Sunny Walt Disney World was the perfect setting for the second annual Making Lifelong Connections Meeting. The purpose of this two-day meeting was to build connections between MCHers from across the country. I learned a lot about the many training programs that the Maternal and Child Health Bureau training grants fund. I had no idea the breadth of interdisciplinary programs and the range of students they attract. For example, I met students in social work, physical therapy, nursing, behavioral health, and the list goes on. It was a pleasant surprise to meet four other maternal and child health trainees from the University of Minnesota that I had not met before. Two were former students of the School of Public Health and the remaining two were from different disciplines.

An important theme of the meeting was leadership development. Michael Fraser, the CEO of the Association of Maternal and Child Health Programs (AMCHP) gave the keynote presentation on being a leader rather than a manager. This presentation got me thinking about ways to mentor and benefit any future team members that I may be in charge in a managerial position. He stressed focusing on the vision of your organization or project and remaining committed to that vision rather than immediate tasks. This was a great takeaway message and guided the remainder of our time in Florida.

The best part of the meeting by far, was seeing fellow classmate, Annie Fedorowicz, present research from her field experience in Mobile, Alabama this past summer. Annie provided a concise, well-thought out, and professional presentation on her research. I greatly enjoyed listening to her presentation and I learned a lot about how pregnancy and contraception are viewed in the neighborhoods where she was working.

It was rewarding to see the successes of colleagues both near and far. A series of MCH trainees presented their work to the meeting attendees. Some projects were nearing their end while some were just beginning. This was an exciting part of the meeting as it was fun to see what other MCH trainees across the country are working on.

The meeting was designed as a way for MCH trainees to network with other trainees from around the country in order to learn from each other and collaborate on projects together in the future. This was especially helpful for me as I recently moved to Chicago, Il and I was happy to meet other MCH trainees and former trainees from the Chicagoland area. This was a pleasant surprise and I’m thankful to be able to start growing my network in Chicago.

Overall, the meeting was a great experience and I’m thankful to have had the opportunity to attend.

Danielle Young is a second year MPH student in the Maternal and Child Health program at the University of Minnesota.

The Star Tribune reports that from 2000 to 2008, the number of children treated for concussions in Minnesota hospitals had increased by 75%. Although most of the injuries were in adolescent boys (ages 15-19), the number of concussions in younger children has sharply increased. Football, hockey, and soccer are the top 3 sports most treated for concussions. These research results come from Minnesota Department of Health Injury and Violence Department epidemiologist, Dr. Leslie Seymour.

An issue to consider with rate changes is whether the actual number of concussions has risen, or the number of children getting treatment has risen. A law (MN Chapter 90) enacted at the start of the school year aims to improve awareness among coaches, parents, and players. Information will reflect the National Centers for Disease Control and Prevention’s (CDC) guidelines and ‘Heads Up’ training.

Dr. Seymour recently received a federal grant to explore the effect of Minnesota’s and various states’ concussion laws. Other possible explanations may be an increase in organized sports involvement or more violent, stronger competition. What are your thoughts on this rise in concussions? Are there any other explanations? What about kids’ participation in extreme sports? Are there disparities between populations?

The archived presentation is now available online: https://umconnect.umn.edu/p51351258/.

For more information on the National Children’s Study, visit their webpage at: http://www.nationalchildrensstudy.gov/Pages/default.aspx

Tradition and superstitions, such as cleanliness and family honor, contribute to the continuation of the practice. For communities that practice the tradition, fears drive families to participate: if a girl is not cut, she will be viewed as an outsider to a community and runs the risk of being unwed. Intervention strategies target men to abandon FGC as a norm, focusing on patriarchal belief systems and the subordination of women.

Although some groups point to the issue of cultural competence, human rights groups and the World Health Organization (WHO) argue that the health risks of FGC outweigh this. Article 25 of the Universal Declaration of Human Rights (UDHR) (created by the United Nations General Assembly in 1948) states that every person has the right to health, well-being, and security. Although critics have argued that the UDHR is framed in a Western lens, the document guides issues that compromise the safety and health of humans, especially if inflicted by another being. According to the World Health Organization, health problems related to FGC include: bleeding; hemorrhaging; increased risk of Sexually Transmitted Infection (STI) and HIV infection; infection of the genitals and urethra; painful scarring and menstruation; trauma and emotional distress; infertility; and problems during labor/pregnancy (http://www.who.int/mediacentre/factsheets/fs241/en/).

Other strategies to decrease the incidence of FGC are seen in the below PBS documentary as well as in a New York Times focus. Grassroots social mobilization agents teach the community about the harms of female genital mutilation by moving this taboo topic out into public discourse. Their efforts are based on the belief that “before abandonment, comes communication and awareness.”

For more information on Female Genital Cutting, please visit the WHO’s website: http://www.who.int/mediacentre/factsheets/fs241/en/. The New York Times video report is available at: http://video.nytimes.com/video/2011/10/16/world/africa/100000001115488/the-fight-against-female-genital-cutting.html

On December 7, 2011, Secretary of Health and Human Services (HHS) Kathleen Sebelius overruled this FDA recommendation. While the Secretary of HHS has the authority to override the FDA, The New York Times reported that this issue was the first time a HHS secretary has publicly overruled the FDA. Secretary Sebelius’ action limits an attempt by the FDA to improve the accessibility of Plan B One-Step among young girls, but it does not affect the legality of the drug. Plan B One-Step remains available, without a prescription, to women who are 17-years old and older; and it is still approved for use, with a prescription, for females who are younger than 17.

Sebelius argued that there should be no change in the current law requiring females younger than 17 to obtain a prescription for Plan B One-Step because they require health-care provider guidance to use the pill properly and safely (to see Sebelius’ counterstatement to the FDA’s recommendation, click: http://www.hhs.gov/news/press/2011pres/12/20111207a.html). However, as FDA Commissioner Dr. Margaret Hamburg stated, “Based on the information submitted to the agency, [the FDA’s] CDER [the Center for Drug Evaluation and Research] determined that the product was safe and effective in adolescent females, that adolescent females understood the product was not for routine use, and that the product would not protect them against sexually transmitted diseases. Additionally, the data supported a finding that adolescent females could use Plan B One-Step properly without the intervention of a healthcare provider.” Further, young girls are able purchase a variety of over-the-counter medications and personal products that could be harmful in large doses, such as Tylenol, with no ill effects. President Barack Obama had the opportunity to overrule Sebelius’ decision, but instead agreed with her, noting that he felt uncomfortable, as a father, with the FDA’s decision.

What’s at play here?  What’s going on in this dance between science and good health policy? Did upcoming presidential race play a role here? Are there additional moral or ethical considerations about the proper age for emergency contraception? What’s going on?

How much should, or do,  data really matter in creating health policy? How we talk about – frame – this and other politically charged health issues matters. Consider the language used in various news sources covering the issue. The emotionally charged responses to this specific drug from both evidence-based and ethical-based sides merge to create a unique and complicated discussion. As we launch into an election year, how can we expand the conversation on the topic with our peers and colleagues to further consider the multiple dimensions influencing the availability and accessibility of Plan B for women of all ages across the U.S.?

December 13, 2011 Coverage Update:  14 U.S. Senators, including Minnesota’s Al Franken, have called for further explanation of Sebelius’ decision made on December 7, 2011. The letter–defending the importance of using science to create policy—asks Sebelius for “specific rationale and scientific data” behind limiting Plan B’s accessibility. To see the letter and co-signers, visit: http://murray.senate.gov/public/index.cfm/newsreleases?ContentRecord_id=77e3d54b-bb6b-4c7c-9f05-bfe8c8d3b304. Sebelius has not yet released a response.

Outrage over the advertisements from mothers and other citizens include criticism over the provocative ad and Mayor Tom Barrett’s approval of its running. However, bringing attention to the issue was the campaign’s main objective; national news sources have started discussions even outside the Midwest.

The American Academy of Pediatrics recommends that babies be brought back to their own crib to sleep after feeding and/or comfort and advises against caregivers using in-bed co-sleepers. No studies have found bed-sharing protective of SIDS. Their policy report opposes bed-share especially if a parent is a smoker, overly tired, uses substances, if the infant is under 3 months of age, if the bed is soft/old, or if other children share the bed. However, there are also some conflicting messages; as public health campaigns increasingly encourage breastfeeding more parents are sleeping with their child. In order to prevent SIDS and other health risks to the infant, being sure to breastfeed in other areas or putting the baby back in the crib is necessary.

Coming from an MCH background, what are your thoughts on the advertisement? Too controversial? Too demanding? Just right? Leave some thoughts below. For more information on Infant Mortality Rates, see the Maternal and Child Health Bureau’s annual Child Health USA 2011 dataset: http://mchb.hrsa.gov/chusa11/city/pages/502im.html.

Rationale: An objective of Health People 2020 states that births should be spaced greater than 18 months (Objective FP-5), based on evidence of improved maternal social and infant health outcomes in increased lengths between births.

Methodology: Using a home visiting Healthy Start program, eligible participants were recruited via a family stress checklist to see if they were at-risk for child maltreatment. Researchers focused on the index child of a rapid repeat birth (RRB)—“the child born immediately prior to a subsequent child in a birth interval.” A baseline interview was conducted within a month of delivery and follow-up collected at age 2 and 7.  RRB was defined as a child born within 24 months of an index child for mothers age 20 and older, and as subsequent birth before age 20 for females age 19 and under.

Variables:

• Parental stress tactics—adjustment problems, child abuse (physical), neglect
• Child Protective Service (CPS) reports
• Child behavior—adaptive behavior and social skills
• Child development—memory, verbal, abstract and quantitative reasoning

Results: RRB did not influence parenting behaviors, including stress and child physical abuse. However, there was an association between RRB and parental neglect. In addition, women with a RRB were more likely to have a substantiated CPS report in their name (after controlling, there was a relative risk of 1.8 compared to women without a RRB).

In addition, index children who had mothers with a RRB had poorer behavioral outcomes and poorer developmental outcomes compared to families without a RRB.

Implications for MCH professionals: These associations can be used to help educate health departments for interventions on increasing birth spacing. Findings are consistent with other research that has reported birth spacing associated with neglectful rather than abusive parenting. Targeting subgroups of children, including index or subsequent children, and mothers who are at risk or show neglectful behavior, may be necessary.

Currently, the child maltreatment death rate is 11 times higher than Italy’s and 3 times higher than Canada’s. In the past 10 years, more than 20,000 children have died because of household abuse. Texas has a child abuse death rate of 4.05/100,000, 4 times higher than New Hampshire and Vermont.

So why these rates, why these disparities?

Many believe the answer is in our child protection service (CPS) workforce. Employees are overworked and the system is slow and ineffective. But as the investigation explains, these critics forget the fact that these services were made to protect children after abuse, not prevent them from being harmed in the first place.

Prevention: the key public health value. Child abuse must be seen as an issue in which the public health field can intervene, even more specifically with a Maternal and Child Health focus. What can MCH leaders focus on to help this phenomenon from continuing to escalate? What are areas with low child maltreatment rates doing that work?

1. The United States has a weak public system— our home visiting programs could be expanded, and until the Affordable Care Act goes fully into effect, we have no universal health care. Texas has low taxes, and high numbers of keeping families together. Compared to other countries, the U.S. has low taxes. Children are more likely to be uninsured, incarcerated, to not finish high school, and to die from abuse if public service programs do not have funding.
2. Child abuse has been found to be interlinked with these factors affecting families, including poverty and teenage pregnancy. When families do not have resources, education, training, or an understanding, children are at greater risk. High stress is also associated with these factors.
3. Education and training of adults who work with children. Diagnosis is difficult when injuries are internal, thus it is important for workers to understand the risks of abuse. This includes pediatricians, social workers, teachers, and counselors.
4. Cutting budgets has been the major focus of 2011, and more states are reducing prevention effort funding. Legislatures are not educated on the consequences of abuse, including the future costs to states in working down-stream. If you work with families early on, it is possible to reduce child abuse and neglect, affecting the life course. States with low child abuse rates invest in working up-stream.

We cannot lobby legislatures to increase funding if we do not have the general public behind us. As MCH leaders, we must work to reverse child abuse as a taboo and silent topic. Media campaigns, outreach, and education must be expanded. In the 20^th century, breast cancer was unmentionable, and now there is a month dedicated to battling it. Spread the word-here is the link to the BBC report: http://www.bbc.co.uk/news/world-us-canada-15288865.

In the 1800’s Dr. W.O. Atwater, known for studying food intake and giving us our knowledge basis on calories, created dietary guidelines only for the American male. In the 1920’s, children were heavily focused on, with milk marketed as a focus on protective foods for kids. Protein rather than fruits and vegetables, was important to pack on energy, especially for factor workers. The U.S. government educated the American family in advertisement messages:

During World War II, new messages of eating nutrient rich foods emerged. With the depression, children were not getting an adequate intake of foods. The war promoted gardening and canning to make sure troops were getting the food they needed across seas:

For the 40’s, the Basic 7 Food Guide was created to reflect the food groups needed, but lacked serving sizes.

The USDA in the 50’s and 70’s then changed to the Basic 4, noting a Daily Food Guide, but did not give caloric intake or the appropriate number amount of fats and sugars. After the first Dietary Food Guide was released, in 1979 guidelines were modified to highlight the need for moderate intake of sweets, alcohol and fat.

In 1984, the American Red Cross created the food wheel, the basis for the food pyramids seen in the 1990’s and early 2000’s:

In 2011, the USDA released its new guidelines in a streamlined approach; its MyPlate symbol is not intended to provide specific messages but reflects the proportion of food that should be eaten:

Although what we think we need to eat has changed over time, the government releasing guidelines promotes the importance of making sure families and children get the adequate nutrition they need.

Information taken from the USDA’s ChooseMyPlate.gov webpage: http://www.choosemyplate.gov/foodgroups/downloads/MyPlate/ABriefHistoryOfUSDAFoodGuides.pdf

The study uses parental responses from the 2007 National Survey of Children’s Health (NSCH) (2011 NSCH data collection is expected to be complete in March 2012). Health indicators include children’s body mass index (BMI), behaviors, skills, chronic disease status, access to health care, socioeconomic status, family structure, parental wellbeing, and community protective and risk factors. Statistically significant comparisons are at the 0.05 level.

The disparities seen in this population may be related to the fact that that children in rural areas are more likely to be poor than those in urban districts. About 23% of children living rurally are part of households with income below the federal poverty line compared to 17% of children in urban areas.  Socioeconomic status is related to poor access to care and thus health problems. Although there are other differences in this population compared to children in other areas, it will be necessary to focus efforts at these correlations.

To see the report, methodology and results, visit the Maternal and Child Health Bureau’s (MCHB) site: http://mchb.hrsa.gov/nsch/07rural/.