The overwhelming social norm for pregnant women in the U.S. is to receive prenatal care from an obstetrician and to give birth in a hospital setting. However, the incidence of midwifery care and out-of-hospital birth is increasing, particularly among White, non-Hispanic women. Florida has been considered a "model" state for home birth midwifery given legislative support that mandates coverage of all types of midwifery (e.g., Certified Professional Midwives and Certified Nurse-Midwives) care in all birth settings (e.g., hospital, home, birth center) and by all forms of insurance (e.g., commercial and Medicaid). Medicaid is the payer source for nearly half of the births in the United States and in Florida. However, Florida is one of only ten states where Certified Professional Midwives, who attend the vast majority of planned home births, are actively able to receive Medicaid reimbursement for home birth care. A key question then becomes, how is the system for Medicaid-funded home birth in Florida functioning? The central aim of this research was to better understand how Medicaid impacts the practice of and access to planned home birth in Florida. This was examined through quantitative analysis of Florida birth certificates as well as through qualitative data collection and analysis that sought to describe the experiences of women who had planned home birth while on Medicaid as well as the experiences of midwives that cared for these women. Findings are presented through the lens of Critical Medical Anthropology, which helps to interpret how and why home birth is systematically supported or threatened by legislation, policy, and practice at the level of the State of Florida, the federal-state Medicaid program, and the professional organizations in the United States involved in maternity care. Key findings demonstrate that the vast majority (87%) of planned home birth in Florida is attended by Certified Professional Midwives, and that while Florida Medicaid paid for 45% of all births between 2005 and 2010, only 31% of planned home births were paid for by Medicaid. However, after controlling for multiple factors (e.g., race/ethnicity, age, parity), in fact women who completed home (vs. hospital) birth were much more likely to be self-pay (AOR 10.1) or on Medicaid (AOR 4.6) compared to private, commercial insurance. Women interviewed for this study who received Medicaid for their home births overwhelmingly appreciated the "safety net" that Medicaid provided to them and the "relief" of knowing that if a hospital transfer was necessary it would be covered. However, they nearly universally stated that they would have found a way to pay for a home birth if they had not received Medicaid. Women felt that home birth with midwives provided them the greatest chance of having a "natural" birth in the environment most likely to maintain autonomy over decisions related to their pregnancy and birth. Several women experienced significant delays in enrolling in Medicaid, and found that the only providers who would provide care during "presumptive eligibility" were Licensed, Certified Professional Midwives. Midwives appreciated the steady, reliable payments Medicaid provided, despite that these were at about 30 to 40% of their rates charged to privately insured or self-pay clients. They felt that providing care to Medicaid funded women served as a form of social justice. They strongly disliked interfacing with Medicaid HMOs. Some midwives felt that the Florida legislation supported their practice, while others felt that it constrained their practice. Medicaid coverage of planned home birth in Florida now stands at a crossroads, given that Florida Medicaid has recently transitioned to a 100% managed care program (i.e., HMOs). These HMOs act as intermediaries between Medicaid providers and their reimbursements, as well as between Medicaid providers and recipients. The new relationships between providers, patients and the HMOs have shifted from that with a state agency to that with a private, for-profit industry. It remains to be seen whether home birth providers will enroll with Medicaid HMOs in order to continue providing care to pregnant women receiving Medicaid. Key policy recommendations therefore are to monitor women's access to pregnancy Medicaid, and specifically access to services mandated under Florida statute, including home birth and midwifery care. Furthermore, the creation of an integrated maternity care system that better supports transfers of care from the home to hospital setting is needed.

This long-standing nature versus nurture debate is cited in behavioral and physical expressions of disease dysfunctions, resiliencies, and recovery. Their purposes are noted both in scientific pursuits as well as literature. This discourse has been particularly intense in the fields of psychology, psychiatry, and biology where there is a long history of scientists’ attempts to disprove or discredit others’ intellectual and professional measures. Interestingly, recent advances in the neurosciences and genetic technologies have brought these fields closer together with a new focus – the interactional relationship between nature and nurture – epigenetics.

Tobacco use is responsible for five million deaths annually and is one of the leading causes of preventable death worldwide. Many smokers initiate smoking behavior during adolescence. Adolescent smoking rates have been on the rise and there are a variety of different factors that contribute to the initiation of smoking behavior. While the World Health Organization (WHO) and the National Cancer Institute (NCI) have endorsed the claim that smoking in movies increases adolescents’ risk of initiating smoking, few studies have examined the impact of media on adolescent smoking in China following the expansion of transnational tobacco companies. The aim of this thesis is to compare the impact of entertainment media (movies, television programs, and music) on tobacco use among adolescents in both the United States and China. Using data from the China Seven Cities Study (CSCS), this thesis examined the impact of media on cigarette smoking among Chinese adolescents, as well as the relationship between smoking and Chinese adolescents’ preference for media from China, other Asian countries, and the U.S. Conducted in 126 middle- and high schools in seven major Chinese cities, the CSCS utilized student and parent surveys to gather information on the following measurements: Ever smoked, 30 day smoking, whole cigarette smoked, and daily smoking; origin of favorite movies, TV shows, and music; perceived stress, hostility, depression, and quality of life. These data indicated that Chinese adolescents who preferred forms of entertainment media from the U.S. or more developed nations of Asia were more likely to initiate tobacco use and experience depression, stress, and hostility than adolescents who preferred forms of entertainment media from China. As China develops and tobacco marketing continues to infiltrate Chinese society, these results suggest that Chinese adolescents will be at a higher risk for tobacco use and tobacco related disease. This thesis analyzes the global impacts of adolescent tobacco use and provides suggestions for future tobacco control campaigns for adolescents in China.

Tanzania, one of many nations in Africa with high infant mortality to preventable diseases, continues to experience relatively low vaccination rates for childhood diseases. In this paper, we examine the maternal barriers to obtaining vaccines for their children in Tanzania. The risk and protective factors we analyzed include age of the mother and children, education level of the mother, number of children, maternal decision-making practices, power dynamics and others. Lack of control, limited decision practices, and decreased maternal empowerment were identified as key barriers to obtaining vaccines for children. Overall, this data is consistent with previous studies regarding barriers to vaccinations in Tanzania and other African nations.

Increasing breastfeeding duration, especially among low-income women, has become a national public health priority. These mothers and their babies have less equitable access to support, resources, and the health benefits of breastfeeding. This thesis examines breastfeeding from a biocultural perspective with a focus on political economy, embodiment, and human rights. This research explores the lived experiences of new mothers who receive services from a community non-profit lactation support program which is aimed at providing in-home postpartum breastfeeding support to low-income/at-risk mothers. Evaluation of program services and analysis of women's narratives will provide insight into improvement of lactation services for all women.

Breastfeeding support for mothers and their babies historically was the informal work of family and community members. In the United States today, breastfeeding support is embedded in the biomedical system, and is provided by a new allied health professional: the International Board Certified Lactation Consultant (IBCLC). This dissertation explores this professionalization of breastfeeding support and the origins of this new profession. It studies how IBCLCs working in the U.S. cultural context perceive and practice the profession and examines the relationship between the profession of lactation consulting and the medicalization of breastfeeding. Oral history interviews with 17 founders of the profession, which was established in 1985, and a content analysis of the professional journal (the Journal of Human Lactation) from 1985 to 2010, allowed me to build the story of how and why breastfeeding support became professionalized and how experiential breastfeeding knowledge entered the domain of expert knowledge. While constrained by the biomedical system in which they created the profession, the founders exhibited a both agency and creativity in their production and reproduction of professional values and practices. Interviews with 30 currently certified IBCLCs and observations of the clinical practice of 3 IBCLCs provided insight into the daily practice of IBCLCs working in different settings--hospitals, WIC clinics, pediatric offices, and private practice. The data collected from these ethnographic methods demonstrated how the medical knowledge base of IBCLCs translates into clinical practice with patients, and allowed me to understand the relationship between the profession of lactation consulting and the medicalization of breastfeeding. While IBCLCs' draw on medicalized knowledge and evidence about breastfeeding and human lactation, their interactions with clients are best described as empathetic and humanistic, and are derived from nursing and mother-to-mother breastfeeding support models rather than from a technocratic, biomedical approach to care. While the appropriation of certain biomedical values and standards helped to legitimize the professionalization efforts of the founders, in practice, lactation consultants apply their medical knowledge and clinical experience in a way that reflects the compassionate, empowering care approach of mother-to-mother breastfeeding support and that thus resists the overt medicalization of breastfeeding.

Addressing the sub-optimal breastfeeding initiation and duration rates has become a national priority. Inadequate support for addressing early breastfeeding challenges is compounded by a lack of collaboration between providers such as lactation professionals, nurses, pediatricians, and the family. The purpose of this exploratory study was to understand International Board Certified Lactation Consultants' (IBCLCs) perceived barriers to managing early breastfeeding problems. This qualitative study was guided by the symbolic interactionist framework through a grounded theory methodological approach. In-depth interviews were conducted with 30 IBCLCs from across Florida. IBCLCs were from a range of practice settings, including hospitals, WIC clinics, private practice, and pediatric offices. Data were digitally recorded, transcribed, and analyzed in Atlas.ti. A range of barriers were identified and grouped into the following categories: indirect barriers such as social norms, knowledge, attitudes; direct occupational barriers such as institutional constraints, lack of coordination, and poor service delivery; and direct individual barriers including social support and mother's self-efficacy. A model was developed to illustrate the factors that influence the role enactment of IBCLCs in terms of managing breastfeeding problems. IBCLCs overwhelmingly wish to be perceived as valued members of a health care team, but often find interprofessional collaboration is a struggle. However, IBCLCs find creative strategies to navigate challenges and describe their role as pivotal in empowering mothers and their families to meet their breastfeeding goals. Though rarely actualized, IBCLCs place strong value on coordinated, team approaches to breastfeeding management that employ transparent communication between providers and focus on empowering and educating mothers. Strategies for better collaboration and communication between IBCLCs and other providers are needed. Findings provide insight into the management issues of early breastfeeding problems and may lead to future interventions to reduce early weaning, thus increasing the lifelong health benefits of breastfeeding to the infant and mother.

This dissertation is motivated by two of the health-related Millennium Development Goals (MDGs): MDG 4, focused on reducing child mortality, and MDG 5, which aims to improve maternal health. My three papers evaluate the health and economic impact, and cost-effectiveness, of interventions to improve maternal and child health in three areas of the developing world using methods from decision sciences and statistics. In paper 1, I use a decision-analytic model that simulates the natural history of pregnancy and pregnancy-related complications to assess the expected health outcomes, costs, and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan. Increasing family planning was found to be the most effective single intervention to reduce maternal mortality. Further findings suggest that a stepwise approach that couples increased family planning with incremental improvements in access to appropriate intrapartum care could prevent 3 out of 4 maternal deaths and would be cost-effective. Paper 2 explores the value of community-based disease management programs for reducing mortality from childhood pneumonia and malaria in 24 countries of sub-Saharan Africa. I use a model-based framework that combines symptom patterns, care-seeking behavior, and treatment coverage from an empirical assessment of household survey data with information on diagnostic algorithms and disease progression from the literature. Results indicate that a community health worker program modeled on currently-existing programs could avert over 100,000 under-five deaths combined across the 24 countries and would be regarded as cost-effective compared to the status quo under typical benchmarks for international cost-effectiveness analysis. My third paper evaluates the effect of Janani Suraksha Yojana (JSY), a conditional cash transfer program intended to promote the use of reproductive health services in India, on childhood immunizations and other reproductive and child health indicators. Using observational data from the most recent district-level household survey, I conduct a matching analysis with logistic regression to assess the associations of interest. Results show that receipt of financial assistance from JSY led to a significant increase in childhood immunizations rates, post-partum check-ups, and some healthy breastfeeding practices, but no impact was found on exclusive breastfeeding and care-seeking behaviors.

Objectives: The goal of this project was to determine the nutritional needs of preschool age children to help guide intervention development. The research aims were 1) to examine and describe young child (ages one to five) nutritional status as it relates to key nutrients associated with stunting and wasting; 2) to determine what key macro- and micro-nutrient deficiencies (primarily iron and zinc) are associated with wasting and stunting. Methodology: Study sample: Sixty-seven families with children ages one to five who participating in routine health care clinic visits during the UK Shoulder to Shoulder Global health brigade visits. Study design: A cross-sectional survey was conducted collecting demographic data, medical history, and dietary intake. Objective measures of height/length and weight were completed; and blood samples were drawn to measure serum micronutrient levels. Nutrition Data System for Research (NDSR) identified nutrient intakes for analytical comparison based on growth parameters. Nutritional and health status were compared to food security and World Health Organization growth reference points of standard deviations on Z-scores of height-for-age and weight-for-age. Analyses: Chi Square, ANOVA, and binary logistic regression tests were run using Statistical Analysis System (SAS) Results: Low serum levels of zinc and iron corresponded to low levels of dietary intake of zinc and iron, limited food security and moderate stunting z = -0 to 1.99 Standard Deviation. Conclusion: This study will inform a comprehensive nutritional intervention for this population. The evidence that specific nutrients are limiting will focus the health promotion objectives.

The purpose of this study was to investigate the influences of smoking on rural and urban pregnant women. More specifically, the variables of the knowledge of health effects, health provider recommendations, subscores from the Health Belief Model (HBM), and social support were explored in relation to the smoking behavior of pregnant women. A secondary purpose was to investigate the accuracy of self-reported smoking during pregnancy using biochemical validation. Pregnant women (N=71) completed an anonymous questionnaire, designed by the researcher, to identify variables that predicted smoking for urban and rural women. Participants also gave a saliva sample for cotinine testing. Approximately 47% of rural participants and 49% of urban participants were classified as smokers. The overall smoking deception rate for the current study was 5.6%. The deception rate for rural and urban participants in this study was 2.8% and 8.6%, respectively. Variables were entered into a standard multiple regression analysis to predict smoking status of the pregnant women. Participants reporting barriers (a component of the HBM) to stopping smoking during pregnancy were significantly less likely to be smokers. Through t-test and chi-square analyses, other variables related to smoking status during pregnancy included: Marital status, financial source for the pregnancy, living with husband or boyfriend, mean scores of the participants‘ knowledge of the health effects of smoking during pregnancy, susceptibility and benefits (constructs of the HBM). Many healthcare providers performed 1A, 2A, and 3A; however, few completed the last step of 4A and none completed 5A. Implications for health promotion specialists include an increase in the education of pregnant women about the health risks of maternal smoking. Additional training for pre-natal healthcare providers is necessary in order to increase the number of healthcare providers that implement all of the 5A‘s. It is important to include the husband/boyfriend in any smoking cessation interventions since they have daily influence on the smoking status of the pregnant woman. Money used to conduct biochemical verification of maternal smoking status could be better spent on patient education of the health risks of smoking during pregnancy and physician education in implementing all 5A‘s in daily practice.