HISTORICAL DEVELOPMENT
One of the greatest achievements of public health in the twentieth century in the United States was the dramatic improvement in the health of mothers and babies: during this period infant mortality declined by greater than 90 percent, and maternal mortality declined by 99 percent. While improvements in living standards, educational levels, and environmental conditions have contributed most to these improvements, public health MCH programs have also played a role.
The development of these MCH programs occurred in the unique political and social landscape of the United States, where a reliance on individualism has shaped the attitude that caring for children is the parents' responsibility, and that government should step in to help only when families and communities are not able to care for their own. The concept of federalism has also played a role in dividing responsibility between the federal government and state and local authorities. Further, the dominance of the biomedical model in the United States has directed most of the monies spent on MCH to the provision of direct clinical services. Some of the major historical developments in MCH are highlighted in Table 1.
Maternal Health. At the beginning of the twentieth century, for every one thousand live births, six to nine women died of pregnancy-related complications. Sepsis was the leading cause of maternal death, with half of the cases following delivery (often performed without following the principles of asepsis), and half associated with illegally induced abortion. Hemorrhage and preeclampsia (convulsions) were other leading causes of mortality. In response to the high maternal and infant mortality rates, and to women's suffrage, Congress passed the Maternity and Infancy Act
Table 1
A Chronology of Maternal and Child Health Services in the United States
SOURCE: Courtesy of author.
1909 First White House Conference on Care of Dependent Children
1912 Children's Bureau created
1921 Maternity and Infancy Act (Sheppard-Towner Act) enacted
1929 Sheppard-Towner Act overturned
1930 American Academy of Pediatrics founded
1935 Title V legislation enacted as part of Social Security Act
1935 Crippled Children's Services (CCS) created
1943 Emergency Maternity and Infant Care enacted (P78-156)
1951 American College of Obstetricians and Gynecologists founded
1965 Medicaid (Title XIX) enacted
1965 Head Start Program started
1965 Community and Migrant Health Center Program created
1972 Special Supplemental Food Program for Women, Infants, & Children created
1973 Roe v. Wade legalizes abortion before fetal viability
1973 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) created
1976 Supplemental Security Income Program for children with disabilities enacted
1979 Pregnancy-Related Mortality Surveillance System established
1981 Title V MCH Services Block Grant to states created
1984 Emergency Medical Services for Children enacted
1989 OBRA 89 expands coverage of prenatal care for low-income women
1991 Healthy Start Program started
1994 Early Head Start Program started
1996 Temporary Assistance for Needy Families (TANF) program created
1997 State Children's Health Insurance Program created
(also known as the Sheppard-Towner Act) in 1921. The Fetal, Newborn, and Maternal Mortality and Morbidity Report of the 1933 White House Conference on Child Health Protection called attention to the link between poor aseptic practice, excessive and inappropriate obstetrical interventions (induction of labor, use of forceps, episiotomy, and cesarean deliveries), and high maternal mortality. During the 1930s and 1940s, hospital and state maternal mortality review committees were established. At the same time, a shift from home to hospital deliveries was occurring. The proportion of infants born in hospitals increased from 55 percent in 1938 to 90 percent in 1948, which was accompanied by a 71 percent decrease in maternal mortality. Medical advances (including the use of antibiotics, the use of oxytocin to induce labor, safe blood transfusions, and better management of hypertensive disorders) accelerated the declines in maternal mortality. Liberalization of state abortion laws, beginning in the 1960s, contributed to an 89 percent decline in deaths from septic illegal abortions between 1950 and 1973. In 1979, the Centers for Disease Control and Prevention partnered with the American College of Obstetricians and Gynecologists in developing the Pregnancy-Related Mortality Surveillance System, and implementing maternal mortality review boards across the country. At the end of the twentieth century, for every 100,000 live births, only seven to eight women died of pregnancy-related complications—a 99 percent reduction of the rate at the beginning of the century.
Infant Health. At the beginning of the twentieth century, for every one thousand live births, one hundred infants died before age one. Infant mortality began to decline in the early part of the twentieth century, following improvements in urban environments (e.g., sewage and refuse disposal and safe drinking water), milk pasteurization, rising standards of living, and declining fertility rates. The Children's Bureau formed in 1912 called for the establishment of the National Birth Registry in 1915. The Children's Bureau became the primary government agency to work toward improving maternal and infant health and welfare for the next thirty years. In 1935, Congress enacted Title V of the Social Security Act, which authorized and appropriated funds for maternal and child health-services programs. Between 1930 and 1949, infant mortality declined by 52 percent, largely due to antibiotics, development of fluid and electrolyte replacement therapy, and safe blood transfusions. It declined further following the implementation of Medicaid, Community Health Centers, and other federal programs in the 1960s. The Special Supplemental Food Program for Women, Infants, and Children (WIC) was created in 1972. Infant survival continued to improve in the 1970s because of technologic advances in neonatal medicine and the regionalization of perinatal services. Medicaid eligibility for pregnant women and infants was significantly expanded in the 1980s to enhance access to, and utilization of, prenatal care. The development of artificial pulmonary surfactant in the late 1980s and the use of antenatal corticosteroids in the 1990s to prevent and treat respiratory distress syndrome in premature infants also contributed to a decline in infant mortality. Other improvements in infant health in the 1990s include a 50 percent decline in the rates of sudden infant death syndrome, advances in prenatal diagnosis and surgical treatment of birth defects; and national efforts to encourage reproductive-aged women to consume folic acid to reduce the incidence of neural tube defects.
Child Health. Industrialization in the late nineteenth century forced many children into hazardous labor in mills, mines, and factories. In 1909, President Theodore Roosevelt convened the first White House Conference on Care of Dependent Children, which called attention to the unacceptably high rate of infant deaths and the detrimental effects of child labor. This led to the creation of the Children's Bureau in 1912 to "serve all children, to try to work out standards of care and protection which shall give to every child his fair chance in the world." Both the establishment of the Children's Bureau and the passage of the Sheppard-Towner Act met with formidable resistance. They were seen by many as governmental intrusion into the relationship between children and their parents, and they were opposed by the American Medical Association (AMA) because of their potential for governmental interference or control over the practice of medicine—despite an endorsement from the Pediatric Section, which split off from the AMA in 1930 to form the American Academy of Pediatrics. The Sheppard-Towner Act was over-turned in 1929. The enactment of Title V in 1935, however, expanded health and social services to mothers and children.
Medicaid was enacted in 1965 as a federal-state partnership to fund health services for low-income families with children. The Head Start program, launched in 1965, provided an intellectually stimulating and healthful environment for preschool children. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program was created in 1967 to fund preventive health services for Medicaid-eligible children, including physical and developmental exams, vision and hearing screening, dental referrals, and immunizations. These advances were followed, however, by a downsizing of federal involvement and the return of power and responsibility for MCH policies to the states in the 1980s. The most significant change was the consolidation of seven categorical MCH programs into the MCH Services Block Grant. Health care coverage for children was re-expanded in 1997 with the creation of the State Children's Health Insurance Program.
Children with Special Health Care Needs. Title V of the 1935 Social Security Act created Crippled Children's Services (CCS), which became the only source of federal funding for the next thirty years for children with special health care needs. Enactment of Medicaid (Title XIX) in 1965 relieved CCS of many of its reimbursement and direct service provision responsibilities. In 1974, the Supplemental Security Income (SSI) Childhood Disability Program began to provide monthly cash payments to low-income children with disabilities and special health care needs. The Omnibus Budget Reconciliation Act of 1989 (OBRA89) directed state Children with Special Health Care Needs programs (CSHCN, formerly CCS) to develop community-based systems of services and to promote and provide family-centered, community-based, comprehensive, and culturally competent services for children with special health care needs. Thirty percent of the MCH Services Block Grant was to be directed toward this use. Alarmed by the rapidly increasing SSI enrollment, Congress redefined disability, restricted eligibility, and reduced cash assistance to children with disabilities in 1996.
