PH 413 Conferencing Exercise

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Each learner will contribute to a discussion involving contributors to improvements in health status for mothers and infants in the U.S. since 1900. Review the "Healthier Mothers and Babies" and "Family Planning" reports in the "Century of Progress in Public Health" case study; there are links to these resources in the PH 413 Exercises Document. There are 2 propositions to be considered:

Position A: public health interventions are primarily responsible for these improvements.

Position B: medical care interventions are primarily responsible for these improvements.

Below, you will find several postings related to each of these positions that provide arguments and evidence in support of one of these positions. You should review the positions and their supporting arguments and evidence before adding your own contribution. Your posting should be brief (less than 100 words) and it should include your arguments, evidence and rationale for the position that you choose.

• I support Proposition A. As early as 1900, Public health was focused on improving environmental and living conditions in urban areas, improving economic and education levels of families and improving nutritional status of mothers and infants. In 1912, the Children's Bureau was formed with the goal of improving maternal and infant welfare. The Bureau also advocated comprehensive maternal and infant welfare services such as prenatal, natal and postpartum home visits by health-care providers. Public health actions played a role in reducing the SIDS rate by recommending that infants be placed to sleep on their backs. Public health has subsidized family planning clinics for an estimated 6.6 million women. These services prevent an estimated 1.3 million unintended pregnancies annually. Health departments regularly administer vaccines which help to promote disease prevention and create healthier moms and babies. Public health has contributed substantially to interventions in infant and maternal mortality.
• Public health interventions were indeed primarily responsible for the improvement in health status over the past century. It is important to note though that advances in science, technology and medicine played significant roles in the improved health this century has shown. These include asepsis in obstetrics, the use of antimicrobial agents, and the development of sophisticated screening procedures. Public health was the key to defining specific health problems through the collection, analysis and interpretation of data. This produced the figures in indices, rates and proportions, which made it possible to perceive the effects of various interventions.
  Prevention was the foremost among its roles, and included the following:
  1. Education and increase of public awareness of the need for prenatal care, sudden infant death syndrome, and the effects of alcohol, tobacco and illicit drugs.
  2. Immunization initiatives to combat the major illnesses implicated in causation of infant mortality.
  3. Focus on contraception to forestall unwanted pregnancies, and for better child spacing
  4. Control of infections through milk pasteurization and better sewage and refuse disposal
  Public health was also the glue that has held all sectors together, cooperating with government, social welfare and medicine, to better direct initiatives and for maximum effect.
• I agree with proposition A, public health interventions are primarily responsible for the health improvements of mothers and infants in the U.S. since 1900. During the first half of the century improvements in medical care contributed greatly. There was technology advances in neonatal medicine, the discovery of antimicrobial agents, and artificial pulmonary surfactant to prevent and treat respiratory distress syndrome in premature babies. There is more that contributed to the success of health status of mothers and infants, and this is public health. Public health deals with mother and infants as a whole not only when there is a medical condition (as do the medical care system). There have been improvements in the environment, living conditions, and milk pasteurization. There has also been preventive programs implemented in prenatal care to educate, and look after pregnant women. Information on sudden infant death syndrome (SIDS) has also contributed to the increase in health status. Also there has been programs on family planning. Although there has been great achievements in the health status of mother and infants due to public health there is still more work to be done. There is still a need for programs that will eradicate racial and ethnic disparities.
• Both medical interventions and public health strategies have contributed to
  the improvement in maternal and infant health over the 20th century. Several of my children are here today due to technological advances in neonatal care. However, medical care tends to be "reactionary" since it often provides services "after the fact" i.e. after disease has set in or an injury has occurred. In my opinion, public health interventions which focus on developing, strategies that promote good health and prevent disease, account for the lion's share primarily due to the following additional reasons:

  *Maternal, prenatal and postnatal care.
  *Well baby care which includes immunizations and screenings.
  *Variety of health education services that are offered.
  *WIC (supplementing the nutritional needs of mothers and their children.)
  *Improving environmental and living conditions in urban areas.
  *Improving the socio-economic status of women.

• I believe that public health was responsible for improvements in maternal and child healthcare. Public health interventions led to access to quality healthcare. Education for the mother about prenatal care, nutrition, and exercise during pregnancy. Public health also identified through surveillance, certain risk factors that may have put the baby or mother at risk. Also, promotion of birth control and family planning led to smaller family size and less risk of infant mortality. Public health was also responsible for developing programs for continuing education of new mothers. Educating the mothers on how to properly care for their children after birth significantly reduced the number of infant mortalities. While progress has been made in medical treatments for pregnant women, intervention and prevention, more so than medicine is definitely responsible for infant and maternal mortality rate decline.
• When dealing with improvements in the health status for mothers and infants in the US since 1900, I believe in proposition A. Public Health interventions are primarily responsible for these improvements through many ways. With improvements in environmental interventions, in access to health care, and in surveillance, a great majority of the decline in infant and maternal morbidity and mortality can be attributed to public health. Prevention encompasses a large aspect of what public health is and through interventions, this can be achieved and continues to do so in this case. The focus from child health to maternal and child health was a very important recognition and therefore many services and programs could be created for this problem. The Children’s Bureau and other federal programs were formed along with recommendations in reducing family size, unintended pregnancies, and unhealthy lifestyle risk factors, by increasing health promotion and family planning. Although medical care interventions are somewhat responsible for the improvements in maternal and child health, public health by far has been primarily responsible.
• I worked in Kenya- Somalia borders for a while! As a medical doctor in an emergency nutritional project . I was in charge of 800 malnourished children and mothers at a time. I had only a few antibiotics, some antimalarial drugs and my stethoscope and otoscope. But we had tons of flour, sugar, oil and dry milk in our warehouse! My main concern was our cook's health and well being! He was the key person in that project! A week without a doctor or a week without a cook? I'm happy we didn't have to choose at the end! For I knew that food is more important than penicillin!
  Infant and Maternal Mortality are embarrassingly high in developing countries! Is it because of oxytocin and artificial pulmonary surfactant shortage? Is it because of health professionals shortage? Or may be because "their intensive care units" are not equipped with the latest hi-tech devices? Well, let's put aside the third world at the moment! May be it is too far to be our main concern!
  What about the prevalence and incidence of toxemia in our well functioning established market economies? How many LBW and preterm babies are there? What is the actual proportion of high risk pregnancies? How often do we administer artificial pulmonary surfactant? And what about the "incidence" of "natural labors", dear fellows?
  How "dangerous" the "medicalization" of human life can be!!!! We tend to forget that PREGNANCY IS NOT A DISEASE!!!
  Pregnancy is a natural phenomenon! It is magical, it is divine, it is pure biology, it is primitive, it is miraculous….But it is definitely not a disease! Why then should we treat all pregnant women as patients? And newborns are just vulnerable human beings, not patients! It is not a miracle that humans survived for thousands of years without obstetrics and pediatrics!
  But now we have the science and the technology to "improve" nature! That is a great achievement! Antibiotics and electrolytes and the surfactant and the intensive care units all are great achievements!
  But don't let them fool us! The majority of mothers and babies don’t need all that stuff. They need a beautiful house, clean water, good food, safe environment and lots of love! Some moms and babies do need doctors and hospitals and oxytocin! Medical care interventions are made for them! They all deserve it, but the majority don't need it! For the majority (which actually mostly influence the indicators!) it is public health interventions that assure their healthy food, the clean water, the family planning, the safe environment….
  Unfortunately love is not included neither in medical nor in public health services……
• While the case study was an excellent example of the impact that public health has made in maternal child health, I assert that medical interventions are primarily responsible for the advancements, or Proposition B. The best evidence of this is the dramatic twenty-year decline in maternal mortality rates, dropping from 700 deaths per 100,000 per live birth in 1930 to under 100 per 100,000 in 1950. (Figure 3-3, Maternal Mortality Rates) From 1939 to 1948, the numbers of infants born in hospitals (a medical intervention) increased from 55 to 90 percent and maternal mortality decreased by 71 percent. At the same time, institutional and physician guidelines were developed (medical intervention). Medical advances (including the use of antibiotics, oxtytocin to induce labor, and safe blood transfusion and better management of hypertensive conditions during pregnancy – all medical interventions) accelerated declines in maternal mortality. That is why I have chosen to support Proposition B.
• Borrowing from King Solomon, I am going to “split the baby” and suggest that the improved health status of mothers is largely due to medical care interventions and the improved status of infants is largely due to public health interventions, even though each population benefited from both types of interventions. Environmental interventions, improvements in education and overall standards of living improved the health status of the whole population. The Children’s Bureau, established in 1912 defined the problems associated with poor maternal and infant health outcomes, shaped the debate and advocated for reform and improvements that changed our overall approach from dealing with bad outcomes to one that included good prenatal care. The health status of mothers has improved largely as the result of improvements in medical care. The leading causes of death for mothers were sepsis, both from unsterile deliveries and illegally induced abortions, hemorrhage and toxemia. Better prenatal care and the shift to hospital deliveries with the establishment of maternal mortality review committees, institutional practice guidelines and physician qualifications resulted in improved health for mothers. Medical advances, including the use of antibiotics, oxytocin, safe blood transfusions and the better management of hypertensive conditions also contributed greatly to these gains. The health status of infants improved as a result of public health efforts, social welfare improvements and clinical medicine. Specific factors include improved environmental and living conditions, especially in urban areas, milk pasteurization, the widespread use of microbial agents, the use of artificial pulmonary surfactant, the “Back to Sleep” campaign and better prenatal care. Federally funded MCH programs and effective health promotion campaigns have also positively influenced health outcomes. The reduction in vaccine preventable illnesses is one example of an effective public health-medical care partnership. Publicly supported family planning services and modern contraception methods have significantly reduced unintended pregnancies and resulted in better health outcomes for both mothers and babies. I am posting this under Proposition B because, on balance, I think that advances in medical care have benefited both moms and babies to a greater extent than public health interventions alone could achieve. While these debates promote a healthy appreciation for the achievements of public health, I question why it is necessary to assign primary responsibility for achievements if we are going to advance the dialogue and partnership between public health and the rest of the health system. This was a hard choice for me.
• Proposition B. The literature supports that medical care interventions are primarily responsible for improvements in health status for mothers and infants in the U.S. since 1900. Although public health was on the forefront of the initial decline for infant mortality, the discovery of antimicrobial agents, fluid and electrolyte therapy, and safe blood transfusions are credited for the accelerated decline. Medical care interventions certainly receive the attention for their contributions. In addition, medical interventions also claim responsibility for major reductions in maternal mortality specifically with the use of antibiotics, oxytocin, safer blood transfusions, and better management of hypertension during prenatal period. Maternal deaths in the early 1900's resulted from poor obstetric education and delivery practices, which improved by the third decade. There have been no major declines in maternal mortality since 1982.
• I believe that medical care interventions are primarily responsible for the improvement of health status for mothers and infants in the 20th Century simple because there were prior reports of linking diseases to the child from the mother before hand. I think Proposition B gives good insight into the "Blood-Line" theory that says you can find out the cause of certain illnesses based on the individual's family background/linage.