A Century Later: Rural Public Health's Enduring Challenges and Opportunities.

The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural-urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678-1686. https://doi.org/10.2105/AJPH.2020.305868).

Voices: A Conversation with Allen J. Wilcox.

Allen James Wilcox was born on 30 September 1946 in Columbus, OH. He studied medicine at the University of Michigan, graduated in 1973, and after a rotating internship, he completed a master's degree in maternal and child health (1976) and a PhD in epidemiology (1979) at the University of North Carolina in Chapel Hill. After graduation, he went to work at the National Institute of Environmental Health Sciences (NIEHS, one of the US National Institutes of Health) in Durham, NC, where he has spent his career. He developed a research program in reproductive and perinatal epidemiology, a relatively unexplored area at the time. His studies include the early pregnancy study, which documented the extent of subclinical pregnancy loss in humans and established the fertile days of a woman's menstrual cycle. He served as the Chief of the Epidemiology Branch from 1991 to 2001, and as Editor-in-Chief of the journal EPIDEMIOLOGY from 2001 to 2014. His textbook, Fertility and Pregnancy-An Epidemiologic Perspective, was published by Oxford University Press in 2010. He was elected to the American Epidemiological Society in 1989, and served as its president in 2003. He also served as president of the Society of Pediatric and Perinatal Epidemiological Research (1996) and the president of the Society of Epidemiological Research (1998). He holds adjunct teaching appointments at the University of North Carolina, Harvard University, and the University of Bergen (Norway), which awarded him an honorary doctoral degree in 2008.

[Enrico Modigliani and the Institution of maternal assistance: a study of the social factors of illegitimate motherhood during early Twentieth century]. / Enrico Modigliani e l'Opera di assistenza materna: i fattori di rischio della maternità illegittima nei primi anni del Novecento.

Enrico Modigliani (1877-1931) was an Italian paediatrician of the early Twentieth century whose work anticipated modern concepts of maternal and child health. Convinced of the importance of creating a network of health and social care for children born out-of-wedlock, he began by providing care to single mothers and their babies at his home on Sundays. In 1918, in Rome, he established the Institution for Maternal Assistance, which aim was to provide single mothers with basic health information as well as tools to face their socioeconomic situation. The Opera encouraged breastfeeding and maternal acknowledgement of the child and promoted the establishment of lactation rooms and nurseries within factories. Moreover, women were supported to find a job which was compatible with their situation. In the first five years of activity, over 1,000 unmarried women were assisted; 95% of them acknowledged their children and 52% found a job. The infant mortality rate fell to 11%, which was much lower than the 35% observed at the time among the social classes which Modigliani called the most miserable. This article reviews Modigliani's paper, in which the paediatrician reported the first five years of activity of the Institution of Maternal Assistance and where he largely focused on the social factors surrounding illegitimate motherhood. The paper was structured like a modern scientific report, with photographic documentation and statistical data, and proposed a point of view regarding social inequality which is surprisingly up-to-date.

Global maternal health and newborn health: Looking backwards to learn from history.

The late appearance of the 'M' on the international health agenda - in its own right and not just as a carrier of the intrauterine passenger - is thought-provoking. The 'M' was absent for decades in textbooks of 'tropical medicine' until the rhetoric question was formulated: 'Where is the "M" in MCH?' The selective antenatal 'high-risk approach' gained momentum but had to give way to the fact that all pregnant women are at risk due to unforeseeable complications. In order to provide trained staff to master such complications in impoverished rural areas (with no doctors), some countries have embarked on training of non-physician clinicians/associate clinicians for major surgery with excellent results in 'task-shifting' practice. The alleged but non-existent 'human right' to survive birth demonstrates that there have been no concrete accountability and no 'legal teeth' to make a failing accountability legally actionable to guarantee such a right.

Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010.

INTRODUCTION: From 1990-2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change. METHODS: This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data. FINDINGS: The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector. CONCLUSIONS: Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.

Infant mortality and isotopic complexity: New approaches to stress, maternal health, and weaning.

OBJECTIVES: Studies of the carbon and nitrogen stable isotope ratios (δ(13) C and δ(15) N) of modern tissues with a fast turnover, such as hair and fingernails, have established the relationship between these values in mothers and their infants during breastfeeding and weaning. Using collagen from high-resolution dentine sections of teeth, which form in the perinatal period we investigate the relationship between diet and physiology in this pivotal stage of life. MATERIALS AND METHODS: Childhood dentine collagen δ(13) C and δ(15) N profiles were produced from horizontal sections of permanent and deciduous teeth following the direction of development. These were from two 19th-century sites (n = 24) and a small number (n = 5) of prehistoric samples from Great Britain and Ireland. RESULTS: These high-resolution data exhibit marked differences between those who survived childhood and those who did not, the former varying little and the latter fluctuating widely. DISCUSSION: Breastfeeding and weaning behavior have a significant impact on the morbidity and mortality of infants and the adults they become. In the absence of documentary evidence, archaeological studies of bone collagen of adults and juveniles have been used to infer the prevalence and duration of breastfeeding. These interpretations rely on certain assumptions about the relationship between isotope ratios in the bone collagen of the adult females and the infants who have died. The data from this study suggest a more complex situation than previously proposed and the potential for a new approach to the study of maternal and infant health in past populations.