An Integrated Framework for Developing Health Services for Prenatal and Maternal Health as Major Global Health Concerns


Austin Psychiatry. 2016; 1(1): 1003.

An Integrated Framework for Developing Health Services for Prenatal and Maternal Health as Major Global Health Concerns

Zarnegar Z*

Children’s Health International, California, USA

*Corresponding author: Zarnegar Z, Children’s Health International, 27329 Paseo Placentia San Juan Capistrano, California, USA

Received: August 24, 2016; Accepted: November 04, 2016; Published: November 11, 2016


Prenatal, perinatal and early childhood health and well-being have longlasting effects for individual children, their families, care-providers, educators, policy makers and the society, making children’s health and its disparities important concerns for all. Although during the last decades great improvements in prevention of infection and mortality among young children have developed, other health concerns such as early childhood mental health and its challenges, childhood obesity, asthma, autistic spectrum disorder and fetal alcohol spectrum disorder have been on the rise and continue to pre-occupy parents, care providers and educators. Infants and toddlers – young children, are the most vulnerable segment of each society and they are at highest risk for exposures to trauma, injury, morbidity and mortality.

Mothers are the cornerstone of each society and thus their health and wellbeing has fundamental impact on the health of their babies, families and the communities in which they live. Maternal mental health/perinatal mental health is defined by the World Health Organization as the mother’s ability to identify and cope with stresses of motherhood as well as other responsibilities she carries as a contributing member of her community. Maternal mental health disorders are identified as major challenges for the health and well-being of the mother and the baby’s developmental outcome.

This brief attempts to explain the relationship between maternal mental health and prenatal/perinatal health and well-being of the baby, consequences of challenging maternal mental health determinants and to identify useful early interventions that have positive outcome on maternal and pre/perinatal developmental health of the baby and mother-infant healthy relationship.

Keywords: Integrated health services; Prenatal; Perinatal/Maternal health; Global health


Concept of health here denotes full health, with multiple determinants including healthy neurobiological, bio behavioural regulatory system, somatosensory integration and processing system, mental, emotional, psychosocial and neuro relational system and cortical, cognitive/intellectual system. This concept of health is developing and shifting within the ecological contexts of genetic and epigenetic domains as the individual child grows.

Given the myriad of factors impacting prenatal health [1-3] strengthening health care delivery systems is essential if we intend to improve maternal, prenatal and child health delivery and quality outcomes for our children in the world.

The likelihood for poor health outcome for young children multiplies with each added risk factor [4]. This list although inclusive, by no means is exhaustive or complete.

Genetic and epigenetic factors directly impact the foetal growth and development as well as infant morbidity and mortality rate. Several risk factors were identified by Kazura, Kidanto, and Massawe [5] influencing neonatal health and morbidity, such as gestation age and birth complications. In their 2002 report, Wardlow and Kessel [6] listed some risk factors for a healthy pregnancy, including malnutrition, obesity, age at pregnancy, lifestyle, exposure to sexually transmitted disease and poverty.

Perinatal/maternal health has direct impact on the developing foetus and the newborn in various manners [7,8] including but not limited to the presence of one or combinations of the following risk factors: prenatal exposure to illicit and legal substances, especially Prenatal Alcohol Exposure (PAE), causing a spectrum of devastating ailments, some of which are life lasting [9]. Poor physical health, nutrition and diet [10-14], mental illness [15-17], poverty and homelessness [18-20], maternal age and race, marital status, life-style, exposure to environmental hazards and pollutants, and poverty [5] are among other remarkable risk factors [21].

Poverty experienced in early years of life is considered nexus to a variety of negative outcomes such as delays in brain development [22,23]; negatively impacting cognitive [24]; speech and language, psychosocial, emotional, and relational domains, as well as behavioural problems [25-27]; lack of social skills [25,28]; disorganized childparent relationships, child maltreatment [29,30]; educational and learning difficulties [31,32]; and homelessness [33].

Young children living without permanent/long-term placement to call home are at the highest risk of any other age group for a number of stressors. Reports by McCoy-Roth, Mackintosh and Murphey [34], showed increasing level of homelessness among children under six years of age with the staggering added number of refugee and displaced young children [35].

Research findings emphasize significant influences of early childhood experiences on children’s health and well-being [36-39]. Negative outcomes for children with early experiences of trauma and toxic stress similar to those occurring while homeless, are multidimensional with devastating consequences for these children, some of which include neuro-physical, psycho-social-emotional, neuro-relational and cognitive development, and behavioural problems [27-29]; lack of sense of safety and security due to their living situations; inability to make a lasting relationship with significant people in their life such as school-mates, peers, and various care providers in their community [40-42]; higher likelihood to have emotional and behavioural difficulties [43-45]; separation from family and placement in foster care [46,47]; hunger, poor nutrition and physical health [11,12].

To improve prenatal, antenatal and maternal/perinatal health along the spectrum to a healthy motherhood and childhood, three major components of health promotion, prevention of disorders and health disparities, as well as ecologically informed intervention through coordinated actions – locally and globally must take place. The coordinated efforts of interdisciplinary team in all levels of service delivery must be considered to help and support the families with young children and expecting parents [48,49].

To reach such a goal, variety of formats have been introduced around the world by strengthening care and quality of antenatal services, by applying an integrated service delivery system, to support healthy prenatal/pregnancy and perinatal/motherhood periods to benefit two generations of mothers and babies. For example are medical homes [50], community centres, specialized centres such as birth centres, diagnostic testing, monitoring and evaluation centres, public health/mental health clinics or hospitals.

The new framework of a one-stop, integrated service delivery centre, which equates mutual respect among the professionals and Para-professionals serving each family of pregnant mother and the baby, with the goal to improve the health and well-being of families in the community, providing continuity of care for the child-parent dyad, and having the capacity to provide prenatal, perinatal and postnatal care in the community, which is different from the medical home with medicalization of the health concept. In this framework, care-providers promote healthy behaviors for the expecting parents, prevent future harm to the families in the community they serve using these techniques and methods: (a) considering health a combination of neurophysiological and neuro-relational, psychosocial, regulatory, somatosensory, and cortical development; (b) the interdisciplinary team of professionals and Para-professionals supporting and serving each family in their community share the knowledge and the information among themselves with equal regards for each other’s expertise, and their team-based decision making on behalf of the child includes the caregivers/expecting parent(s) in each family; (c) educating the expecting mothers and those around her of the risk factors and their short/long-term impacts on the baby and baby’s developmental domains, on the mother, mothering capacity and child-mother relationships; (d) teaching the expecting mothers and the community at large on the significant benefits of safe, nurturing, supportive, reliable and predictable maternal care, home and the community essential for the healthy prenatal, perinatal and postnatal growth and development of each and every human baby; (e) becoming aware and discuss stigma, discrimination, customs and traditions and existing legal barriers violating human rights of women and young children for any reason, including but not limited to the access to equal healthcare, knowledge and education; (f) reaching the unreachable – the homeless pregnant mothers, babies and young children – the most vulnerable and neediest amongst us providing time-sensitive services; (g) developing emergency-response capability and be prepared for environmentally known risk factors, natural or man-made; (h) providing ecologically fit and appropriate scientifically proven or promising interventions with follow up and home visitations, individualized for each family; (i) becoming a safety net for women and children victimized by violence at home and/or community, providing support, and need-based access to resources needed; (j) strengthening priorities by providing leadership in the community on comprehensive services including health promotion, disease prevention and ecologically based, appropriate prenatal, perinatal and postnatal intervention; (k) leading productive health and education for safe alternatives and healthy childhood; (l) offering benefits from state of the arts research and advance scientific knowledge to improve the access and quality of the existing services; (m) becoming aware of the available and accessible services in the larger community of service providers and global resources and partnerships to benefit those they serve.

Numerous documentations by researchers and social scientists have identified the significant role of the early childhood mental health professional as the team members serving the mothers and their babies due to their education, training, expertise, knowledge and experience in providing needed multi-level and comprehensive care for young children and their caregivers from early diagnosis, assessment and evaluation, advocacy for health promotion, prevention and treatment intervention modalities. Through research and data gathering they can also further the field of prenatal and perinatal mental health representation in policy making on behalf of the youngest and the most vulnerable among us [51-53].


  1. Greenberg RS. The impact of Prenatal Care in Different Social Groups. American Journal of Obstetrics and Gynecology. 1983; 145: 797-801.
  2. Daher M. World Report on Violence and Health. Le Journal MédicalLibanais. The Lebanese Medical Journal. 2002; 51: 59-63.
  3. O’Hara MW, Swain AM. Rates and Risk of Postpartum Depression - a Meta- Analysis. International Review of Psychiatry. 1996; 8: 37-54.
  4. Stevens GD. Gradients in the Health Status and Developmental Risks of Young Children: The Combined Influences of Multiple Social Risk Factors. Maternal and Child Health Journal. 2006; 10: 187-199.
  5. Kazaura MR, Kidanto HL, Massawe SN. Levels, Trends and Risk for Early Neonatal Mortality at Muhimbili National Hospital, Tanzania, 1999-2005. East African Journal of Public Health. 2006; 3: 10 -13.
  6. Wardlaw GM, Kessel MW. Perspectives in Nutrition. 5th Edn. Boston Burr Ridge: Mc Graw Hill. 2002: 157-198.
  7. Gray R. Life stage: Pre-conception and Pregnancy. Our Children Deserve Better: Prevention Pays. In: Annual Report of the Chief Medical Officer. 2012; Chapter 5: 1-13.
  8. Pan American Health Organization, Perinatal Factors Affecting Human Development. Proceedings of the Special Session Held during the Eighth Meeting of the PAHO Advisory Committee on Medical Research 10 June 1969. Pan American Sanitary Bureau, Regional Office of the World Health Organization. 1969; Scientific Publication No. 185.
  9. Zarnegar Z, Hambrick EP, Perry BD, Azen SP, Peterson C. Clinical Improvements in Adopted Children with Fetal Alcohol Spectrum Disorders through Neuro developmentally Informed Clinical Intervention: A Pilot Study. Clinical Child Psychology and Psychiatry. © The Author(s) 2016; 1-17.
  10. Scott-Pillai R, Spence D, Cardwell C, Hunter A, Holmes V. The Impact of Body Mass Index on Maternal and Neonatal Outcomes: A Retrospective Study in a UK Obstetric Population, 2004-2011. BJOG [Internet]. 2013; 8: 932-939.
  11. Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X. Pre-Pregnancy Body Mass Index in Relation to Infant Birth Weight and Offspring Overweight/Obesity: A Systematic Review and Meta-Analysis. PLoS One. 2013; 8: e61627.
  12. Poston L. Maternal Obesity, Gestational Weight Gain and Diet as Determinants of Offspring Long Term Health. Best Practice & Research Clinical Endocrinology Metabolism. 2012; 26: 627-639.
  13. Painter RC, Roseboom TJ, Bleker OP. Prenatal Exposure to the Dutch Famine and Disease in Later Life: An Overview. Reproductive Toxicology. 2005; 20: 345-352.
  14. Veenendaal MVE, Painter RC, de Rooij SR, Bossuyt PMM, van der Post JAM, Gluckman PD, et al. Transgenerational Effects of Prenatal Exposure to the 1944–45 Dutch Famine. BJOG: An International Journal of Obstetrics and Gynecology. 2013; 120: 548-554.
  15. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A metaanalysis of Depression during Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction. Archives of General Psychiatry. 2010; 67: 1012-1024.
  16. Heron J, O’Connor TG, Evans J, Golding J, Glover V. The Course of Anxiety and Depression through Pregnancy and the Postpartum in a Community Sample. Journal of Affective Disorders. 2004; 80: 65-73.
  17. Hay DF, Pawlby S, Waters CS, Sharp D. Antepartum and Postpartum Exposure to Maternal Depression: Different Effects on Different Adolescent Outcomes. Journal of Child Psychology and Psychiatry. 2008; 49: 1079-1088.
  18. Doyle O, Harmon CP, Heckman JJ, Tremblay RE. Investing in Early Human Development: Timing and Economic Efficiency. Economics and Human Biology-Journal. 2009; 7: 1-6.
  19. Gray R, Bonellie SR, Chalmers J, Greer I, Jarvis S, Williams C. Social Inequalities in Preterm Birth in Scotland 1980–2003: Findings From an Areabased Measure of Deprivation. BJOG: An International Journal of Obstetrics and Gynecology. 2008; 115: 82-90.
  20. Weightman AL, Morgan HE, Shepherd MA, Kitcher H, Roberts C, Dunstan FD. Social Inequality and Infant Health in the UK: Systematic Review and Meta-analyses. BMJ Open. 2012; 2: e000964.
  21. Mosha TCE, Philemon N. Factors Influencing Pregnancy Outcomes in Morogoro Municipality, Tanzania. Tanzania Journal of Health Research. 2010; 12: 249-260.
  22. Shonkoff JP, Phillips DA. From Neurons to Neighborhoods: The Science of Early Childhood Development. National Academy of Sciences - National Research Council and Institute of Medicine. Committee on Integrating the Science of Early Childhood Development. Washington, DC. 2000.
  23. Wolfe DA. Child Abuse: Implications for Child Development and Psychopathology 2nd Edn. Thousand Oaks, CA: Sage. 1999.
  24. Korenman S, Miller JE, Sjaastad JE. Long-term Poverty and Child Development in the United States: Results from the NLSY. Children and Youth Services Review. 1995; 17: 127-155.
  25. Brooks-Gunn J, Duncan GJ. The Effects of Poverty on Children. Future of Children. 1997; 7: 55-71.
  26. Duncan GJ, Brooks-Gunn J, Klebanov P. Economic Deprivation and Early Childhood Development. Child Development. 1994; 65: 296-318.
  27. Huston AC, McLoyd VC, Coll CG. Children and Poverty: Issues in Contemporary Research. Child Development. 1994; 65: 275-282.
  28. Jensen BA. Nordic Approach to Early Childhood Education (ECE) and Socially Endangered Children. European Early Childhood Education Research Journal. 2009; 17: 7-21.
  29. Gilbert R, Spatz Widom C, Browne K, Fergusson D, Webb E, Janson J. Burden and Consequences of Child Maltreatment in High-Income Countries. The Lancet. 2009; 373: 68-81.
  30. Veltman M, Browne K. Three Decades of Child Maltreatment Research: Implications for the School Years. Trauma, Violence & Abuse. 2001; 2: 215- 239.
  31. Burchinal MR, Roberts JE, Hooper S, Zeisel SA. Social Risk and Developmental Patterns during the First Four Years. Developmental Psychology. 2000; 36: 793-807.
  32. U.S. Department of Education. Report to the President and Congress on the Implementation of the Education for Homeless Children and Youth Program Under the McKinney-Vento Homeless Assistance Act. 2006.
  33. Bassuk EL, DeCandia CJ, Beach CA, Berman F. America’s Youngest Outcasts: A Report Card on Child Homelessness. American Institute for Research. The National Center on Family Homelessness for every child a chance. 2014.
  34. McCoy-Roth M, Mackintosh BB, Murphey D. When the Bough Breaks: The Effects of Homelessness on Young Children. Child Trends: Early Childhood Highlights. 2012; 3: 1-11.
  35. Zarnegar Z. Separation and Loss due to Political and Social Conflicts: The Impact on Early Childhood Development. Zero to Three Journal. 2011; 31: 52-57.
  36. Shonkoff JP. Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy. Child Development. 2010; 81: 357-367.
  37. Shonkoff JP, Garner AS, Siegel BS, Dobbins MI, Earls MF, McGuinn L, et al. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. American Academy of Pediatrics. 2012; 129: e232-246.
  38. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006; 256: 174-186.
  39. McLoyd VC. Socio economic Disadvantage and Child Development. American Psychologist. 1998; 53: 185-204.
  40. Department of Health and Community Services. Healthy people 2010: Understanding and Improving health. 2nd Edn. Washington, D.C: U.S. Government Printing Office. 2000.
  41. Center for the Study of Social Policy. Protecting children by strengthening families: Aguidebookfor early childhood programs [On-line]. 2004.
  42. Ochshorn S. Partnering for Success: Community Approaches to Early Learning. New York: Child Care Action Campaign. 2000.
  43. Shea P, Shern D. Primary Prevention in Behavioral Health: Investing in our Nation’s Future. Alexandria, Virginia: National Association of State Mental Health Program Directors (NASMHPD). 2011.
  44. Blasé K. Fact Sheet: Implementing Initiatives to Prevent Behavioral Health Problems and Promote Emotional Well-Being. 2011.
  45. Center for the Study of Social Policy. Results-based Public Policy: Strategies for Promoting Children’s Social, Emotional and Behavioral Health. Policy for 2012.
  46. Fisher PA, Chamberlain P. Multidimensional Treatment Foster Care: A program for Intensive Parenting, Family Support, and Skill Building. Journal of Emotional & Behavioral Disorders. 2000; 8: 155-164.
  47. Fisher PA, Chamberlain P, Leve LD. Improving the lives of foster children through evidenced-based interventions. Vulnerable Child Youth Study. 2009; 4: 122-127.
  48. CDC Global Health Strategy 2012-2015. Centers for Disease Control and Prevention Global Health Strategy.
  49. Maternal and Child Health. USAID.
  50. American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002; 110: 184-186.
  51. Nelson F, Manis K. Water Cooler Policy Report; Informing Advocacy for Children Birth to Five-California Infant and Toddler Early Learning Policy Recommendations. Los Angeles, CA: Advancement Project. 2012.
  52. American Academy of Pediatrics. Policy statement; Scope of healthcare benefits for children from birth through age 26. Pediatrics; 2012; 129: 185- 189.
  53. Zimskind L, Mastrianni A. Supporting Children’s Health in Orange County. Policy Brief. Children & Families Commission of Orange County, California. 2013.

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Citation:Zarnegar Z. An Integrated Framework for Developing Health Services for Prenatal and Maternal Health as Major Global Health Concerns. Austin Psychiatry. 2016; 1(1): 1003.

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