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Friday, 19 August 2011

Maternal-infant care - a great public health success story.

Public health has its roots in communicable disease control (actually in ‘biological’ warfare in biblical times).  Then it wandered into occupational health issues in the mid 1800’s.  The turn of the 1900’s saw a growing interest in maternal and child health.  At that time about 1 in 200 births resulted in the death of the mother and one in ten the death of the infant before their first birthday.  Today, those numbers are 1 in 11,000 mothers and 5.1 infant deaths per 1000 live births.
Incredible improvements - due mostly to the simple public health interventions of improved nutrition and better hygiene.
Today there rightly remain concerns for the thriving growth of the infant.  Death is not the only health outcome of concern and issues like attachment in the first hours to year of life are receiving more attention as they relate to our health as adults. 
There is also a “quality of birth experience” that has driven change to the birthing experience for some mothers and at times can be at a odds with increasing risks to the baby.  On the other hand, formal health care services are not yet always aligned with ensuring a good quality of experience while maximizing the reduction in risk.   
There is a good recent Canadian set of surveys and studies on the maternity experience at http://www.phac-aspc.gc.ca/rhs-ssg/survey-eng.php  
Notably, Caesarean section rates continue to increase and often exceed 1/3rd of births.  This was considered acceptable until 2009 when new guidelines now stress that C-sections should only be provided when there is a threat to infant or mother http://www.sogc.org/guidelines/documents/gui221PS0812.pdfRates have yet to  not come down yet, nor has promotion of the new guidelines received much attention.     
Good news - breastfeeding initiation rates are in the 90% range.  Continuation through 6 months is much lower than needed to promote the health of infants. More good news is the routine circumcision is decreasing and now about 1/3rd of male infants.   Two more public health success stories.
Midwifery is reinvigorating the health system approach to normalizing the birth process,  this is a great thing.  Many physicians have shied away from continuing obstetrical practice.  While specialization in managing only one component of our health care has some value, it undermines the primary health care relationship that should form the foundation of personal health care.  Collaboration between health care providers is essential, and with this the sharing of information referenced in the previous blog on electronic health records. 
Lacking in many parts of the country is a dedicated focus to maternal child health based on public health principles.  Replacing this are specific approaches driven by philosophy and often in competition.  The undermining of the public health approach to maternal-child health is perhaps something only to be mourned now - and hopefully without the need to mourn mothers or children who suffer because of the change.

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