National Perinatal Association
2008 Annual Conference
Loma Linda University Children’s Hospital
Kim Carter
Founder & Executive Director
Time for Change Foundation
November 19, 2008
Financial Disclosure
Neither I, nor my significant other/spouse, have
any financial interest/arrangements or affiliation
with one or more of the corporate organizations
offering financial support or educational grants for
this continuing medical education program.
Definitions
 Institutional – a standard practice, relationship, or
organization in a society or culture.
 Violence – intense, turbulent, or furious and often
destructive action or force.
 “Institutional Violence” (for this presentation) – a
standard practice in society that has become a destructive
force and has a negative impact on the unborn child.
Presentation Objectives
 To identify risk factors associated with highly stressful
pregnancies
 To identify external factors that play key roles in
perpetuating violence during pregnancy
 To identify barriers to accessing risk appropriate care and
prenatal care
Institutional Practices
 Denial of Cash Aid Welfare
 Lack of Health Insurance
 Lack of Prenatal Care
 Underutilization of Referrals & Transport
 Minimal Promotion of Breastfeeding
 Racism
Institutional Violence:
Denial of Cash Aid Welfare
 CalWORKS cash aid can be used for housing, food, utilities,
transportation, and other living expenses. Not being able to pay
for these basic necessities has harmful effects on the unborn
child.
 A Pregnant Woman Only (PWO) who is an adult (age 18+ years)
and has no children living with her is not eligible to receive
CalWORKS until she is in her third trimester of pregnancy.
 Not being able to afford housing and transportation are also
barriers for accessing prenatal care.
(Source: TANF, 2006)
Critical Periods in Human Development1
Red areas indicate highly sensitive periods when teratogens may induce major anomalies
Institutional Violence:
Lack of Health Insurance2,3
Percent of females (age 18-64 years) who reported not
having current health insurance coverage, 2005
25.0%
20.0%
17.3%
16.1%
17.8%
15.0%
10.0%
5.0%
0.0%
Source: CHIS, 2005
Women’s Health, 2007
San Bernardino
County
California
United States
Institutional Violence:
Lack of Health Insurance (cont.)
 Even among those who have health insurance coverage, many
health insurance companies have limitations on coverage for
pregnant women in terms of location of delivery.
 Therefore, adequacy of health insurance coverage also
contributes to institutional violence on the unborn child.
 Lack of adequate health insurance is a barrier for accessing
prenatal care services.
Institutional Violence:
Lack of Health Insurance (cont.)
AB 1962 (De La Torre) – Insurance Code relating to health
care coverage:
• AB 1962 would have required all health insurance policies
to provide coverage for maternity services including
prenatal care, ambulatory care maternity services,
involuntary complications of pregnancy, neonatal care,
and inpatient hospital maternity care, including labor and
delivery and post partum care.
• AB 1962 was vetoed by Governor Schwarzenegger in 2008.
Source: CA Legislative info 2008
Institutional Violence:
Lack of Prenatal Care4
Source: Women’s Health, 1999
Prenatal care consists of much more than just monitoring the mother's
diet and weight. Keep in mind that during pregnancy it is not just the
health of the pregnant woman that must be watched, but also the health
of the unborn baby. Maternal difficulties such as diabetes (which can
develop as a result of being pregnant even if diabetes was not present
before), insufficient weight gain, and high blood pressure, if gone
untreated, can be harmful to the fetus.
A doctor can also monitor the baby's well being directly by listening to
the fetal heartbeat, checking the size and positioning of the uterus and
fetus, and testing for various abnormalities. Some conditions, if detected
prenatally, can be treated before the baby is born. In other instances,
early detection can allow the proper medical facilities to be present at the
time of birth to allow the baby full access to the help it needs.
Institutional Violence:
Lack of Prenatal Care5 (cont.)
According to the March of Dimes, women who see a
health care provider regularly during pregnancy have
healthier babies, are less likely to deliver prematurely,
and are less likely to have other serious problems
related to pregnancy.
(Source: March of Dimes, 2008)
Institutional Violence:
Lack of Prenatal Care6,7 (cont.)
Percent of live births with late or no prenatal care, 2005
5.0%
“Late prenatal
care” defined as
care beginning
in the third
trimester.
4.0%
3.5%
3.2%
2.7%
3.0%
2.0%
1.0%
0.0%
Source :
(CA Dept of Public Health, 2006)
San Bernardino
County
California
United States
Source:
NCHS, 2005
Institutional Violence:
Underutilization of Referrals & Transport8
 Risk appropriate care refers to an organized and
coordinated system that provides services based on need
for mothers and newborns during pregnancy, labor, birth,
and the newborn period.
 In addition, California Children’s Services (CCS) has
defined four levels of NICU care for birthing hospitals.
Source: (Inland Counties Regional Perinatal Program)
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
The four levels (from lowest to highest) are:
 Primary: A nursery designed to provide care for healthy
mothers and newborns.
 Intermediate Neonatal Intensive Care Unit (NICU):
A nursery that has the capability of providing neonatal
services for sick neonates and infants who do not require
intensive care but do require care at a higher level than
provided in a general nursery.
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
 Community NICU: Having the capability of providing a
full range of neonatal care services – or intensive,
intermediate, and continuing care – for severely ill
neonates and infants. In addition, Community NICUs
provide support to Intermediate NICUs. A Community
NICU may not have a full range of sub-specialties or
provide certain pediatric surgeries.
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
 Regional NICU: Has the capability of providing a full
range of neonatal care services encompassing intensive,
intermediate, and continuing care. This includes neonatal
surgery for severely ill neonates and infants. In addition,
Regional NICUs provide support to Community and
Intermediate NICUs. A Regional center provides a full
range of sub-specialties, such as cardiology and neurology.
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
Region 7 birthing facilities that currently have NICUs defined as Community and
Regional level (n = 14; 7 in Riverside County and 7 in San Bernardino County):
Riverside County
San Bernardino County
Desert Regional Medical Center
Arrowhead Regional Medical Center
John F. Kennedy Memorial Hospital
Kaiser Foundation Hospital Fontana
Kaiser Foundation Hospital Riverside
Loma Linda University Medical Center
Parkview Community Hospital
Redlands Community Hospital
Rancho Springs Medical Center
St. Bernardine Medical Center
Riverside Community Hospital
San Antonio Community Hospital
Riverside County Regional Medical Center
St. Mary Medical Center
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
Healthy People 2010 Goal: 9.0 per 1,000 live births as the annual rate of very low
birthweight births (VLBW). VLBW defined as less than 1,500 grams.
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
2001
2002
2003
2004
2005
2006
Birth location
#
%
#
%
#
%
#
%
#
%
#
%
Facility with community/regional
NICU
336
81.2
354
75.6
382
80.3
440
84.6
420
76.9
417
78.5
Other locations
78
18.8
114
24.4
94
19.7
80
15.4
126
23.1
114
21.5
Total
414
100
468
100
476
100
520
100
546
100
531
100
100
HP 2010 Objective = 90%
37
28
46
67
71
61
2005
2006
80
60
Percent
Healthy People
2010 Goal: 90%
of very low
birthweight
(VLBW) births
born at Level III
hospitals or
subspecialty
perinatal centers.
VLBW defined as
less than 1,500
grams.
40
20
0
2001
2002
2003
Year
2004
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
 California Perinatal Transport System (CPeTS) established by
California Assembly Bill 4439 in 1976
 to facilitate transports of critically ill infants and mothers with high
risk conditions to Neonatal Intensive Care Units (NICUs) and
Perinatal High Risk Units
 to collect and analyze perinatal and neonatal transport data for
regional planning, outreach program development, and outcome
analysis
 CPeTS has engaged the California Quality Care Collaborative (CPQCC)
to manage the data system
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
CORE CPETS Acute Inter-Facility Neonatal Transport Form
Institutional Violence:
Underutilization of Referrals & Transport8 (cont.)
Barriers and key transport issues:
 Perceived underutilization of maternal transport
 Perceived delay in decision to transport infant
 Difficulty obtaining transport placement/acceptance
 Delay in effecting transport following decision
 Consistent referring facility competency regarding infant
stabilization prior to transport team’s arrival, as well as
transport team competency
Institutional Violence:
Minimal Promotion of Breastfeeding9
 In California, only 43% of newborns were exclusively
breastfed in the early post-partum period in 2006. In 2007,
the rate was 42.7%.
 In San Bernardino County, 34.6% of newborns were
exclusively breastfed in the early post-partum period in
2006. This increased to 38.4% in 2007.
 Healthy People 2010 goal is 75%.
Source:
Ca Department of Public Health, 2006, 2007
Institutional Violence:
Minimal Promotion of Breastfeeding9 (cont.)
Barriers to exclusive breastfeeding practices:
 Very few health care professionals have received training or kept
current about the science of lactation despite new published research
on anatomy, maternal and infant assessment, effective breastfeeding
interventions and the development of new community resources for
referrals.
 Some hospitals hinder exclusive breastfeeding practices by providing
new mothers with complimentary diaper bags that contain baby
formula and pacifiers, which undermines the intrinsic desire of the
baby to latch on.
Institutional Violence:
Minimal Promotion of Breastfeeding9 (cont.)
 Few hospitals have policies that effectively promote and protect
breastfeeding.
 Few workplaces, educational sites, and childcare centers support
breastfeeding mothers.
 Due to the lack of social and professional support, many mothers have
little confidence and fear attempting to breastfeed.
Institutional Violence:
Minimal Promotion of Breastfeeding (cont.)
 In the United States, social norms do not support or
embrace breastfeeding practices, as demonstrated by:
 Lack of portrayal in mainstream media
 Minimal funding for breastfeeding promotion compared with
advertising of baby formula
 Lack of accommodations for breastfeeding mothers in social
settings
 There is no glamour or appeal associated with breastfeeding
Institutional Violence:
Minimal Promotion of Breastfeeding8,10 (cont.)
 The Baby-Friendly Hospital Initiative (BFHI) is a global program
sponsored by the World Health Organization (WHO) and the United
Nations Children’s Fund (UNICEF) to encourage and recognize
hospitals and birthing centers that offer an optimal level of care for
lactation. The BFHI assists hospitals in giving breastfeeding mothers
the information, confidence, and skills needed to successfully initiate
and continue breastfeeding their babies and gives special recognition
to hospitals that have done so.
 Currently, 10 out of the 31 birthing facilities in Region 7 have been
designated as Baby-Friendly Hospitals and Birth Centers.
Source:
Baby-Friendly USA, 2006
Institutional Violence:
Racism11
 According to the Institute of Medicine Committee on
Understanding Premature Birth and Assuring Healthy
Outcomes, racism is another form of chronic stress that
may contribute to premature birth.
 Maternal stress may cause the release of certain hormones,
which may cause premature contractions and preterm
delivery.
 Black women may experience stress from racism
throughout their lifetime. This may help explain why Black
women are more likely to deliver prematurely than women
from other racial/ethnic groups.
Source:
March of Dimes, 2006
Institutional Violence:
Racism15 (cont.)
Source:
CA – Newsreel, 2008
Institutional Violence:
Racism12 (cont.)
 Kure Walters (a SIDS fundraiser and educator in Riverview,
Florida) hears women say they’re deterred from preconception
and perinatal care because of racism in physicians’ offices and
hospitals.
 Based on her own experience, she recalls when “on my first visit
to a new gynecologist, the staff assumed I was on Medicaid and
were very dismissive. When they asked for my Medicaid card
and got my card from an excellent insurer, their attitude was
much more positive.”
Source: Nursing Spectrum, 2008
Institutional Violence:
Racism12 (cont.)
 According to Versie Johnson-Mallard, PhD, WHNP-bc (a clinical
researcher and assistant professor at the University of South
Florida College of Nursing, Tampa), “the women who show up in
their second trimester may not have known they were pregnant,
or they waited weeks for Medicaid before they could request an
appointment. The woman who didn’t get an ultrasound may
have had difficulty getting an appointment due to work or lack of
transportation. If they’re told or it’s implied that they’re lazy or
irresponsible, it’s a deterrent to going back.”
Institutional Violence:
Racism12 (cont.)
 Barbara Cottrell, ARNP, MSN (an associate professor at the
Florida State University College of Nursing, Tallahassee) studied
272 black women on perinatal care preferences. According to
Cottrell, “don’t make them feel rushed, explain as much as
possible, ask how they’re doing, show warmth, and be
conversational instead of authoritarian.”
 It’s hard for women on the receiving end to tell if providers are
rude or rushed, rather than racist. Regardless, unless providers
attain and maintain rapport, patients may not disclose life
circumstances interfering with proper care and compliance.
Outcomes:
Infant Mortality Rates13,14
 According to the Centers for Disease Control and Prevention
(CDC), infant mortality is one of the most important indicators
of the health of a nation, as it is associated with a variety of
factors such as maternal health, quality and access to medical
care, socioeconomic conditions, and public health practices.
 In 1960, the U.S. had the 12th lowest infant mortality rate and by
2004, the U.S. was ranked 29th. The most recent study, published
in July 2008 titled “The Measure of America” estimates that the
U.S. is now in 34th place.
Source:
(13) CDC, 2008
(14) World Socialist, 2008
Outcomes:
Infant Mortality Rates15 (cont.)
Source:
Ca Newsreel, 2008
In 33 other countries, a baby has a better chance of living until the age of
one than here in the United States.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Iceland
Finland
Singapore
Spain
Sweden
Japan
Czech Republic
Norway
Belgium
Denmark
France
Italy
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Germany
Greece
Slovenia
Portugal
Korea
Australia
New Zealand
Cyprus
Canada
Netherlands
Switzerland
Luxemburg
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
Israel
Austria
Malta
Ireland
United Kingdom
Croatia
Estonia
Slovakia
Cuba
United States
Outcomes:
Infant Mortality Rates16 (cont.)
 According to a 20/20 documentary entitled
“Babyland”, the United States has the highest rate of
infant mortality amongst the richest countries in the
world.
 Tennessee has the highest rate where every 43 hours, a
baby dies in Memphis.
Outcomes:
Infant Mortality Rates16 (cont.)
Source: (13) CDC,2008
Outcomes:
Infant Mortality Rates13,17 (cont.)
(17) CA Dept of Public Health,
Infant Mortality Rate (per 1,000 live births)
Overall infant mortality rates (per 1,000 live births) among San
Bernardino County, California, and United States residents, 2001-2006
10.0
8.0
6.0
4.0
HP 2010 U.S. Goal: 4.5
2.0
0.0
2001
2002
2003
2004
2005
2006
San Bernardino County
7.7
7.6
7.0
6.9
6.6
6.7
California
5.3
5.4
5.2
5.2
5.3
5.0
United States
6.8
7.0
6.8
6.8
6.9
6.7
Outcomes:
Infant Mortality Rates13,17 (cont.)
Infant Mortality Rate (per 1,000 live births)
Infant mortality rates (per 1,000 live births) by race/ethnicity among
San Bernardino County, California, and United States residents, 2005
25.0
20.0
15.0
10.0
5.0
0.0
San Bernardino
County
California
United States
White, Non-Hispanic
6.7
4.6
5.8
Black, Non-Hispanic
17.8
12.7
13.6
6.6
5.3
6.9
Overall
Black infants die at a rate three times higher than that of White infants.
Outcomes:
Infant Mortality Rates15 (cont.)
Source:
CA Newsreel
 Assumption: Higher education improves birth outcomes.
Infant Mortality Rate (per 1,000 live births)
 United States infant mortality data, 2005:
15.0
10.0
9.8
10.0
3.7
5.0
0.0
Black Educated
Women
White Educated
Women
White NonEducated Women
 Data suggests that White non-educated women have better birth
outcomes than Black educated women.
Outcomes:
Infant Mortality Rates15 (cont.)
 Question: Is this a “genetic factor” pre-disposed by DNA?
 Study conducted using three different cohorts revealed that
while African American women born in the United States
had poor birth outcomes, immigrant Africans had birth
outcomes equal to that of White women born in the United
States. However, after one generation in the United States,
those immigrant Africans were exhibiting the same dismal
birth outcomes as the United States-born African
American women.
Outcomes:
Infant Mortality Rates15 (cont.)
 Infant mortality is not just a problem for African Americans.
When we remove the data for African Americans, we find that
White babies still have a death rate that ranks the United States
23rd. This means that there are at least 22 other countries in the
world that have better birth outcomes than White babies in the
United States.
 During the 1960’s, the infant mortality gap was closing due to
effective social policies and programs. During the 1980’s,
however, these programs were eliminated and infant mortality
increased.
Outcomes:
Prematurity (Preterm Births)18
Most pregnancies last around 40 weeks. Babies born
between 37 and 42 completed weeks of pregnancy are
called full term. Babies born before 37 completed
weeks of pregnancy are called premature or preterm.
Source: March of Dimes (2008)
Outcomes:
Prematurity (Preterm Births)17,19 (cont.)
Percent of births that were preterm among San Bernardino
County, California, and United States residents, 2005
12.7%
15.0%
11.0%
10.8%
10.0%
HP 2010 Goal: 7.6%
5.0%
0.0%
San Bernardino County
Source: (17) CA Dept. of Public Health, 2001, (19) CDC, 2005
California
United States
Outcomes:
Prematurity (Preterm Births)17,18,20 (cont.)
 Premature birth is a serious health problem. Premature
babies are at increased risk for newborn health
complications, as well as lasting disabilities, such as mental
retardation, cerebral palsy, lung and gastrointestinal
problems, vision and hearing loss, and even death.
 Disorders related to short gestation (prematurity) and low
birthweight were the 2nd leading cause of death among
resident infants in San Bernardino County (2005),
California (2005), and the United States (2004).
Source: (17) CA Dept of Public Health, 2004 (18) March of Dimes, 2008 (20) CDC, 2008
Outcomes:
Low Birthweight Births21
 Babies born weighing less than 5 pounds, 8 ounces (2,500
grams) are considered low birthweight.
 Low birthweight babies are at increased risk for serious
health problems as newborns, lasting disabilities and even
death.
Source: March of Dimes, 2008
Outcomes:
Low Birthweight Births17,19 (cont.)
Percent of births with low birthweight among San Bernardino
County, California, and United States residents, 2005
10.0%
8.2%
7.2%
6.9%
8.0%
6.0%
HP 2010 Goal: 5.0%
4.0%
2.0%
0.0%
San Bernardino County
Source: (17) CA Dept. of Public Health, (19) CDC, 2005
California
United States
Outcomes:
Low Birthweight Births21 (cont.)
Advances in newborn medical care have greatly
reduced the number of deaths associated with low
birthweight. However, a small percentage of survivors
develop mental retardation, learning problems,
cerebral palsy and vision and hearing loss.
Source: March of Dimes, 2008
Outcomes:
Health Risks of Not Breastfeeding22
 Babies who are not exclusively breastfed for 6 months
are more likely to develop a wide range of infectious
diseases including ear infections, diarrhea, respiratory
illnesses and have more hospitalizations.
 Infants who are not breastfed have a 21% higher
postneonatal infant mortality rate in the United
States.
Source: US Dept of Health & Human Svcs.,2005
Outcomes:
Health Risks of Not Breastfeeding22 (cont.)
•
•
•
•
•
•
•
•
Higher rates of SIDS in the first year of life
Higher rates of Type 1 and Type 2 Diabetes
Lymphoma
Leukemia
Hodgkin’s Disease
Overweight & obesity
High cholesterol
Asthma
Babies who are not breastfed are sick more often and have more
doctor visits.
Source: US Dept of Health & Human Svcs.,2005
Outcomes:
Economic Costs23
 The average first-year medical costs, including both
inpatient and outpatient care, were about 10 times greater
for preterm infants ($32,325) than for term infants ($3,325).
 Average length of a hospital stay for a preterm infant:
13 days – nine times longer than a term infant
 Average length of a hospital stay for a term infant:
1.5 days
Source: Institute Of Medicine & March of Dimes, 2006
Outcomes:
Economic Costs23 (cont.)
In 2005, preterm births cost the United States at least
$26.2 billion, or $51,600 for every infant born preterm.
The costs broke down as follows:
 $16.9 billion (65 percent) for medical care
 $1.9 billion (7 percent) for maternal delivery
 $611 million (2 percent) for early intervention services
 $1.1 billion (4 percent) for special education services
 $5.7 billion (22 percent) for lost household and labor market
productivity
Source: Institute Of Medicine & March of Dimes, 2006
Outcomes:
Economic Costs (cont.)
What ever happened to “an ounce of prevention is
worth more than a pound of cure?”
 By not providing supportive services to the mothers who are
experiencing multiple stressful situations during their
pregnancies, enormous costs are spent on the care of premature
and very low birth weight babies. These costs could be
minimized by investing in effective prevention services to reduce
the many risks associated with institutional violence.
 Everyone shares the cost of caring for premature babies.
Policy Recommendation #1
Welfare (CalWORKS) reform of eligibility
requirements:
 Pregnant Women Only (PWO) should be able to access this
program during their first two trimesters of pregnancy
instead of having to wait until their third trimester.
Policy Recommendation #2
Health education related to transport issues:
 Hospitals need to inform expecting moms in advance which hospital(s)
they have transfer agreements with should it be required for the mom
or her baby8.
 Physicians and other health care practitioners need to take a more
active role in making sure high-risk pregnancies are delivered in
Community and Regional level hospitals.
 Health insurance companies need to have flexibility in coverage
guidelines to allow for moms to choose where they want to deliver.
Policy Recommendation #3
Information-sharing during transport:
 Have electronic patient records available to any physician
and/or healthcare professional who needs to do an
assessment before performing any medical services to
pregnant women.
 Infrastructure should allow for cross-hospital sharing and
out-of-state access to patient records, as needed.
Standards of Care Recommendations
 There are 10 designated Baby-Friendly birthing
facilities in Region 7. There are only 20 designated
facilities in the entire State of California10. The State
needs to increase the number of designations.
 Increase the number of birthing facilities in Region 7
that are designated as California Children’s Services
(CCS) approved hospitals.
Baby Friendly USA , 2006
References
1
Critical Periods of Fetal Development.
http://www.cerebralpalsychildren.com/CPFetal.html
2
California Health Interview Survey. (2005). www.chis.ucla.edu
3
Women’s Health USA. (2007). Health services utilization: Health insurance.
http://mchb.hrsa.gov/whusa_07/healthservutiliz/0402hi.htm
4
Women’s Health. (1999). The importance of prenatal care.
http://www.womenshealth.org/a/pre_natal_care.htm
5
March of Dimes. (2008). Pregnancy & newborn health education center: Prenatal
care. http://www.marchofdimes.com/pnhec/159_513.asp
6
California Department of Public Health. (2005). Birth statistical master file.
7
National Center for Health Statistics. (2005). Final data for 2005, Table 26(b).
References (cont.)
8
Inland Counties Regional Perinatal Program. www.cdph.ca.gov/rppc
9
California Department of Public Health Genetic Disease Screening Program, Newborn
Screening Data. California in-hospital breastfeeding as indicated on the newborn
screening test form Statewide, County and Hospital of occurrence, 2006 and 2007.
http://www.cdph.ca.gov/programs/BreastFeeding
10
Baby-Friendly USA. (2006). What is the Baby-Friendly Hospital Initiative and why do
we need it? http://www.babyfriendlyusa.org
11
Institute of Medicine Committee on Understanding Premature Birth and Assuring
Healthy Outcomes, Board on Health Sciences Policy, Behrman, R.E., and Butler, A.S.
(eds.). (2006). Preterm birth: Causes, consequences, and prevention. Washington,
DC: The National Academies Press. www.marchofdimes.com
12
Nursing Spectrum. (2008). Stress may spur Black infant mortality. www.nurse.com
References (cont.)
13
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics. (2008). Recent trends in infant
mortality in the United States. http://www.cdc.gov/nchs/data/databriefs/db09.htm
14
World Socialist Web Site. (2008). US infant mortality rate now worse than 28 other
countries. http://www.wsws.org/articles/2008/oct2008/mort-o18.shtml
15
Adelman, L. (Executive Producer & Co-Director). (2008). Unnatural causes: Is
inequality making us sick? California Newsreel.
16
20/20. (August 22,2008). Babyland. New York: American Broadcasting Company.
17
California Department of Public Health. Death and Birth Records, 2001-2006.
18
March of Dimes. (2008). Fact sheet: Preterm birth.
http://www.marchofdimes.com/professionals/14332_1157.asp
References (cont.)
19
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics. (2008). Births: Final data for 2005.
http://www.cdc.gov/nchs/fastats/infant_health.htm
20
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics. (2008). Deaths: Leading causes for
2004. http://www.cdc.gov/nchs/fastats/infant_health.htm
21
March of Dimes. (2008). Fact sheet: Low birthweight.
http://www.marchofdimes.com/professionals/14332_1153.asp
22
The National Women’s Health Information Center, Office on Women’s Health in the
U.S. Department of Health and Human Services. (2005). Benefits of breastfeeding.
http://www.4woman.gov/breastfeeding/index.cfm?page=227
23
Institute of Medicine and March of Dimes. (2006). Preterm birth: Causes,
consequences, and prevention.
http://www.marchofdimes.com/prematurity/21198_10734.asp
Thank You
Contact Information
Kim Carter
Founder & Executive Director
Time for Change Foundation
www.Timeforchange.us
(909) 886-2994
Questions