The evolving role of leadership and change in maternal and child health epidemiology.

Beginning in the 1980s, there was a growing recognition of the need to quantify the work and contributions of state maternal and child health (MCH) departments [1]. In 1987, the Maternal and Child Health Epidemiology Program (MCHEP) was initiated by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) to provide epidemiologic leadership for State MCH programs [2, 3]. The success of the MCHEP spawned subsequent initiatives to build MCH data capacity including the development of a National Action Agenda, which was led by the Association of Maternal and Child Health Programs (AMCHP) and CityMatch, and included other national organizations such as the Association of Schools of Public Health, the Association of Teachers of Maternal and Child Health, the Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials [4, 5]. The National Action Agenda focused on increased funding in CDC and HRSA for three areas: better training, stronger data and information systems, and more field-based capacity building. These efforts contributed to a plethora of programs in these areas, including the strengthening of masters, doctoral, and post-doctoral MCH epidemiology training opportunities through programs such as: the MCHB MCH Graduate Student Epidemiology Program for master’s level students; the MCHB MCH Epidemiology Doctoral Fellowship Program; and the CDC/MCHB MCH Epidemiology Master’s and Post-Doctoral Fellows Program, directed by CSTE [6, 7]. Programs to strengthen the analytic skills of the present workforce have included: the MCHB/CDC MCH Epidemiology Methods Training Course; the MCHB MCH Navigator, designed to address and support continuous MCH professional and workforce development needs, including epidemiology; the CDC/MCHB pre-conference trainings at the MCH Epidemiology Conference, administered by the Association of Maternal and Child Health Programs, which have featured such trainings as data linkage, geographic information systems, and needs assessment; pre-conference trainings and focused MCH epidemiology tracks at the CityMatCH and Association of Maternal and Child Health Program Conferences, including trainings on synthetic estimates, small area analysis, and communicating data findings; the CDC evaluation practicum developed to provide a framework for evaluating state MCH programs; and the CDC distance-based course in epidemiologic methods [8–13]. Additionally, the MCH Epidemiology Conference was established in the mid-1990’s, and has served as the focal point for the latest developments in the field [14, 15]. In turn, many factors in maternal and child health data collection and analysis have improved. Since the inception of the program, the capacity of State MCH programs to provide and analyze data has greatly increased [16–19]. Data systems unavailable to states before the late 1980’s, such as linked birth-infant death files, the Pregnancy Risk Assessment Monitoring System (PRAMS), the Youth Risk Behavioral Surveillance System, the Title V Information System, the National Survey of Children’s Health (NSCH), the National Survey of Family Growth, and the National Survey of Children with Special Health Care Needs, are now routinely used. Data systems that are state-based have greatly enhanced our understanding of population-based factors, and have influenced state policies in maternal and child health. For example, data from the Pregnancy Risk Assessment Monitoring System has provided information on state smoking policies on maternal smoking and quit rates [20], breast feeding rates as affected by policy on hospital formula bags [21], and state early discharge policies for newborns [22]. Furthermore, advanced computer software has allowed data systems like vital statistics and Medicaid data to be linked to examine such issues as birth outcomes among Medicaid recipients. A major challenge for leadership in maternal and child health epidemiology was how to increase data and analytic capacity at the State level. In that regard, there has been a great deal of success, as measured by CSTE’s periodic surveys on epidemiologic capacity. From 2004 to 2009, MCH State epidemiologists had the second largest increase in staffing and analytic capacity among all the epidemiologic areas examined, after bioterrorism [23]. As a further measure of success, these assessments also indicated that the percent of states reporting full maternal and child health epidemiologic capacity increased during that time period from 43 to 55 %. Maternal and child health outcomes have also changed since the inception of MCH epidemiology programs. The preterm birth rate and low birth weight rate both rose over 20 % between the early 1990’s and 2006, then began a slight decline [24]. The cesarean section rate climbed almost 50 % between 1996 and 2010 [24]. The Back to Sleep Campaign and the introduction of pulmonary surfactants in the early 1990’s led to a decline in the infant mortality rate through 2000. Infant mortality remained stagnant till 2007, when the decline resumed [25, 26]; yet despite recent declines, the US ranks 34th in the world for infant mortality rates in 2011 [27]. The percent of children with special health care needs has increased, and much of that increase has occurred among developmental conditions such as autism spectrum disorders and attention deficit disorders [28]. The percent of children classified as overweight or obese increased dramatically between 1990 and 2010 [29, 30]. The analytic understanding of these changes in maternal and child health would not have occurred without the work of MCH epidemiologists. But, times have changed, and therefore, the challenges for MCH epidemiology have changed too. The passage of the Affordable Care Act (ACA) in 2010 increased the emphasis of the health care system on prevention and health promotion, as well as increasing coverage for those previously uninsured. Budgetary limitations have meant cutbacks at the local, State, and Federal levels, as well as even greater demands for accountability for dollars and demonstration of impact. It is becoming more difficult and costly to obtain needed data. There has been a decline in the response rates for all types of surveys, whether they are in-person surveys, like the National Health Interview Survey, or telephone surveys such as the National Survey of Children’s Health. It is no longer enough to report simple associations only between a risk factor and an outcome. Theories on life course and fetal origins of adult disease have accelerated the need to account for the complexities that shape the health of children. Prenatal and early life experiences have been seen as having increasing importance on the health of adult populations [31–33]. Advances in communication technology have also affected the speed and mechanisms of MCH information: policy makers and the public expect data and information to be provided more rapidly. What are the challenges that leaders in MCH epidemiology will face in the future?