Are We Properly Capturing the Maternal-Child Health Continuum?

Traditionally, doctors divide into those who practice adult medicine and those who practice pediatrics. With the exception of family physicians, there is little crossover in medicine — despite the fact that there is not a precise moment in which children magically become adults.

One other potential physician group that spans the divide is perhaps maternal-fetal specialists, who monitor the adult and unborn child at the same time. But in this case, there is a magical moment of distinction in which the obstetrician treats the mother and the neonatologist or pediatrician takes over treatment of the infant: birth.

What science and medicine are quickly realizing, however, is that even that magic cut-off between a baby’s dependency on the mother’s womb and breathing his or her own air is muddled. There are instances and events that occur during pregnancy that determine the eventual health of the child far more than the pediatric practitioner will. There are other circumstances in which the child’s health is determined by that of the mother even before the child is conceived.

In addition to the child-adult continuum, we thus must acknowledge the mother-child continuum.

Adult clinicians and OB/GYNs — like myself — bear in mind that things as simple as poor diet and as complex as addictive behaviors result in intergenerational effects. For example, adolescent practitioners taking care of young women must now acknowledge research indicating the impact of women’s weight trajectories on the weight of their eventual offspring. Similarly, the premature delivery of a baby girl puts that baby at risk of premature childbirth for her own pregnancies as well. Even more complex is the situation when events experienced by the mother in one gestation influence outcomes of future pregnancies. And as the science of epigenetics develops, it’s looking likely that the known connections between a mother’s health and that of her offspring will only continue to grow.

Case in Point: Preterm Births and the Maternal-Child Health Continuum 

Among preterm births, about 60 percent are spontaneous (labor starts before 37 weeks of gestation on its own and doctors are unable to stop it). Research into what triggers early labor is critical to be able to prevent or treat spontaneous preterm birth in the future.

However, the remaining of 40 percent preterm births result from physicians purposely ending the pregnancy early (medically indicated delivery) as a result of their determination that the risk of death and disability to the mother and baby from continuing pregnancy outweighs the risk of prematurity. The decision of when to delay delivery in such cases (expectant management) as opposed to when to induce labor or perform a Cesarean section (interventionist approach) is one of the most artful skills obstetricians and maternal-fetal medicine specialists need to develop during their training and career.

Unfortunately, the criteria at the base of this decision are still imperfect and, for most clinical scenarios, they were developed many years ago. Randomized controlled studies that are performed across the United States and several policies endorsed by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine or the Centers for Medicare and Medicaid Services have been essential in providing some level of uniformity in decision making for maternal-fetal medicine. But there is still a long way to go in implementation of evidence-based criteria across different institutions and levels of care.

Perhaps the lowest hanging fruit in preventing prematurity and improving maternal-neonatal health outcomes is in research aimed at refining the decision-making process that leads to physician-indicated preterm birth. Providing objective measures of severity for different pregnancy-related conditions as well as for pregnancy health, implementation of standardized protocols and improved communication among health care providers involved in the continuum of care surrounding birth could make a significant dent in the number of premature newborns.

So What’s an Adult (or Pediatric) Clinician to Do?

Where evidence supports it, it behooves us to treat women as if their eventual offspring are also our patients. Indeed, adult practitioners who work to improve the health of their female patients could have as much to do with the future of child health as pediatricians.

Another way we can make strides to acknowledge the maternal-child health continuum is to support research in the field. I am often questioned about my role as a physician trained in obstetrics working in research at a children’s hospital. To me it makes perfect sense. Unless and until we have people studying the intricate links between the health of the mother and that of her unborn child, we won’t truly know what to recommend for either of them.

Unveiling the influences that connect maternal and child health is, I would argue, the responsibility of researchers at pediatric academic hospitals at least as much — and probably more so — than that of researchers focused on adult or population health. Institutions and organizations that pride themselves on their efforts to improve the immediate and long-term health of children as a group must start supporting efforts of both maternal-fetal medicine physician and neonatologists to understand the impact of parents’ health on their offspring. It is a fascinating frontier in medical science, and importantly, it is one that could provide critical insight into improving the health of entire future populations.