A comprehensive definition of maternal, or reproductive, health was one of many important contributions of the landmark United Nations International Conference on Population and Development (ICPD) held in September 1994 in Cairo, Egypt. The ICPD definition stated that "Reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so."
Measuring Maternal Health
The most common indicator of maternal health used internationally is maternal mortality, usually measured as the ratio of deaths to women while pregnant or within forty-two days of termination of pregnancy per 100,000 live births. Deaths are usually included only if the cause is related to or aggravated by the pregnancy or its management. Maternal mortality is a rare event in the United States. However, the 1998 ratio of 7.1 deaths per 100,000 live births was higher than the ratio in many other industrialized countries. No progress was observed in the United States in the 1990s, and disturbing differences persist in the incidence of maternal death among ethnic groups. African-American women have three times the risk of maternal mortality compared with white women, and the risk of death for Latinas or Hispanic women also appears to be significantly higher than the risk for white women.
In order to prevent maternal mortality and eliminate disparities, researchers must determine the fundamental causes of pregnancy-related deaths. Defining and measuring maternal morbidity is also critical because illnesses and complications of pregnancy are far more common than maternal deaths. While it is not easy to obtain an accurate count of all of the deaths that might be precipitated by pregnancy or childbirth, the legal requirement for registering deaths and filing death certificates assures a fairly high level of completeness. Measuring the morbidity that accompanies women's reproductive lives is much more difficult.
The U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, developed an initiative called Healthy People, which establishes new health objectives for the nation every ten years. The overall goals of Healthy People 2010 are to increase longevity and quality of life and to eliminate health disparities in the population. One aim is to reduce maternal mortality by more than 50 percent, to an overall ratio of 3.3 deaths per 100,000 live births by the year 2010.
A similar objective for maternal morbidity cannot be set because severe complications throughout pregnancy are too difficult to measure reliably with existing data. Instead, Healthy People 2010 focused its attention on problems that occur during labor and delivery. Most women in the U.S. deliver their babies in hospitals with trained providers who record any complications to the mother and the newborn. In 1998, hospital discharge data indicated that women experienced complications of labor and delivery in nearly one-third (31.2) of every 100 deliveries. The objective for improving this rate is a target of twenty-four complications per 100 deliveries by the year 2010.
Two other maternal health outcomes were targeted for improvement in the Healthy People 2010 objectives, even though data that is gathered will not facilitate adequate monitoring of these events. The first is ectopic pregnancies, sometimes called tubal pregnancies, that result from the implantation and development of a fertilized egg in a woman's fallopian tubes or elsewhere outside the uterus. This condition, which can pose extreme danger to women and sometimes causes death if not detected and treated in a timely fashion, appears to be on the rise in the U.S. The second concern is postpartum complications, including depression as well as physical problems such as hemorrhage and infection.
Since reproductive health, according to the ICPD definition, encompasses positive aspects beyond the absence of disease or disability, many other indicators would be required to monitor maternal wellness. For example, women's psychological health, quality of life, level of satisfaction in intimate relationships, and overall physical condition would need to be measured. Indicators that track threats to women's reproductive health, such as domestic violence, toxic environmental exposures, and hazards in the work-place, should also be taken into account. Accessibility and quality of gynecology, family planning, abortion, preconception, prenatal delivery, and postpartum services are important issues to monitor. Since most women spend many more years raising children than they do bearing children, maternal well-being should encompass the experience of childrearing as well as women's development throughout the life cycle. Older women are often ignored in the realm of reproductive health, although menopause has become a topic of public discussion and reproductive cancers are receiving new attention.
Maternal Health and Child Health
Common sense as well as scientific evidence tells us that the health of women and the health of their children are closely related. Persistent infant health problems such as low birth weight and prematurity have been linked to maternal conditions that precede pregnancy, and may even be traced through previous generations in a woman's family. A woman in poor health who wants to become pregnant is more likely to experience infertility. Once she does become pregnant, she is less likely to have a healthy infant and less able to marshal the consistent energy and resources needed to promote childhood health. Women and their children share the same social and economic environments; poverty, inadequate housing, and unsafe neighborhoods create multiple stresses and potentially harmful exposures for women, children, and all family members.
In the late twentieth century there was an increase in public awareness and concern about infant health problems stemming from pregnant women's use of substances, including tobacco, alcohol, and illicit drugs, and from sexually transmitted diseases, including HIV and AIDS. Domestic violence is also understood as a public health problem affecting pregnant women and mothers. These behaviors and risks may be found throughout the entire population, but the consequences are often worse for disadvantaged women who have less access to health care and other support services.
Government programs that subsidize health care for children sometimes support women only while they are pregnant or recovering from childbirth. Gender discrimination or lack of support for women, as well as economic and racial inequities, is harmful to the health of families. Knowledge and understanding of the reciprocal needs of women, men, and children are needed to promote the physical and mental health of families and larger communities.
The developing fetus is most vulnerable to many influences soon after conception when women are often unaware of their pregnancies, especially in the case of an unintended pregnancy. Nearly half (49%) of pregnancies to women in the U.S. are not the result of conscious planning at the time of conception. Thus, healthy fetal development in the first trimester requires health screening and education among sexually active women before they become pregnant. Preconceptional health care is a model that provides guidelines for examination, counseling, and treatment of women who may be thinking about getting pregnant. Universal recommendations for all women of childbearing age are likely to reach more potential mothers and may have long-term benefits for the women themselves, regardless of their decisions about childbearing. Examples of such recommendations include smoking cessation, HIV antibody testing, and consumption of vitamins containing folic acid for prevention of birth defects. Utilization of family planning services and routine preventive health care will help women plan the timing of wanted pregnancies and maintain their own health, thus helping them to improve the health of their children.
Prenatal care provides an important opportunity to address the unmet health needs of pregnant women. Although interventions during pregnancy are too late to promote optimal reproductive outcomes for many women, surveillance and care during pregnancy are important for the medical and psychological well-being of both mothers and children. Nutritional, educational, and psychosocial services for women and families are available in comprehensive prenatal care settings. An important role of prenatal care is to engage women in ongoing relationships with health-care providers, so they will have continuing contact with caring professionals after childbirth and during the interval before subsequent pregnancies.
The postpartum period is an important time for establishing positive family relationships, particularly because the social demands on new mothers are significant. In addition to routine preventive care, developmental screening, and treatment of any special needs in childhood, the best way to promote children's health is to ensure healthy mothers and well-functioning families. Physical health is basic to child-rearing responsibilities, but psychological and other supports beyond the medical realm are also essential. Women shoulder the major burden of childcare in most families, a stressful job under the best of circumstances. Taking care of children with special health care needs is even more challenging, requiring guidance and respites for parents as well as supportive services to guarantee the best possible futures for the children.
Because motherhood has been perceived by society as central to women's identities, there is often a gap in access to and utilization of health services after women complete their childbearing years. Women live longer than men, but suffer from a higher rate of chronic diseases later in life. Some of these chronic conditions are influenced by women's reproductive histories, and the continuum of health-care needs is important throughout the life cycle. As more women have entered the workforce, they have accumulated social roles without obtaining relief from traditional responsibilities. As adults, "baby boomers" are becoming caretakers of aging parents while they are still providing support for their own children. Women in this "sandwich generation" deserve social recognition and support for maintaining their own health as they face these new physical and emotional challenges.
Bennet, Trude. "Women's Health in Maternal and Child Health:Time for a New Tradition?" Maternal and Child Health Journal 1 (1997):253-265.
Bennet, Trude, Milton Kotelchuck, Christine E. Cox, Myra J. Tucker, and Denise A. Nadeau. "Pregnancy-Associated Hospitalizations in the United States in 1991 and 1992: A Comprehensive View of Maternal Morbidity." American Journal of Obstetrics and Gynecology 178 (1998):346-354.
Chavkin, Wendy, Vickie Breitbart, and Paul H. Wise. "Finding Common Ground: The Necessity of an Integrated Agenda for Women's and Children's Health." The Journal of Law, Medicine and Ethics 22 (1994):262-269.
Healthy People, 12/2000. In the U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [web site]. Available from http://www.health.gov/healthypeople/; INTERNET.
Rohweder, Catherine L., Tracy Schaffzin, and Allan Rosenfield."Public Health Perspectives in the Care of Women and Children." In J. J. Sciarra ed., Gynecology and Obstetrics, revised edition. Philadelphia: J. B. Lippincott, 1995.
Zapata, B. Cecilia, and Trude Bennett. "Women's Health: A Life Cycle." In Jonathan B. Kotch ed., Maternal and Child Health: Programs, Problems, and Policy in Public Health. Gaithersburg, MD: Aspen Publishers, 1997.