Maternal & Reproductive Health
Improving the well-being of women is an important public health priority in the District of Columbia and the nation. Pregnancy can provide an opportunity to identify existing health risks in pregnant people and to prevent future health problems for their children . Mother and child well-being determine the health of the next generation and can help predict future public health challenges for families, communities, and the healthcare system .
Maternal health is profoundly impacted by the health of women prior to conception and can be improved and protected through interventions that strengthen women’s health and promote planned pregnancies. The trend in pregnancy-related deaths are troubling - mortality has been increasing and each year, with 700 women dying each year as a result of pregnancy or pregnancy-related complicated across the United States . In 2017, the District's pregnancy-related mortality rate (41.9 per 100,000 live births) was higher than the U.S. average (29.1 per 100,000 live births) [3, 4]. Chronic health conditions, such as diabetes and hypertension, are the primary risk factors for pregnancy-related mortality. According to the CDC, cardiovascular conditions amounted to one-third of all pregnancy related deaths between 2011-2015. 
The DC Healthy People 2020 goals for this topic include:
1. Women of child-bearing age, fathers, infants, and children have equitable access to high quality and appropriate health care.
2. Health issues for mothers, infants, and children are rare and they thrive in their environments.
Perinatal health is the health of pregnant people and babies during pregnancy, childbirth, and the postpartum period through the first six weeks after birth. Over the past five years in the District, the fertility rate has remained stable -- ranging between 53.2 live births per 1,000 females (15-44 years of age) in 2013 to 51.3 in 2017 -- and in 2017 the rate remained lower than the US average (51.3 compared to 60.3) . In 2017, across all pregnancy outcomes in the District there were 9,559 live births (85%), 1,613 reported abortions (14.3%) and 72 fetal deaths (0.6%) ). Over 50% of these births were to non-Hispanic Black mothers, though there has been a slight decrease in the percentage over the past several years. 
Overall birth trends for this time period indicate an increase in births to non-Hispanic White mothers, people with more than a high school education, and people aged between 30-39 years old . DC Health has adopted a new approach to address perinatal health disparities. The framework to improve perinatal health outcomes is based on the overarching goal of ensuring every community understands its health risks and role in improving perinatal health outcomes. 
The seven core priorities that drive the District's programmatic efforts to improve perinatal health outcomes in the community are :
• Every teenage girl and woman in DC is in control of her reproductive health.
• Every pregnant woman receives patient-centered, high quality prenatal care beginning in the 1st trimester.
• Every healthcare provider has the tools and resources they need to provide quality care and manage complex social needs of women and infants.
• Every healthcare facility providing maternal and infant care has the tools and resources to practice evidence-based healthcare and to document Quality Improvement and Quality Assurance activities.
• Every newborn receives high-quality neonatal care in the hospital and outpatient setting
• Every parent has the life skills and resources needed to nurture and provide for their family.
• Every infant, mom, and dad has a safe and healthy environment to thrive and receive the support they need to promote early childhood development and learning.
Between 2015-2016, the 65.7% of live births in the District were to women who initiated prenatal care during the first trimester of pregnancy . However, when disaggregated by race/ethnicity, 52% of non-Hispanic Black mothers initiated prenatal care in the first trimester compared to 86% of non-Hispanic White mothers and 64% of Hispanic mothers of any race. Mothers who received no prenatal care during pregnancy were three times more likely than mothers who initiated prenatal care at any time during pregnancy to have a low birth weight baby .
Studies indicate that access and type of insurance coverage, race, and educational attainment are factors that affect access to prenatal care, and the same holds true for District mothers. According to the DC Pregnancy Risk Assessment conducted in 2017, respondents who never sought prenatal care reported not being aware of their pregnancy, longer wait times to see a provider, and lack of access to insurance as some of the major barriers to seeking care.
Breastfeeding is considered the best source of nutrition for infants. The American Pediatrics Association recommends exclusive breastfeeding for the first six months and continued breastfeeding for at least an additional six months after the child starts complimentary foods . Children who are breastfed are less likely to develop diseases like asthma, diabetes, and obesity. Researches have also found protective effects of breastfeeding to the mother from breast and ovarian cancer, high blood pressure, and diabetes. Nationally, in 2015 less than 50% of infants were exclusively breastfed through three months and about 25% were exclusively breastfed through 6 months. In the District, for the same year, 83% of infants were ever breastfed, 65.5% continued breastfeeding at six months, and 43% at twelve months .
Racial disparities exist among women who are able to continue breastfeeding. Nationally, White infants (44.7%) and Latinx infants(46%) are more likely to be breastfed as compared to Black infants (27.5%) infants. Research indicates a connection to immigration status to breastfeeding as well, for infants in the U.S. with foreign-born parents every additional year of parental residence in U.S. brings a four percent decrease in the rate of breastfeeding .
Maternal morbidity refers to the physical and mental conditions associated with pregnancy that affect the health of the mother and baby. These can range from chronic physical health conditions such as hypertension, obesity, and diabetes to mental health conditions like depression . Postpartum depression is depression that occurs after having a baby. Feelings of postpartum depression are more intense and last longer than those of “baby blues,” a term used to describe the worry, sadness, and tiredness many women experience after having a baby. “Baby blues” symptoms typically resolve on their own within a few days .
The effects of pregnancy complications can be detrimental to the life and well-being of the mother and the baby. Preterm birth and low birth weight are some of the resulting ramifications for the baby. Preterm birth refers to a baby born before 37 weeks of gestation. A baby born with a birth weight of less than 5.5 lbs. or 2500 grams is considered to have low birth weight. Infants born preterm and with low birth weight are at risk of developing infections and may suffer from long term problems such as learning disabilities and delayed mental and social development . The percentage of low birth weight infants is greater among mothers who had previous preterm births, received no prenatal care, or had pre-pregnancy diabetes or hypertension .
Non-Hispanic Black mothers are two times more likely than non-Hispanic White and Hispanic/Latinx mothers of any race to have low birth weight babies . Among mothers who smoked during pregnancy the percentage of low birth weight was 24.6% compared to those who didn’t smoke during pregnancy at 9.7%. Low birth weight was also higher for mothers with gestational hypertension and eclampsia . In 2016-2017, the burden of mothers delivering in DC hospitals with gestational hypertension was 11% and with gestational diabetes was 5% .
The CDC defines pregnancy-related death as the death of a woman while pregnant or within one year of the end of a pregnancy -- regardless of the outcome, duration or site of the pregnancy -- from any cause related to or aggravated by the pregnancy or its management; and maternal death as the death of a woman while pregnant or within 42 days of the end of a pregnancy, from any cause related to or aggravated by the pregnancy or its management [2, 20]. The United States ranks poorly in pregnancy-related mortality in comparison to most other industrialized countries, and the issue is especially dire in DC -- the District’s pregnancy-related mortality rate was 41.9 per 100,000 live births between 2013-2017, while the national rate was 20.7 .
The risk of maternal mortality and pregnancy-related complications can be reduced by increasing access to quality of preconception (before pregnancy), prenatal (during pregnancy), and interconnection (between pregnancies) care . In 2018 the DC government commissioned an interdisciplinary Maternal Mortality Review Committee to evaluate maternal mortalities, identify risk factors, and recommend systemic improvements to integrate public and private systems serving pregnant women in the District.
When choosing the most appropriate contraception method, elements such as safety, accessibility/affordability, and effectiveness play an important role, and women, men, and couples all benefit from contraceptive counseling (when available) and a voluntary, informed choice of contraceptive method. Dual protection from the simultaneous risk for HIV and other sexually transmitted infections (STIs) should also be considered. While hormonal contraceptives and intrauterine devices (IUDs) are very effective at preventing pregnancy, they do not protect against STIs, including HIV. Consistent and correct use of the male latex condom reduces the risk for HIV infection and other STIs, including chlamydia, gonorrhea, and trichomoniasis, some of which may cause complications during pregnancy or birth.
A family planning assessment of the District by the George Washington University's Milken School of Public Health found that majority of surveyed clinics prescribe and dispense Depo Provera (80%), IUDs (70%), and implants (90%). It noted that these methods are usually available on the same day at the same appointment. According to the survey, although contraceptive services are available in the District, there is a disconnect with utilization and limited availability of adolescent-friendly services .
The 2017 Youth Behavior Risk Surveillance System (YRBSS) collected information about contraceptive/birth control use among sexually active high school students, revealing that 61% of students reported using a condom during their last sexual intercourse, higher than the national rate reported at 54% . Slightly more than 20% used either birth control pills, an IUD or implant, a shot, patch, or birth control ring to prevent pregnancy and 22% reported not using any method to prevent pregnancy at last intercourse. Among adults, in 2017, 59.9% of survey respondents in the District of Columbia (aged 18 and older) reported that they did not use a condom the last time they had sex .
Abortion Access and Outcomes
For surveillance purposes, abortion is defined as an intervention performed by a licensed clinician with the intention of terminating an on-going pregnancy. Nationally, in 2015 there were 638,169 abortions (188 abortions per 1000 live births) among women aged 15-44 years. Overall, the number of reported abortions decreased by 2 percent from the previous year . There are several factors limiting women’s access to safe abortion services. These factors vary from growing legal restrictions to structural barriers such as affordability, access to transportation and child care services among others. In the District the numbers of reported induced abortions decreased between 2011 and 2016 from 17.2% of reported pregnancies to 11.8%, but increased to 14.3% in 2017 . Public funding is available for abortion only in cases of life endangerment, rape or incest. DC has the least restrictive abortion laws in the country and is most protective of the rights of adolescents to access abortion care without parental involvement . Recently, the DC Vital Records Modernization Act of 2019 included specific reporting from providers to be able to better characterize and report induced terminations of pregnancy in the District. 
Assets & Resources
• DC Healthy Start enhanced medical homes for pregnant and reproductive-age women
Community of Hope, Mary’s Center, Children’s National Health System Adolescent sites
Promising Practices & Policies:
• MICH-I Increase minimum wage to a living wage.
• MICH-II Increase centering pregnancy programs (services for pregnant women in intimate group settings).
• MICH-III Screen women related to intimate partner and/or sexual violence and refer to services if warranted.
• MICH-IV Increase the number of family-friendly work environments and the adoption of breastfeeding policies that provide adequate time and places for working mothers to breastfeed or pump.
• MICH-V Increase the proportion of children with special health care needs who have access to a medical home.
• The District is expanding options to increase patient engagement in clinical care including doula-based strategies, group prenatal care, and care coordination. The city is also streamlining the access to 17P, an underutilized medication for at-risk women to reduce preterm birth.
• DC Healthy Start is a comprehensive assessments and linkages, health promotion and education for preconception, prenatal, interconception, and postpartum women and their families.
Citations & Additional Data Resources
1. Healthy People 2020. Maternal, Infant, and Child Health. 2018
2. CDC Reproductive Health. Maternal Mortality. 2019
3. DC Health. DC Perinatal Health and Infant Mortality. 2018
4. DC Health. Reported Pregnancies and Pregnancy Rates in the District of Columbia 2013-2017. 2019
5. CDC Nutrition. Infant and Toddler Nutrition: Breastfeeding. 2018.
6. CDC Breastfeeding. Breastfeeding Report Card, Unite States 2018. 2018
7. Center for Social Inclusion. Removing Barriers to Breastfeeding: A Structural Raced Analysis of First Food. 2015
8. CDC Reproductive Health. Maternal and Infant Health. 2018
9. CDC Reproductive Health. Depression Among Women. 2019
10. CDC Reproductive Health. Pregnancy Mortality Surveillance System. 2019
11. Moaddab, Amirhossein MD et al. Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. Obstetrics & Gynecology, October 2016 - Volume 128 - Issue 4 - p 869-875
12. America’s Health Rankings. Public Health Impact: Maternal Mortality. 2018
13. Milken Institute School of Public Health and Washington Area Women's Foundation. Family Planning Community Needs Assessment. 2018
14. DC YRBS 2017
15. DC BRFSS 2017
16. CDC MMWR. Abortion Surveillance-United States, 2015. 2018
17. Guttmacher Institute. Ensuring Access to Abortion at the State Level: Selected Examples and Lessons. 2019
18. DC Register. DC Vital Records Modernization Act of 2019. 2019
19. 2014-2017 Inpatient and Outpatient Hospital Discharge Data, DC Hospital Association
20. DC Health Mortality Report 2013-2017
Photo by Dexter Chatuluka on Unsplash