Maternal and Child Health
Abstract and Keywords
Social reform efforts of the settlement-house movement have provided, in part, the foundation for today’s Maternal and Child Health Bureau’s policies, programs, and services. Planning, implementing, and evaluating policies and programs that affect the health and well-being of mothers and children require a multidisciplinary approach. Social workers, whose skills encompass direct services, advocacy, planning and research, community development, and administration, have a critical role to play in improving the health outcomes of maternal and child populations.
During the settlement-house movement of the 1890s, social workers labored to improve the health and welfare of the individuals in the communities where the settlement houses were located. In 1893, for example, Jane Addams organized a medical dispensary at the Hull-House settlement. The same year, the first milk station was established in New York City. A short time later, social reformers in Boston and Kentucky acted to improve the health of pregnant women by expanding prenatal care to include an assessment of social and environmental conditions. Working collaboratively with midwives, social workers visited the homes of pregnant women and assessed physical, social, and environmental conditions to ensure that the women and their soon-to-be-born infants would have the safe, clean homes needed to reduce their health risks (Schild & Sable, 2012). Social-work reform efforts were pivotal to developing maternal and child health as a core component of community public-health practice.
Federal and State Legislation
Founded in 1904 by Florence Kelley and Lillian Wald, the National Child Labor Committee directed its efforts to monitoring the effects of child labor on the health and development of children. The National Child Labor Committee played a pivotal role in the first White House Conference on Children, which was held in 1909. One of the consequences of the White House Conference was Congress’ establishment of the Children’s Bureau in 1912. The creation of the Children’s Bureau served to legitimate the federal government’s responsibility for the health and well-being of all American children.
The Act establishing the Children’s Bureau mandated officials investigate and report all matters pertaining to the welfare of children. Foremost among the problems dealt with were those related to the health of children. As the Children’s Bureau evolved, it came to be seen as the natural agency to be entrusted with the administration and coordination of programs related to maternal and child welfare. The close ties between the Children’s Bureau and professional social work were profound; in fact, the first five chiefs of the Bureau were social workers: Julia Lathrop, Grace Abbott, Katharine Lenroot, Katherine Oettinger, and Martha May Eliot, who was also a pediatrician.
During this same time period, in 1908 the first Bureau of Child Hygiene was established in New York city by Dr. Josephine Baker. By 1923, Child Hygiene bureaus had been established in all states. The Child Hygiene bureaus were typically responsible for disease prevention and education; they developed programs on the day-to-day basics of hygiene for immigrants living in slum neighborhoods, trained young girls on the basics of infant care so they could better care for their siblings while their mothers worked, and created policies that would impact maternal and infant mortality (Parry, 2006).
Several factors came together in the early 1920s that led to the enactment of new federal maternal and child health legislation. Research conducted by officials at the Children’s Bureau, the identification of maternal and child health problems, legislative advocacy calling for the development of new policies to solve the problems identified, and a series of legislative reviews of the Bureau’s research findings prompted Congressmen Morris Sheppard of Texas and Horace Towner of Iowa to draft the Maternity and Infancy Act, which later became the Sheppard–Towner Act of 1921. In effect from 1921 to 1929, the Sheppard–Towner Act authorized grants-in-aid to states for the promotion of maternal and child health programs (Copeland, 2005; Jaros & Evans, 1995; Schild & Sable, 2012). The legislation was controversial; critics viewed it as an intrusion on the family, which they believe was not to be regulated by government, and as a precursor to socialized medicine. The Children’s Bureau in general and Sheppard–Towner in particular provoked major opposition for the American Medical Association (Golden & Markel, 2007).
Although the Sheppard–Towner Act did not survive a second reauthorization, the debates on the need to respond to the welfare of children and maternal health remained strong (Lesser, 1985; Markel & Golden, 2005). The Act initiated discussions on several proposals—federal funding for child health, encouraging mothers to seek early care for children—that were deemed valuable to retain. Yet another outcome of the Act was the creation of programs for children that were divided by those needing government assistance (welfare) and those who were capable of paying (fee-for-service) (Markel & Golden, 2005). Perhaps it was this mentality that allowed the Title V program to emerge as more successful than the Sheppard Act. The Sheppard–Towner Act was the forerunner to Title V, the maternal and child health service provisions of the Social Security Act of 1935. Much of the discussion around the development of Title V was based on the emerging philosophy that the welfare of children was critical. This stemmed from the national concern of children as laborers and the need to protect them. Title V represented a multidisciplinary perspective that childhood was a time of growth and development and that children should not be exploited as cheap laborers or young adults (Lesser, 1985). Additionally, there was growing concern about the need to reduce the infant mortality rate (Markel & Golden, 2005). The Title V program delineated services and policies that reflected the varying needs of the population. It was encapsulated into the overarching policy initiative in the Social Security Act, which was seen as necessary in addressing the economic security of U.S. citizens. Addressing the needs of children, an unprotected and vulnerable group, was viewed as a crucial aspect of this economic security.
Title V established the federal government’s role for providing and regulating comprehensive maternal and child health services and included several programs: Maternal and Child Health (MCH) Services, Crippled Children Services, Child Welfare Services, and Vocational Rehabilitation Services (Jaros & Evans, 1995; Schild & Sable, 2012). States were given the authority to establish their own maternal and child health programs, but these programs were subject to the approval of a federal board of maternity and infant hygiene. Social workers from the Children’s Bureau contributed to the inclusion of Title V in the Social Security Act of 1935 and were also involved in planning responses to other health and social service needs, such as the Emergency Maternity and Infant Care Program that existed from 1943 to 1948 to provide services to the wives and infants of servicemen (Copeland, 2005).
The Title V legislation was formulated in response to pressure from various social, political, and health interest groups. It identified public funds for comprehensive health care for handicapped children, delineated the federal government’s leadership role, and provided direction for the development of federal and state administrative structures to implement maternal and child health services. Perhaps most important, it signaled the central, instrumental role of social work in maternal and child health services. Title V remains the primary legislative expression of the country’s commitment to health care for maternal and child populations (Jaros & Evans, 1995; Moniz & Gorin, 2007).
Title V has undergone several amendments since its original enactment in 1935. First, the administration of Title V underwent changes. The Children’s Bureau was divided into four separate units under the administrative order in 1969. Child Welfare Services and the Juvenile Delinquency Service remained in the Social and Rehabilitation Service. The MCH programs including the Crippled Children’s programs were transferred to the Health Services and Mental Health Administration (Hutchins, 1994). After several more reorganizations, the Maternal and Child Health Bureau (MCHB) was finally established under the Health Resources and Services Administration of the Public Health Service in 1989.The most significant changes in Title V occurred under the Omnibus Budget Reconciliation Act of 1981, when seven categorical programs were consolidated into an MCH Services Block Grant program. The MCHB administers these block grants to states for the primary purposes of reducing infant mortality and increasing women’s access to prenatal care. As with the Children’s Bureau, social workers have been an integral part of the MCHB, where the establishment of a position of Chief Social-Work Officer cemented the close ties between public health and social work. Edith M. Baker (1935–1955), Virginia Insley (1955–1980), and Juanita Evans (1980–2000) have all served as the MCHB’s chief social-work officer (Schild & Sable, 2012).
The Omnibus Budget Reconciliation Act of 1989 changed the provisions of the MCH Block Grant program. The 1989 act mandates that states provide specific percentages of their funds to Children’s primary prevention services, Children with Special Health Care Needs (the former Crippled Children’s Services) programs, and administration. In addition, it directs states to expand maternal and infant home-visiting programs and enhance rural projects for mothers and children. It also required states to use any remaining block grant funds on Special Projects of Regional and National Significance. Finally, the Act required states to coordinate their Title V programs with their Medicaid programs, a mandate that structurally facilitated initiatives between maternal and child health and social-work services (Moniz & Gorin, 2007; Schild & Sable, 2012).
The 1989 amendments provided increased accountability for the Title V legislation while retaining flexibility. However, the recent amendments in the 1990s and 2000s displayed unceasing conflict between flexibility and accountability (Association of Maternal and Child Health Programs, 2003). In 1993, the Government Performance and Results Act required federal agencies to report on their performance results to improve effectiveness and public accountability (U.S. Department of Health and Human Services, Health Resources and Services Administration, & Maternal and Child Health Bureau, 2012b). This ultimately led to the establishment of the Title V information system in 1996. Under Title V, the major legislative initiatives Healthy Start in 1991 and the State Child Health Insurance Program in 1997 were adopted to tackle the nation’s persistent concerns regarding infant mortality and health-insurance coverage for children. Despite a reauthorization battle between Congress and President G. W. Bush, who vetoed the legislation twice, the State Child Health Insurance Program (now called the Child Health Insurance Program) was reauthorized by President Obama under the Children’s Health Insurance Program Reauthorization Act in 2009, which provided over $30 billion through 2013 (Olson, 2012). In 1996, Congress added the Abstinence Education program to Title V separately as part of the Personal Responsibility and Work Opportunity Reconciliation Act. Although the Obama administration has eliminated funds in their previous budgets, the Abstinence Education program has hardly disappeared in federally funded teen pregnancy–prevention programs (Kliff, 2012). The Affordable Care Act (ACA) included the restoration of funds for Abstinence Education, and the Abstinence Education Reallocation Act of 2013 (2013, § 13) was introduced in the 113th Congress. Major additional funding for community-based abstinence education was added to the Special Projects of Regional and National Significance in 2000 (U.S. Department of Health and Human Services, Health Resources and Services Administration, & Maternal and Child Health Bureau, 2012a).
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) and the Health Care and Education Reconciliation Act (Pub. L. No. 111-152), which are collectively known as the ACA, in an effort to improve affordability of access to health care. On June 28, 2012, the ACA, in a historical decision, was passed by the U.S. Supreme Court by a vote of 5 to 4. This act ensures that health-insurance coverage, access to quality health-care services, and public-health promotion and prevention programs for all women, children, and families are vital to the citizenry of the United States. The ACA includes numerous provisions, including expanding Medicaid, subsidizing insurance premiums, providing incentives for businesses to provide health-care benefits, prohibiting denial of coverage or claims based on preexisting conditions, establishing health-insurance exchanges, and support for new preventive health services. In addition, three new sections were added to Title V under this act. Maternal, Infant, and Early Childhood Home-Visiting Programs (Section 511) are implemented through the MCHB in collaboration with the Children’s Bureau in the Administration for Children and Families to reduce infant and maternal mortality and its related causes. Grants are authorized for services for individuals with postpartum conditions and their families (Section 512). Finally, the Personal Responsibility Education Program (Section 513) was authorized to reduce and prevent teenage pregnancy and sexually transmitted infections (Association of Maternal and Child Health Programs, 2010, 2012).
Contemporary MCH Issues
The MCHB’s mission is to protect, promote, and improve the health and well-being of all women, newborns, children, and adolescents. Its programs and activities strive to strengthen and support the maternal and child health infrastructure and to assure the availability and accessibility of preventive and primary-care services for women, children, and adolescents. Evidence indicates that the programs have had “positive impact,” contributing to the reductions in infant mortality rate and increases in the percentage of pregnant women who receive prenatal care in the first trimester (Association of Maternal and Child Health Programs, 2010). Beyond the many successes, however, the early 21st century is an appropriate time to identify health conditions and issues that remain challenges as the MCH programs are expanding with the implementation of the ACA.
The differences in infant mortality rates by race and ethnicity indicate that a significant disparity remains in MCH services. Eliminating racial and ethnic disparities has been a major goal of the U.S. health-care system. Although America is becoming a more diverse country, the MCH populations reflect even greater diversity. In addition, more children are identified as multiracial than are adults (U.S. Census Bureau, 2011). These racially and ethnically diverse children are experiencing the highest burden of health-related problems in MCH care. Effective health promotion is designed, delivered, and evaluated when culturally based health beliefs, practices, credible sources of information, and contexts for each population are addressed (Idali Torres, Marquez, Carbone, Stacciarini, & Foster, 2008). Research pointed out that poor cross-cultural communication between health-care providers and patients has resulted in poorer health outcomes and less effective participation in treatments (Cooper & Roter, 2002). On the other hand, health outcomes of diverse populations are improved when culturally competent interventions are provided (Goode, Dunne, & Bronheim, 2006). Therefore, the MCHB has realized that cultural and linguistic competence is essential for reducing disparities by improving access, utilization, and quality of health care. One purpose of the Maternal, Infant, and Early Childhood Home Visitation program is to meet the needs of underserved minority women and their families with limited social-support networks. Also, the National Center for Cultural Competence, supported by the MCHB, operates Family Professional Partnership/Cultural Competence programs that aim to increase the capacity of health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems. The MCH training programs are designed not only to develop health-care providers who are prepared with the knowledge and skills necessary to assure and champion the health and well-being of people from diverse backgrounds, but also to increase diversity among the MCH care providers (National Center for Cultural Competence, 2009).
Another issue rests on the fact that MCH services have focused mostly on the individual level—infants, children, and their mothers. However, as the MCHB’s approach has evolved and expanded to incorporate an ecological systems perspective, attention has focused on the larger context of families, communities, and societies where mothers, infants, and children reside. The ecological systems perspective recognizes that families encounter many biopsychosocial issues that affect their health status. Making it more complicated, the environmental factors that may impact the families’ health are changing rapidly. Given the complex and multifaceted aspects faced by the families, the collaboration of many disciplines has been encouraged in MCH services (Dodds et al., 2010; Margolis, Rosenberg, Umble, & Chewning, 2012). To keep up with its mission of improving the health, safety, and psychological well-being of the maternal and child population, the MCHB has dedicated training for interdisciplinary scholars and practitioners who will be well prepared to meet the rapidly changing needs (Shlafer et al., 2013). Current interdisciplinary training programs in the MCHB include Leadership in Adolescent Health, Leadership Education in Neurodevelopmental Disabilities, Pediatric Pulmonary Centers, and Schools of Public Health, which provide interdisciplinary leadership training to graduate and postgraduate professionals from a wide variety of professionals.
In addition, the MCHB now adopts the life-course perspective for strategic planning (U.S. Department of Health and Human Services, 2011). The life-course perspective acknowledges the differences in health status from one point in time to another time period. Throughout the life span of both women and children and across different generations, interrelated social networks, economic, environmental, and physiological factors contribute, in different ways and to different degrees, to health and well-being. This perspective recognizes that adverse or risk factors act negatively on health outcomes, whereas protective or positive factors act to improve health-status outcomes throughout the lifespan.
Therefore, the life-course perspective validates the need to develop and provide appropriate services according to different periods of life. In addition, this perspective creates the possibility for planning prevention programs that are more effective than providing programs after the risk factors appear.
Future Challenges and Trends
A critical and evolving challenge for the MCHB is the impact of the human papillomavirus on women and infant health. Approximately 10 of the 30 identified genital human papillomavirus strains can lead to cervical cancer, genital warts, or, in some cases, respiratory tract warts in children. Human papillomavirus is the most common sexually transmitted disease, with approximately 20 million individuals currently infected and 6.2 million new individuals infected each year. It is estimated that half of all those infected are adolescents and young adults between the ages of 15 and 24 (Centers for Disease Control and Prevention & U.S. Department of Health and Human Services, 2011). In 2006, the Food and Drug Administration licensed the first vaccine to prevent cervical cancer and gynecological diseases caused by certain strains of genital human papillomavirus. The Advisory Committee on Immunization Practices recommends the use of this vaccine by females 9–26 years of age (Henry J. Kaiser Family Foundation, 2007).
The expanded role of the MCHB requires educators, practitioners, researchers, and policy makers to design interventions that are systemic and multileveled. The social ecological model provides the appropriate framework for this approach. This model recognizes the interconnectedness of individuals with their environment and provides a framework for addressing and intervening at the individual, interpersonal, organizational, community, and policy levels (Bronfrenbrenner, 1979). A paradigm shift from focusing on changing individual health behavior to examining how those behaviors are influenced and impacted by culture, values, policies, and social and community norms is required for effective intervention. The health-care issues affecting women and children are numerous and complex. Therefore, it is critical that MCHB policies, services, and research reflect this interconnectedness by intervening at all levels.
The Role of Social Work in the Maternal and Child Health Arena
Social workers’ roles in maternal and child-health services are broad and diverse. Both the holistic view of the MCHB and the utilization of the life-course perspective are highly compatible with social work’s person-in-environment orientation. As the scope of MCH services has evolved, expanded, and changed to improve the health status of women and children, the need for social workers’ diverse skills has become ever more important. As noted above, social-work leadership has been critical in the MCH at federal, state, and local levels.
Today, social workers can be found engaged in the design, development, implementation, and evaluation of the policies, programs, and services created to improve the health-status outcomes of maternal and child populations. The focus on health disparities is central to social-work practice in public health. Moreover, as funding agencies continue to call for greater coordination, collaboration, heightened evaluation, and accountability, MCH programs and services will continue to depend on social workers’ expertise.
Social-work skills in direct practice, advocacy, planning and evaluation, community organization, administration, and coalition building are all applicable to the maternal and child health arena. To intervene effectively, the needs of maternal and child populations must be assessed from both an ecological systems and a life-course perspective that takes into account physical health, emotional well-being, family strengths and needs, and community resources and challenges. Moreover, collaborating and communicating effectively with other care providers from a wide variety of professional disciplines is essential to effectively server the clients and their families. As in the past, the social-work profession is uniquely qualified to play a leadership role in the MCH field, and the ongoing involvement of social workers will continue to shape MCH policy, programs, and services for future generations.
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