. We find support for both hypotheses but observe that the way public health expenditures are measured has an impact on the findings. Other important implications of the study are noted. To our knowledge, this is the first article that has taken an aggregate state perspective over time and applied it to specific measures of infant health.

[Teenage pregnancy as a public problem: a critical view]

The present work is a review of the most commonly used arguments to define pregnancy during adolescence as a public problem: its supposed increase, contribution to accelerated population growth, adverse effects on maternal and child health and contribution to the persistence of poverty. Some elements are proposed for an alternative explanation with the intention of defining with more rigour and pertinence the real problems related to pregnancy during adolescence, thus allowing an improvement in the design of policies and programs to confront it.

Perinatal health care policy: how it will affect the family in the 21st century

Demographic trends, pressures to reduce medical care costs and to improve access, biomedical research, and women's preferences for health care will result in many important changes in perinatal health care during the next 2 decades. These changes have the potential for influencing family structure and functioning. For example, the rates of teen-age pregnancy, unwanted or mistimed pregnancy, and infertility, with all their attendant adverse consequences, might be reduced.

Health care reform as an ongoing process

Reform in maternal and infant health care is presented as an ongoing process. Three phases of reform occurring during the past 4 decades that have been initiated or involved nurses are discussed: the childbirth education movement, which signalled the beginning efforts of parents to regain responsibility and control of their birth experience; the acceptance of nurse-midwives as primary care providers working in concert with obstetrical specialists; and the free-standing birth center as a holistic environment for the practice of midwifery and the care of women anticipating a medically uncomplicated childbirth experience. These reforms represent a paradigm shift that fits all current proposals for reform of the health care system.

Promoting maternal-child wellness in the workplace

With increased numbers of women in the workplace, corporations are recognizing the need for maternal-child wellness programming. Prenatal risk assessment and screenings with follow up educational programs can reduce infant mortality and morbidity, thereby reducing dollars spent by industry for health care of women and children. Occupational health nurses can serve as change agents in implementing prenatal, postnatal, and family oriented wellness programs in the workplace.