Thesis (Ph. D.)--University of Iowa, 2008. / Thesis supervisor: Michael O'Hara. Includes bibliographical references (leaves 119-128).

This thesis focuses on infant and maternal health through the examination of different government regulated policy interventions. Specifically, this thesis comprises of three essays. First, I examine the effect of a reduction in coal-fired power plant emissions on infant health outcomes of downwind counties. Second, I analyze how limiting lawyers’ contingency fees affects physicians’ decision to perform C-sections on women and, ultimately, its effect on infant mortality. The third, and final, paper investigates whether or not medical malpractice tort reforms have altered physicians’ decision to take part in defensive medicine. Chapter 1 examines the Clean Air Interstate Rule (CAIR) which mandated the reduction of power plant emissions in the eastern United States. This policy improved air quality in neighbouring downwind counties, greatly reducing exposure to a specific form of pollution—fine particulate matter. I investigate the impact of this reduction exposure on birth outcomes using data from the U.S. Natality Detail Files. I find that female babies experience improvements in premature birth and low/very low birth weight status which are driven by the reduction in prematurity. I also focus on full-term babies to better isolate the impact of prematurity from fetal growth on birth weight. Consistent with recent work, I find that full-term male babies experience an increase in birth weight, demonstrating an improvement in intrauterine growth due to lower exposure to fine particulates. Finally, I find a reduction in infant mortality for babies whose mothers were categorized as “high-risk” pregnancies, suggesting that reduced exposure may lead to improved birth outcomes among those most at risk. Chapter 2 analyzes a limit on contingency fees for lawyers in medical malpractice cases enacted in Nevada. Generally, such limits are thought to change the composition of liability cases as they induce lawyers to drop more frivolous cases in favour of ones involving death and serious injury. Inadvertently, obstetricians faced a greater fear of litigation. Applying synthetic control methods, I find a 2.8 percentage point increase in the C-section rates of high school dropout patients, translating to a ten percent increase after the reform. There is no statistically significant difference in C-section rates after the enactment of the reform on patients with at least a college degree, and further, no statistically significant effect on infant mortality. Limiting contingency fees in medical malpractice cases induces obstetricians to engage in defensive medicine by performing more C-sections on low income patients, illustrating that tort reform can alter physician procedural patterns, albeit in heterogeneous ways. Chapter 3 continues with the theme of government regulated policy intervention by examining the effects of medical malpractice tort reform on maternal and infant health. Numerous papers examined the effects of tort reforms on physician behaviour using data from the 1990s. However, a medical malpractice “crisis” in the early 21st century saw many US states adopt tort reforms to alleviate this issue. Using data from 1995 to 2012 I observe that tort reforms are not as effective as they once were. However, I find evidence that physicians’ procedural choices are affected by tort reforms. Not only are C-section rates and “preventable” complications affected by tort reforms, but I also observe that tort reforms influence physicians’ decisions with non-risky patients. / Thesis / Doctor of Philosophy (PhD)

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Maternal, neonatal and infant mortality is still high globally, but worse in low-resourced countries such as Kenya. Progress in reducing maternal mortality in Kenya is slow, with an estimated maternal mortality ratio of 400 deaths per 100,000 live births. Similarly, the infant mortality rate is tabulated at 39 deaths per 1000 live births. Given the high prevalence of maternal and newborn mortality and morbidity in low-income countries such as Kenya, it is vital to maximize nurses’ and midwives’ capacity to contribute to the reduction of this burden of disease during the perinatal period. As the main healthcare providers in rural Kenyan facilities, nurses and midwives are best positioned to provide effective maternal, newborn, and infant health (MNH) services. They provide both health promotion and disease prevention care throughout pregnancy, labor and delivery, and the early postpartum period. One way of achieving this is through effective postpartum care, a period of perinatal care that is plagued with high rates of pregnancy-related complications. A significant amount of research has been conducted on improving MNH in developing and low- to middle-income countries. However, there is a paucity of literature examining the experiences of nurses and midwives providing postpartum care in these settings. As is evident in the existing literature, nurses’ and midwives’ experiences and perspectives have not been explored to the fullest. This study, therefore, was guided by critical theory and Foucault’s concepts of knowledge and power. Using focused ethnography (FE) as the research methodology, the study had four specific objectives: 1) To describe how the sociopolitical and cultural contexts of healthcare influence the provision of postpartum care by nurses and midwives; 2) To identify the facilitators influencing nurses’ and midwives’ ability to competently provide postpartum care; 3) To identify the barriers to nurses’ and midwives’ ability to competently provide postpartum care; and 4) To explicate nurses’ and midwives’ current knowledge regarding best practices in postpartum care. As consistent with FE methods, this study employed individual in-depth interviews and focus groups to obtain data. Thematic analysis based on Braun and Clarke (2006) was used to analyze data. Credibility, transferability, dependability, and confirmability were used to ensure the trustworthiness of the research process. The analysis of data generated six themes: 1) Provider-Client Relationships; 2) Fostering a Healthy Work Environment; 3) Barriers to Postpartum Care; 4) Transcending Adversity; 5) Social Support Systems; and 6) Policies and Infrastructure Influencing Postpartum Care. The study findings demonstrated that nurses and midwives providing postpartum care in rural Kenya are the backbone of the healthcare system and greatly influence the health outcomes of the people they serve. Facilitators and barriers to the nurses’ and midwives’ work while providing postpartum care in this complex environment were identified. In this study, I have shown how gender, class, and power relations may be influencing the perinatal care that the nurses and midwives provide to postpartum women. The study also shines a light on how maternal and infant health may be influenced by power, politics, and policies. Therefore, I propose that use of an intersectionality lens to examine the experiences of nurses and midwives providing perinatal healthcare in rural Kenya could illuminate power dynamics within the healthcare sector. This study recommends relevant education, healthcare policies, and practice guidelines that support building the capacity of nurses and midwives through an inclusive, structured process, creating a robust environment in leadership, education, research, and nursing/midwifery practice.

Victoria’s first Baby Health Centre opened in June 1917 in the inner Melbourne suburb of Richmond. By 1950, 398 centres including fifteen mobile circuits, were available to mothers across Victoria. This study documents and analyses the combination of influences that underpinned the growth of Victoria’s Baby Health Centres. / Firstly, concern about infant mortality rates encouraged the growth of the international welfare movement. The international movement provided legitimacy for local concerns and motivated and sustained the women who acted locally. In addition, the changing role of women following the achievement of suffrage and the rise of voluntarism combined to establish a combination of professionalism and voluntarism which was socially acceptable for the women involved. Baby Health Centres were instigated through municipal councils by local groups such as the Country Womens Association, and with the centralized support of the Victorian Baby Health Centres Association and the Society for the Health of the Women and Children of Victoria. The development of two dedicated voluntary associations caused both friction and competition and a dynamic which created a model of service provision still in existence today. / Secondly, the study looks at the role of several individual women in the growth of Victoria’s centres and circuits. Both voluntary and professional workers made significant contributions to the development of a model of universal service provision for mothers and babies. / Thirdly, the study records the voices of eight mothers and two Infant Welfare sisters of the 1940s. Their comments and stories illuminate the relationship between baby health centre sisters and mothers and the mother’s willingness to incorporate the advice into daily practice. / The history of Victoria’s Baby Health Centres is one of a unique combination of professional and voluntary activism. This recipe led to the development of a well utilized statewide service which has become part of Victoria’s societal and health framework.

Thesis (Ph. D.(Communication Pathology))--University of Pretoria, 2002. / Summary in English and Afrikaans. Includes bibliographical references (leaves 146-156).

Thesis (Ed.D.)--Teachers College, Columbia University. / Typescript; issued also on microfilm. Sponsor: Margaret G. Tyson. Dissertation Committee: Marie Seedor. Includes tables. Includes bibliographical references.

Background: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH). Methods: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 ( N = 757) and in 2014 ( N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6 - 10 and during weeks 6 - 8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention. Results: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6 - 10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration. Conclusion: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

Objetivo: Avaliar a adequação da dieta de crianças de 12 a 32 meses em relação ao consumo de porções dos grupos alimentares e de energia, macro e micronutrientes. Métodos: estudo descritivo, com uma amostra de conveniência com crianças de 12 a 32 meses de Ribeirão Preto, SP, participantes de um amplo projeto temático denominado Projeto Brisa. Para a avaliação dietética foi utilizado o recordatório alimentar de 24 horas, os alimentos e preparações consumidos pelas crianças foram inseridos no software Virtual Nutri Plus para cálculo nutricional e transformados em porções relacionadas aos oito grupos da Pirâmide Alimentar Infantil. A variabilidade intrapessoal da dieta foi corrigida com a replicação de três R24h, em dias aleatórios, em uma subamostra de 20% da população do estudo. Esses dados foram submetidos ao Multiple Source Method (MSM) e obtida a dieta usual que foi analisada de acordo com a Estimated Average Requirement (EAR) e Tolerable Upper Intake Level (UL) das Dietary Reference Intake (DRIs) e expressa em proporção de crianças com ingestão de nutrientes abaixo ou acima dessas recomendações. As porções alimentares foram analisadas por meio dos guias alimentares infantis brasileiros. A associação entre os valores consumidos de energia, macro e micronutrientes e porções alimentares com as variáveis de interesse foi avaliada por meio do teste de qui-quadrado. Resultados: A amostra de 491 crianças foi estratificada em três faixas etárias, com predomínio de crianças entre 18 a 23 meses (52%), meninas (52,5%) eutróficas (92,9%), cujas mães tinham 9 a 11 anos de estudo (57,4%) e referiram cor da pele branca (55,2%); os prematuros representaram 22% da amostra estudada. Apenas 7,4% pertenciam a classes econômicas menos favorecidas. A alimentação das crianças apresentou consumo insuficiente de carboidrato e gordura, 38,5% e 29,5%, adequado de energia e excessivo de proteínas (79,8%). Entre os micronutrientes, Ferro, vitamina C e vitamina B12 tiveram os maiores percentuais de consumo adequado (98,6%, 97,0% e 94,9%, respectivamente), enquanto cálcio (27,3%), folato (74,8%) e vitamina E (37,7%) apresentaram maiores frequências de consumo insuficiente. A ingestão acima de UL foi mais expressiva em vitamina A (43,6%) e zinco (33,6%). O consumo de porções alimentares nas crianças mais novas, até 23 meses, foi insuficiente de carnes e ovos (42,7%), leites, queijos e iogurtes (47,7%) e excessivo dos grupos de cereais, pães e tubérculos, frutas e óleos e gorduras. Nas maiores de 24 meses o consumo insuficiente foi mais elevado no grupo dos cereais, pães e tubérculos (56,1%) e frutas (75,8%). O alto consumo insuficiente de verduras e legumes e excessivo de açúcares e doces foi encontrado em todas as crianças. Conclusão: A alimentação das crianças foi marcada por inadequações na ingestão de nutrientes, consumo insuficiente de verduras e legumes e excessivo de alimentos fontes de açúcares e doces. No entanto, a ingestão de ferro e vitamina A, micronutrientes mais deficientes no Brasil, apresentaram baixas taxas de consumo inadequado. O excesso de peso foi observado em apenas 35 (7,1%) e esteve associado ao maior consumo excedente de energia. / Objective: To assess dietary adequacy in 12-t0-32-month old children regarding the intake of portions of food groups and energy and of macro- and micronutrients. Methods: A descriptive study of a convenience sample of 12-to-32-month-old children from Ribeirão Preto, SP, participating in an ample thematic project denoted BRISA Project. The 24 hour food recall was used for assessment and the foods and preparations consumed by the children were inserted in the Virtual Nutri Plus software for nutritional calculation and transformed into portions related to the eight groups of the Infant Food Pyramid. Intrapersonal dietary variability was corrected with three R24h replication on random days in a 20% subsample of the study population. The data were submitted to the Multiple Source Method (MSM) and the usual diet was obtained and analyzed according to the Estimated Average Requirement (EAR) and the Tolerable Upper Intake Level (UL) from the Dietary Reference Intake (DRIs) and expressed as the proportion of children with nutrient intake below or above these recommendations. The food portions were analyzed using Brazilian infant food guides. The association of the energy, macro- and micronutrient values consumed and food portions with the variables of interest was determined by the chi-square test. Results: The sample of 491 children was stratified into three age ranges, with a predominance of children aged 18 to 23 months (52%), of normal weight (92.9%) girls (52.5%) whose mothers had 9 to 11 years of schooling (57.4%) and who reported white skin color (55.2%). Preterm babies represented 22% of the study sample. Only 7.4% belonged to less privileged economic classes. The children\'s diet showed insufficient carbohydrate and fat intake, 38.5% and 29.5%, adequate energy intake and excessive protein intake (79.8%). Among the micronutrients, iron, vitamin C and vitamin B12 showed the highest percentages of adequate intake (98.6%, 97.0% and 94.9%, respectively), whereas calcium (27.3%), folate (74.8%) and vitamin E (37.7%) showed higher frequencies of insufficient intake. Intake above UL was more expressive for vitamin A (43.6%) and zinc (33.6%). Among younger infants (up to 23 months of age), food portion intake was insufficient regarding meat and eggs (42.7%), milk, cheese and yogurt (47.7%), and excessive regarding cereals, breads and tubercles, fruits, oils and fats. Among children older than 24 months, insufficient intake was more marked regarding cereals, breads and tubercles (56.1%) and fruits (75.8%). A markedly insufficient intake of vegetables and legumes and excessive intake of sugars and sweets was observed in all children. Conclusion: The diet of the children studied was marked by inadequate nutrient intake, insufficient vegetable and legume intake and excessive intake of foods containing sugars and sweets. However, low rates of inadequate intake were observed for iron and vitamin A, the micronutrients more deficient in Brazil. Excess weight was observed in only 35 children (7.1%) and was associated with excessive energy intake.

Health at birth is considered an important indicator of health outcomes in adulthood. It is also shown to have a strong association with future educational attainment and labor market outcomes. I examine the effects of behavioral and environmental factors on infant health. The factors I focus on include alcohol consumption during pregnancy, extreme weather events associated with climate change, and pollution that may result from unconventional oil and natural gas development. In Chapter II, I examine the effects of point-of-sale alcohol warning signage that alcohol retailers are required to post in some states on alcohol use during pregnancy and on birth outcomes. I find that point-of-sale warning signs discourage alcohol consumption among pregnant women and are associated with a decrease in the odds of newborns having very low birth weight or being very pre-term. The findings of this research inform decision makers about a potentially effective mechanism through which alcohol consumption among pregnant women can be reduced. They also suggest causal evidence for the link between prenatal alcohol exposure and inferior health at birth. Chapter III documents that exposure to heat waves during pregnancy is associated with increased likelihood of the mother experiencing an adverse health condition during pregnancy and the newborn having an abnormal condition at birth. The results provide an assessment of the magnitude and timing of the effects of extreme heat events associated with climate change on infant health which is potentially helpful in enhancing the effectiveness of adaptation efforts. Finally, Chapter IV provides an empirical investigation of the link between unconventional oil and natural gas development and infant health. The results indicate that unconventional drilling activity is associated with a small, but statistically significant, decline in birth outcomes, especially for those living in rural areas. Given that it is estimated that the rapid expansion in unconventional oil and gas extraction will continue for at least a few more decades, the results of this study may contribute to the discussions related to initiation or tightening of regulations and monitoring efforts to control pollution. This dissertation includes previously unpublished co-authored material.