On a recent day in late July, 2011,Courtney Allen, a certified nurse midwife with OneWorld Health Center inOmaha, Nebraska, conducted an initialexam on a 36-week pregnant woman for thevery first time. Unfortunately, Allen says, thisis now an almost daily event since the elimi-nation of a highly effective government poli-cy which provided funds to cover prenatalcare for women in Nebraska. Enrollment in care during the first trimester

(first three months) of pregnancy is a reflec-tion of timely initiation of prenatal care. Earlyprenatal care is associated with positive preg-nancy outcomes, since early and regular pre-natal care typically includes basic preventivecare such as nutrition counseling and supple-ments, screening for risk factors, and educa-

tion related to a variety of self-care topics. The value of early prenatal care is not basedon the isolated care provided in the firsttrimester, rather, it is based on the presump-tion that early care leads to regular prenatalvisits throughout the pregnancy. It is alsoimportant to remember that the percentageof pregnant women who initiate prenatal carein the first trimester is a required clinicalmeasure for federally-funded health centers.Enrollment of women into prenatal care inthe first trimester is an acceptable way tomeasure access to care for pregnant women. Since the 1980s, Nebraska has provided

prenatal care under its Medicaid program toall pregnant, low-income women regardless oftheir citizenship status. However, late in 2009the U.S. Department of Health and Human

Services, Centers for Medicare and MedicaidServices (CMS) notified the state of Nebraskathat they could no longer provide Medicaidfunds to cover prental care for certain individ-uals. CMS advised Nebraska instead to provideprenatal care through the state Child HealthInsurance Program (CHIP). At that point, theNebraska Department of Health and HumanServices sent the issue to the state legislaturefor the authority to provide funding for prena-tal care through CHIP. Although a bill wasintroduced in the state legislature and a hear-ing was held, the proposed bill was eventuallypulled by the state senator who had intro-duced it because she felt there were notenough votes for it to pass.

Volume 17, Issue 3July/August 2011

The Migrant Health News SourcestreamlineAccess to Prenatal Care: The Case of NebraskaJillian Hopewell, MPA, MA

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Without state approval for prenatal carecoverage through CHIP, on March 1, 2010,Nebraska ended Medicaid benefits for 1,540women, about 25 percent of the pregnantwomen eligible under the old rules. Sevenhundred were U.S. citizens and legal immi-grants and the other 840 were undocumentedimmigrants. (http://www.womensradio.com/articles/Nebraska-Prenatal-Bill-Stirs-Fight-Over-Immigration/4635.html) The women who lostcoverage included undocumented immi-grants, legal residents with less than 5 years inthe U.S., other legal immigrants, and patientsotherwise not eligible (i.e. not willing to seekchild support from the child’s father).

The impact of these policy changes hasbeen profound for this vulnerable populationas well as for migrant and community healthcenters in Nebraska. OneWorld CommunityHealth Center in Omaha, Nebraska, is one ofthe health centers that have been dramati-cally affected by the changes in prenatalinsurance coverage. Figures 1 and 2 demon-strate the immediate impact this policy hadon insurance rates of prenatal patients at thehealth center.

OneWorld Health Center is a federally-funded health center located in southOmaha, Nebraska. This is an urban area witha sizable Hispanic/Latino population; approx-imately 85% of the health center’s clients areHispanic/Latino. The area employs a numberof individuals in factory work including meatprocessing and tortilla plants. There is a sig-nificant migrant population that also usesthe health center. Health center personnelsay that every day they see new clients whohave just moved to the area.

OneWorld has a strong maternal healthprogram with four nurse-midwives on staff.The midwives have hospital privileges andaverage 25-30 births/month. The midwiferystaff also provide primary care and gynecol-ogical services as do the other primary careclinicians employed by the health center.

Prior to the Medicaid policy change inearly 2010, OneWorld had made steadyprogress in improving rates of entry into pre-natal care. By 2009 OneWorld had an overallrate of 82.2% entry into prenatal care in thefirst trimester of pregnancy. This rate is sig-nificantly higher than the national rate in theU.S. and is also higher than other communi-ty-based health centers in Nebraska.

Immediately after the Medicaid coveragewas eliminated OneWorld experienced a dra-matic drop in the number of women comingin for prenatal care in the first trimester from82.2% to 59.7%. By mid-2010 this rate hadincreased to 64%, but is still significantlybelow the 2009 rates.

Table 1 shows the impact of this policychange on a neighboring state, health

centers in Nebraska and OneWorld inparticular.

The aggregate numbers are disturbing,but the true impact of these changes is feltdramatically at the practice level. Prior to2010 OneWorld saw most women in theirfirst trimester of pregnancy while now theyare seeing women late in the 2nd trimesterand into the 3rd trimester. Clinic staff reportthat the principal reason women state fornot coming in sooner is that they cannotafford to pay for prenatal care.

As a result of late prenatal care the healthcenter is seeing an increase in pregnancycomplications including undiagnosed gesta-tional diabetes, high blood pressure, andfetal abnormalities that would have other-wise been diagnosed. Recently they had acase of a 16-year-old patient who was neverseen for prenatal care. The patient was takento an emergency department following aseizure episode in her home as a result ofpregnancy induced high blood pressure. Thepatient had to have an emergency C-Section

and the baby spent weeks in the NeonatalIntensive Care Unit. This patient’s case ofpreeclampsia would likely have been diag-nosed and managed if she had been seenfor prenatal care.

In another recent case, a woman present-ed in the clinic saying that she was “duetomorrow” and worried about her baby. Anultrasound revealed that the gestational ageof the fetus was over 43 weeks. The placentameasured at a grade 3, meaning that circu-lation to the baby was seriously compro-mised. The woman had to have an emer-gency C-Section and the baby was sent tothe Neonatal Intensive Care Unit.

To better understand the impact of insur-ance coverage for prenatal care, Dr. KrisMcVea, Medical Director at OneWorld HealthCenter, examined rates of three major prena-tal screening tests: the Quad Screen whichtests for genetic problems; the Group B Strepwhich identifies a potential newborn infec-

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n Access to Prenatal Care: The Case of Nebraska continued from page 1

Figure 1Q4 2009 Prenatal CareInsurance Coverage atOneWorld Health Center

Figure 22010 Prenatal Care

Insurance Coverage atOneWorld Health Center

(Source: Kris McVea, MD, Medical Director, OneWorld Health Center)(Source: Kris McVea, MD, Medical Director, OneWorld Health Center)

Uninsured12.0%

Medicaid73.5%

Commercial14.5%

Uninsured72.0%

Medicaid22.0%

Commercial 6.0%

Table 1Entry into Prenatal Care Comparison to Other CHC’s

January to June 2010

2009 2010 Midterm

CHC’s Nationally 67.3% —

Iowa CHCs (neighboring state that 72.1% 77.5%did not eliminate Medicaid coverage)

Nebraska CHCs 76.9% 52.9%

OneWorld Community Health Center 82.2% 64%

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n Access to Prenatal Care: The Case of Nebraska continued from page

tion; and the Glucose Tolerance Test whichtests for gestational diabetes. Figure 3 showsthe rates of each test among the insured ver-sus the uninsured at OneWorld HealthCenter. While the Group B Strep test was notaffected by a lack of insurance, the rates ofwomen who received the Glucose ToleranceTest and the Quad Screen was significantlylower among the uninsured. According to Dr.McVea, the reason for the decreased screen-ing is that uninsured women self ration theirhealth care expenses, electing to attendfewer visits and forgoing some laboratorytests in order to decrease their costs.

Dr. McVea explained that she also seesthe impact of a decrease in prenatal visits inthe delivery outcomes of patients atOneWorld. More women are choosing tostay home and labor because emergencyMedicaid does not cover an evaluation inthe hospital if the woman does not actuallydeliver. This has led to at least two deliveriesin the clinic, four unintentional home deliv-

Figure 3Prenatal Test Rates in Insured versus

Uninsured Patients at OneWorld Health Center

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eries and a number of women deliveringvery soon after hospital arrival. All of thesesituations mean that there is less of a chancefor monitoring labor or conducting routinecare such as administering antibiotics ifneeded for Group B Strep.

Clinic ResponseIn response to the serious decline in early pre-natal visits, OneWorld has instituted a newprogram called Every Baby Matters whichallows women to come in for a prenatal visitat the much reduced rate of $5.00 per visit.Currently the clinic is absorbing the costsassociated with these visits. Additionally,OneWorld has an established relationshipwith Creighton University Medical Centerwhich has agreed to offer reduced rates onultrasound and perinatologist visits. To pro-mote these programs, OneWorld participatesin baby fairs in the community and distrib-

utes flyers about the services they offer. The health center is challenged to find

services and resources for the women who docome in for care. Health center staff doeseverything they can to maximize what theydo in a given appointment. Additionally, theyprovide ongoing education to women toemphasize the importance of prenatal care.In general, their work has become moreintensive on a day-to-day basis since the policy changes took effect.

Policy ResponseThe health care advocacy community inNebraska has rallied around this issue andmade significant strides towards policychanges that could result in the restoration ofprenatal care benefits. Becky Gould, JD, theExecutive Director of Nebraska Appleseed, anon-profit, nonpartisan public interest lawfirm, says that there has been a strong recog-

nition of the shortsightedness of denyingaccess to prenatal care. Appleseed and otheradvocates have been working with the statelegislature and are hopeful that a new billwhich would restore prenatal care coveragewill advance out of committee this Januarywhen the state legislature returns to session.Gould says that “the health care communityhas fought hard on this issue and has done afantastic job of providing data on the impactthis policy has had on their practices. It ishugely important to have the medical com-munity engaged in healthcare advocacy.”

On a practice level, until the policy isreversed, clinicians such as Dr. McVea,Courtney Allen, and the other staff membersat OneWorld continue to explore creativemechanisms for bringing women into care inthe hope that progress that was made inNebraska for pregnant women and their chil-dren will not be completely lost. n

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MCN’s Health Network is available to health-care organizations to provide case manage-ment, referral and record transfer services forindividuals who are likely to move duringcare?that is broader than treatment treat-ment. The following case illustrates how thisprogram works for migrant women duringpregnancy. Names and other details havebeen changed to protect patient privacy.

X iomara was referred to HealthNetwork in May of 2010 by a healthdepartment in a southeastern state thatsent enrollment forms for this 21-year-old woman for the prenatal arm ofHealth Network. This referral set intomotion a series of interactions thatensured that this young migrant womanwould not fall through the cracks in thenetwork of healthcare services for theunderserved.

Once the enrollment paperwork wasprocessed in MCN’s Austin, Texas office,the case was assigned to Gracie Castillo,one of four bilingual Health Networkassociates. Gracie proceeded to contact theclient, and establish a better understandingof her situation. Xiomara stated that thiswas her first pregnancy, she was at aboutthree months, and she was stayingtemporarily at a motel. She mentioned thatshe was planning on moving — perhaps toPennsylvania sometime during the summer— though she did not have an exactaddress at that point. She expressedconcern about the cost of care involvedwith her pregnancy at her current locationand had made an appointment at adifferent clinic from the one that hadenrolled her in Health Network. Gracieprovided an overview of Health Networkservices and gave the woman a direct toll-free number to call in case immediateassistance was required.

The next step was to get medicalrecords from the enrolling clinic. Thehealth department had limited records,however, since they had only performed apregnancy test and had then referredXiomara elsewhere for prenatal care.Records were also requested from asecondary site where the client had beenseen. Xiomara called Gracie a few dayslater complaining that she had had someabdominal pain a few days earlier. She hadgone to the clinic but was instructed to goto the emergency room since the ob/gynphysician was not on site that day. Sheadmitted that she had not gone because ofconcern about the cost of a hospital visitand was relieved that she was no longer

having pain. Gracie was able to locate ahospital clinic in her area that waswilling to work with the patient’sfinancial situation and arranged anappointment for Xiomara.

For two months the patient attendedmultiple appointments at the newlocation, touched base regularly with Health Network regarding herprogress and her pregnancy proceedednormally. She received appropriate lab work, an ultrasound, and alsocompleted financial paperwork. HealthNetwork obtained medical records from this site and included these in the patient’s file.

When Gracie made a routine follow upcall to Xiomara about a month later, thepatient did not answer her phone,despite numerous attempts andvoicemails. It was not until three monthslater that the patient called HealthNetwork, reporting she had moved toanother state and had recently gone tothe emergency room there because ofunbearable pain. She did not know heraddress in the new location and said shewould call back when she knew exactlywere she was staying. She mentionedthat she would only be there for a coupleof weeks. She called back with heraddress. Health Network located a clinic,forwarded medical records to the clinicand made an appointment of Ximoara.

Another month passed when Xiomaradid not answer her phone but she finallyreturned a call in October, stating that shehad just delivered a healthy baby girl bycesarean section. She had returned to heroriginal residence in the southeast and wasconcerned because of swelling, redness andgeneral discomfort around her surgicalincision. She had attempted to make anappointment at the clinic but the only timeavailable was a week away. Graciecontacted the clinic to explain the situationand was able to get an appointment for thenext day. Despite transportation difficultiesand her husband’s work demands, she wasable to attend the visit and was giventreatment. She recovered well and had asix-week post partum visit, as Gracie hadencouraged.

Typically Health Network considers aprenatal case to be completed after thepost partum visit takes place and allrecords are received. Xiomara provided anunusual opportunity for follow up whenshe called Gracie four months after herbaby’s birth to express her appreciationfor Health Network’s involvement in her

case. She confided that her relationshipwith her husband had dramaticallychanged after having her baby — she was thrilled that she was no longer avictim of abuse.

According to protocol, this case wasclosed after being reviewed by MCNclinical staff. All notes for interactions withthe client and the various healthcareorganizations involved in Xiomara’s careare documented according to HIPAAstandards. Through three moves, fivehealthcare organizations and 43 contactswith Health Network, this patient’senrollment in Health Network reveals theimpact of “bridge case management”, notonly through the mechanical services ofscheduling appointments and transferringmedical records, but also through the morepersonal avenue of direct communicationwith patients and their clinicians.

For additional information about HealthNetwork see www.migrantclinician.org/services/health-network.html. n

Pregnancy on the MoveRicardo Garay, Manager, Health Network and Candace Kugel, FNP, CNM, Clinical Specialist, Women’s Health

Photo courtesy of Candace Kugel

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Certified Nurse Midwives (CNMs) areadvanced practice nurses trained toprovide primary care for women across thelifespan with a special emphasis onpregnancy, childbirth, and gynecologicand reproductive health. The presentationGiving Birth to Quality Perinatal Care Services:Midwifery Models for FQHCs, developed anddelivered by Barbara Boehler, CNM; CandaceKugel, FNP, CNM; Denise Henning, CNM;and Martha Carter, MBA, CNM, at the 2011National Association of Community HealthCenter’s Policy and Issues Forum identifiedthe benefits and considerations associatedwith implementing midwifery models ofcare in Community and Migrant HealthCenters (CMHCs). An audience of healthcenter clinicians, executive directors, stateand regional primary care partners, CMHCboard members and advocates were inattendance to receive the presentation.

Considering midwifery models of careare of critical interest in 2011 as state andfederal government policies affectinghealth centers and health care for millionsof Americans are being decided, and bothU.S. birth and maternal mortality rates areup from the 1990’s. In 2007, the nation’smaternal mortality rate was 17 maternaldeaths for every 100,000 live births, amore than 200% increase from 8 of100,000 live births in 1990. Similarly, bothpreterm birth and low birth weight ratesshow increases, and racial and ethnicminorities are significantly overrepresentedin these worsening outcomes. When weconsider that the U.S. currently has one ofthe highest maternal mortality ratesamong developed nations, the urgency ofaddressing disparities in maternal andinfant health is self-evident. Expandingemployment of CNMs in communityhealth centers is an option for relief.

The practice of midwifery, which means“with woman,” recognizes the woman as aunique individual in the context of herfamily and community, supports andprotects the normal physiologic process oflabor and birth and establishes the womanas an active partner in her own care.

In multiple studies of low-risk, low-income women in collaborativeCNM/obstetrician care, participants hadmore spontaneous vaginal births, lowerutilization of resources and no differencesin adverse outcomes compared to thosein traditional (obstetrician-only) care.Additionally, participants obtainedappointments more quickly, spent moretime with providers and were provided

more health information than those intraditional care.(1-2) We can assu me thepractical application of the collaborativecare model indicates that CNM utilizationis ideal for diverse patient populations:allowing women to be matched to theappropriate level of care, increasingaccess to care, leading to better healthoutcomes and lower preterm birth rates,as well as providing greater patientsatisfaction with treatment and servicesand promoting better communicationamong pro viders.

Midwifery models of care are realisticoptions for CMHCs and other medicalsettings. CNM practice is legal in all 50states and CNMs have prescriptiveauthority. Required credentials are aMaster’s degree and board certification.Ninety-eight percent of CNM deliveries arehospital-based.

CNMs’ scope of practice extendsbeyond the realm of attending births.Nurse-midwives provide prenatal care,annual gynecological exams, familyplanning counseling and services,preconception care, depression screeningand school physicals. Practice mayencompass colposcopy, limitedultrasounds, IUD and Implanon insertions,circumcisions and first assistance atcesarean sections.

Considerations in creating infrastructurefor and implementing a midwifery care

model include the clinical, financial andpractical. Volume is key to sustainability ofperinatal care services. Creating a medicalhome for pregnant patients from the onsetis a systematic way of increasing thelikelihood that those utilizing obstetric andgynecological services will also accessCMHCs’ pediatric and family medicineservices.

Practical considerations includeaccommodating scheduling demands,which may differ from that of otherproviders (i.e., ideally, on call hours andoffice hours are not scheduled at the sametime), and that providing support staff forCNMs is necessary.

In essence, midwifery and collaborativecare models benefit both the health center and the patient. CNM utilization is a gateway to high quality, low-costperinatal care services that are potentiallymore patient-centered than traditionalmodels to populations in need: thosesuffering the greatest barriers to accessinghealth care. n

References:1. Jackson, DJ, et al. Outcomes, safety and resource

utilization in a collaborative care birth center pro-gram compared with traditional physician-basedperinatal care. American Journal of Public Health2003. 93; 6:999-1006.

2. Hankins, GD, et al. Patient satisfaction withcollaborative practice. Obstet and Gynecol, 1996;88:6:1011-15.

Considering Midwifery Models of Care for FQHCsRobyn Northup

Women’s Health ResourcesRecommended by MCN

1. The first report to comprehensively explore current midwifery practices across the globe, the State of the World’s Midwifery 2011: Delivering Health, Saving Lives,was released in June by the International Confederation of Midwives in Durban,South Africa.

2. MCN is an outreach partner for Text4baby a service for pregnant women thatprovides free educational text messages in English or Spanish. Enroll your preg-nant women! See www.text4baby.org.

3. The Southern Poverty Law Center produced a report called “Injustice on ourPlates: Immigrant Women in the US Food Industry” (http://www.splcenter.org/ get-informed/publications/injustice-on-our-plates), an examination of workplaceexploitation sexual violence in the lives of immigrant women.

4. Childbirth Connection has launched a new site focused on maternity care systemimprovement, designed to engage diverse stakeholders in quality improvementefforts. The site offers full access to the landmark 2020 Vision and Blueprint forAction, an Action Center, a database of quality improvement projects, an interac-tive data center, and many more tools and resources. Go to TransformingMaternity Care

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BACKGROUND

In the U.S., 85% of English speakingHispanics (31 million Hispanics) own a cellphone and out of these 83% send and orreceive text messages. There is a lot to belearned about the usage of cell phones forHispanic migrant workers; however, anec-dotal evidence suggests that the majority ofmigrant workers own and use cell phones astheir primary method of communication.Text messaging represents an enormous yetuntapped channel for delivering vital healthinformation to those who need it most. Thisis the opportunity that an innovative newprogram called text4baby has seized.

Hispanics are the largest and the fastestgrowing minority group in the UnitedStates, much of this growth is attributed tonew births. Unfortunately, among Hispanicwomen 12.2% of live births are prematureand this population experiences major bar-riers to accessing prenatal care services.These barriers are exacerbated for migrantworkers who face very complex challenges.

National Healthy Mothers, HealthyBabies Coalition (HMHB) is committed tohelping women have healthy pregnanciesand healthy babies. To help address factorsthat contribute to the problem of prematu-rity, HMHB launched text4baby, a freemobile information servi ce that providespregnant women and new moms withinformation to help them care for theirhealth and give their babies the best possi-ble start in life.

Text4baby is a free service where womencan sign up to receive this service in Spanishby texting BEBE to 511411 (or BABY forEnglish). Once enrolled, they receive weeklytext messages, timed to their due date ortheir baby’s date of birth. The texts continuethrough the baby’s first year. These mes-sages focus on a variety of topics critical tomaternal and child health, including birthdefects prevention, immunization, nutrition,seasonal flu, mental health, oral health andsafe sleep. Text4baby messages also connectwomen to bilingual prenatal and infant careservices and other resources. Thanks to thepartnership of CTIA-The Wireless Foundation,the text messages are completely free ofcharge.

As one young Latina participant said, “Ifyou use text4baby, you’re going to have aresource that’s going to help you under-stand what to expect, and not only that...it’s also going to give you phone numberswhere you can find help for whatever deci-

sion making you need to make for yourbaby. I’ve been using it and it’s helped me,so I hope you use it too.”

OUTREACH PARTNERSText4baby is made possible through a broadpublic-private partnership. Johnson & Johnsonis the founding sponsor, and founding part-ners include the National Healthy Mothers,Healthy Babies Coalition, Voxiva, CTIA-TheWireless Foundation and Grey HealthcareGroup. U.S. government partners include theWhite House Office of Science andTechnology Policy, the Department of Healthand Human Services, the Department ofDefense Military Health System, and the U.S.Department of Agriculture. Free messaging isgenerously donated by participating wirelessservice providers.

The HMHB Coalition is working with abroad range of partners to encourage theLatinas they reach to take advantage of thisfree service. Over 600 outreach partnersimplement text4baby, including major med-ical associations, state and local health depart-ments, community health centers, WIC pro-grams, non-profits and community organiza-tions. Outreach partners include: National

Alliance for Hispanic Health, National Councilof La Raza, Migrant Clinicians Network,National Hispanic Medical Association and theLatino Caucus of the American Public HealthAssociation.

Text4baby promotional materials aremade available in Spanish and English tobetter support partners serving monolingualand bilingual Spanish-speaking women.These include informative posters and fliers,in addition to tearpads and referral cardswith clear instructions on how to enroll inthe service. Many activities have been exe-cuted by text4baby partners some of theseinclude: showcasing the Spanish-languageposter in a mall kiosk, inclusion of text4babyinformation in bilingual e-newsletters orprint newsletters, using posters in healthclinics and exam waiting rooms, the creationand distribution of bilingual fliers and otherpromotional materials, training of bilingualhealth center staff to inform and assistHispanic women who wish to enroll.

Visit www.text4baby.org to find out howyou can become a partner, who is promotingthe text4baby in your community, as well asto join statewide collaborations to get theword out. n

Text4baby Outreach to the Hispanic CommunityLuisa F. Soaterna-Castañeda

Photo courtesy of Shannon Aichele

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ENVIRONMENTAL /OCCUPATIONAL HEALTH SECTION

The following article is excerpted with permis-sion from Environmental Health Perspectives,Volume 119, Number 8, August 2011. To readthe full article go to: http://ehp03.niehs.nih.gov

Organophosphate (OP) pesticides arewidely used in agriculture, and severalare registered for home garden use [U.S.Environmental Protection Agency (EPA)2006]1. In 2010, 32 OP pesticides were registered in the United States (U.S. EPA2010).2 In 2007, 15 million kilograms of OPpesticides were used in the United States, rep-resenting 36% of all insecticides used (Grubeet al. 2011).3 In California, 1.6 million kilo-grams of OP pesticides were used in agricul-ture in 2008; the top five active ingredientswere chlorpyrifos, malathion, phosmet, ethep-hon, and dimethoate [California Departmentof Pesticide Regulation (CDPR) 2010].4

OP pesticides have well-known neurotoxicproperties, with the primary mechanism ofaction involving inhibition of acetylcholi -nesterase at high doses (Sultatos 1994).5 Atdoses lower than those needed to inhibitacetylcholinesterase, certain OP pesticidesaffect different neurochemical targets, includ-ing growth factors, several neurotransmittersystems, and second-messenger systems(Slotkin and Seidler 2007;6 Verma et al. 2009)7.

Most human studies showing adversehealth effects of OP pesticides have beencarried out in occupational settings withhigh exposure levels (Kamel et al. 2007).8Children may experience chronic, low-levelexposure due to historical home use, livingnear an agricultural field, and residues infood (Bradman et al. 2007;9 Lu et al.2004).10 Children are at higher risk for pesti-cide toxicity than are adults because thedeveloping brain is more susceptible to neu-rotoxicants and the dose of pesticides perbody weight is likely to be higher in children(Weiss 2000).11 Children also have loweractivity and levels of enzymes that detoxifyactivated forms of certain OP pesticides(Holland et al. 2006).12

Epidemiologic studies suggest that prena-tal exposure to OP pesticides is associatedwith poorer neurobehavioral development ininfants (Engel et al. 2007;13 Young et al.2005)14 and toddlers and preschoolers(Eskenazi et al. 2007;15 Handal et al. 2008;16Rauh et al. 2006).17 Postnatal OP exposurehas also been associated with behavioral

problems; poorer short-term memory, exec-utive function, and motor skills; and longerreaction time in children (Bouchard et al.2010;18 Grandjean et al. 2006;19 Rohlman etal. 2005;20 Ruckart et al. 2004)21. Few studieshave assessed exposure to OP pesticidesboth prenatally and during childhood.

The Center for the Health Assessment ofMothers and Children of Salinas (CHAMA-COS) study is a birth cohort study investigat-ing pesticide and other environmental expo-sures and the health of pregnant women andtheir children living in an agricultural commu-nity. Our findings suggest that most maternalpesticide exposure probably occurs throughthe diet, as is the case for the general U.S.population, but with additional residentialnondietary exposure most likely from ingressof pesticides from agricultural use into homes(Harnly et al. 2009);22 McKone et al. 2007).23Previous reports on the CHAMACOS cohortsuggested that prenatal, but not postnatal,exposure to OP pesticides was associated withincreased odds of pervasive developmentaldisorder and lower scores of mental develop-ment at 2 years of age (Eskenazi et al.2007),15 and with poorer attention skills aswell as hyperactive behaviors at 5 years of age(Marks et al. 2010).24 It remains unclearwhether cognitive deficits associated with pre-natal exposure to OP pesticides are persistent,because cohort studies have not followedchildren to school age, when deficits mayhave greater implications for school perform-ance. Here, we report the associationbetween prenatal and postnatal exposure toOP pesticides, indicated by urinary dialkylphosphate (DAP) metabolite concentrations,and cognitive abilities of 7-year-olds.

DiscussionOur findings suggest that prenatal exposureto OP pesticides, as measured by urinaryDAP metabolites in women during pregnan-cy, is associated with poorer cognitive abili-ties in children at 7 years of age. Children inthe highest quintile of maternal DAP concen-trations had an average deficit of 7.0 IQpoints compared with those in the lowestquintile. Associations were linear, and weobserved no threshold. However, DAP con-centrations during childhood were not asso-ciated with cognitive scores in this cohort ofchildren.

Developing fetal nervous systems may be

more vulnerable to in utero exposure to OPpesticides because of the many uniqueprocesses occurring during this stage ofdevelopment, such as cell division, migra-tion, differentiation, formation of synapses,pruning of synapses, apoptosis, and myelina-tion (Tau and Peterson 2010)(25). Fetalexposure to OP pesticides occurs via passageof the OPs through the placenta (Rauh et al.2006(17); Whyatt et al. 2009(26)). In addi-tion, DAP metabolites have been detected inamniotic fluid (Bradman et al. 2003) (27).

Previous reports from this cohort havealso shown associations of prenatal but notpostnatal OP exposure with adverse neu-robehavioral functioning (Eskenazi et al.2007 (15); Marks et al. 2010 (24)). Our find-ings are consistent with those of other inves-tigations of adverse associations betweenprenatal exposure to OP pesticides and cog-nition (Harari et al. 2010 (28); Rauh et al.2006(17)). In contrast to the present find-ings, a few other studies reported that OPmetabolites measured in children were asso-ciated with poorer cognitive abilities (Lizardiet al. 2008(29); Ruckart et al. 2004(21)).However, these studies differed in exposureand/or the outcomes found to be associatedwith OP pesticides. For instance, Ruckart etal. (2004)(21) examined the relationshipbetween methyl parathion—an OP pesticiderarely used in the Salinas Valley—and foundno association with general intelligence in 6-year-olds but did find adverse associationsbetween concurrent exposure and other spe-cific neuropsychological domains (i.e., poor-er memory, attention, and motor skills). In astudy of 48 children 7 years of age, Lizardi etal. (2008)(29) reported that those withdetectable levels of DAPs had a worse per-formance on a test of executive function,but not on the Full-Scale IQ, compared withthose with nondetectable levels. Studies ofwomen who worked in floriculture inEcuador found associations with certain spe-cific neurobehavioral domains in their chil-dren but did not assess general intelligence(Grandjean et al. 2006(19); Handal et al.2007(30), 2008; Harari et al. 2010(16)).

This study has limitations, mostly relatedto the assessment of exposure to OP pesti-cides. Assessing OP exposure is challengingbecause of their fast clearance from the

Prenatal Exposure to Organophosphate Pesticides and IQ in 7-Year-Old ChildrenMaryse F. Bouchard, Jonathan Chevrier, Kim G. Harley, Katherine Kogut, Michelle Vedar, Norma Calderon, Celina Trujillo, Caroline Johnson, Asa Bradman, Dana Boyd Barr, and Brenda Eskenazi

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ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

body, with complete excretion in the urinewithin 3–6 days (Bradway et al.1977)(31). We observed that prenatalexposure indicated by the average of twoDAP metabolite measures taken duringpregnancy was associated with markedlypoorer cognitive performances. However,the association of DAP metabolites meas-ured at one point in time during pregnan-cy—either earlier or later during gesta-tion—was not as strongly associated withcognitive scores. Considering the rapidmetabolism of these compounds, it seemslikely that exposure assessment based on asingle urinary DAP measure is less repre-sentative of longer-term exposure than areserial measurements. In addition, DAPmetabolites in urine may in part reflectexposure to preformed DAPs present inthe environment or food (Lu et al.2005);32 therefore, the proportion of uri-nary DAP metabolites that reflect exposureto parent pesticide compounds isunknown. However, these sources ofexposure misclassification are nondifferen-tial and would bias results toward the null.Despite the limitations pertaining to theuse of urinary DAPs as exposure indicatorsto OP pesticides, they may provide thebest integrated measure available at thistime. Indeed, for many OP pesticides, nomethods currently available measure pesti-cide-specific metabolites in urine or OPparent compounds in blood.

Prenatal exposure to OP pesticides, pri-marily with DM rather than DE metabo-lites, was associated with poorer cognitionat 2 years of age in this cohort (Eskenaziet al. 2007),15 as well as in the 7-year fol-low-up we report here. The exception wasthat DE metabolites were more stronglyassociated than DM metabolites withdeficits on Processing Speed. The strongerassociations with DM metabolites for mostcognitive measures could be explained bythe greater toxicity of some of these OPpesticides. For example, oxydemeton-methyl, which devolves to DM metabo-lites, is the most toxic of OP pesticidesused in the study region and representsthe greatest cumulative risk (Castorina etal. 2003).33 On the other hand, DEmetabolites may be less stable and, conse-quently, poorer exposure biomarkers(Bradman et al. 2007);9 this would likelybias the effect estimates toward the null.

The present study also has considerablestrengths, perhaps most notable amongthem being its longitudinal design. We

Table 1. Study cohort characteristics and maternal urinary DAP concentrations

(mean of two measures taken during pregnancy), CHAMACOS (n = 329).Geometic mean DAP

Cohort Characteristic n (%) (95% Cl) (nmol/L) p-Valuea

Child’s sex 0.50Boys 154 (47) 136 (115-161)Girls 175 (53) 126 (108-146) 0.71

Maternal Education 100 103 (31) 103 (95-136)

HOME score at 6 months 0.10 ≤ 31.0 139 (42) 150 (128-177) 31.1-33.3 85 (26) 118 (95-147) > 33.4 105 (32) 117 (97-141)

Family income at 7 years 0.31< Poverty level 232 (71) 125 (109-142)Within 200% of poverty level 95 (29) 143 (116-179)> 200% of poverty level 2 (1) 283 (207-389)

Language of WISC-IV verbal subtests 0.77English 108 (33) 133 (108-160)Spanish 221 (67) 129 (113-149)

Maternal country of birth 0.55Mexico 282 (86) 133 (118-152)United States 43 (13) 115 (83-160)Other 4 (1) 94 (62-186)

Mother performed farm work during pregnancy 0.64Yes 145 (44) 123 (105-146)No 180 (55) 136 (117-159)Missing 4 (1) 160 (31-2539)

Farmworker in household during pregnancy 0.76Yes 273 (83) 128 (113-145)No 54 (16) 142 (110-189)Missing 2 (1) 108 (89-131)

a One-way analysis of variance on log10-transformed DAP concentrations.

Table 2. Change in cognitive scores in children tested at 7 years of age, for a

10-fold increase in maternal DAP concentrations (nmol/L) measured in the first and second half of pregnancy (≤ 20 weeks, > 20 weeks), CHAMACOS.

FIRST HALF OF PREGNANCY SECOND HALF OF PREGNANCY ♌-Coefficient ♌-Coefficient

Cognitive test n (95% Cl) p-Value n (95% Cl) p-Value

WISC-IV scale Working Memory 267 -1.6 (-4.2 to 1.0) 0.22 279 -3.0 (-6.4 to 0.4) 0.08Processing Speed 268 -1.5 (-3.9 to 0.9) 0.21 280 -2.6 (-5.9 to 0.7) 0.12Verbal Comprehension 291 -2.6 (-5.1 to -0.1) 0.04 309 -3.1 (-6.4 to 0.2) 0.06Perceptual Reasoning 292 -1.2 (-4.1 to 1.7) 0.42 309 -2.4 (-6.3 to 1.4) 0.22

Full-scale IQ 266 -2.3 (-4.9 to 0.2) 0.07 279 -3.5 (-6.9 to -0.1) 0.04

Estimates were adjusted for HOME score at 6 months and maternal education and intelligence. VerbalComprehension and Full-Scale IQ were also adjusted for language of assessment.continued on page 10

n Prenatal Exposure to Organophosphate Pesticides and IQ in 7-Year-Olds continued from page 8

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measured urinary DAP concentrations dur-ing prenatal development and throughoutchildhood. We followed children until 7years of age, when the tests of cognitivefunction are more reliable than at youngerages (Honzik 1976).34 As in any epidemio-logic study, the reported associations couldbe attributable to uncontrolled confounders,but we were able to examine or adjust fornumerous important factors over the life-time of the child, including exposure toother environmental agents, several socioe-conomic indicators, maternal cognitive abili-ties, and child stimulation. Urinary DAP con-centrations during pregnancy were weaklyassociated with measures of socioeconomicstatus, such as maternal intelligence andeducation. Furthermore, the study popula-

tion had a homogeneous socioeconomicprofile, reducing the potential for uncon-trolled confounding.

The level of urinary DAP metabolites inthe pregnant women in the present studywas higher than in a representative U.S.sample of women of reproductive age[National Health and Nutrition ExaminationSurvey (NHANES) 1999–2000] (Bradman etal. 2005).35 In the present group, the medi-an of total maternal DAP concentrations was128 nmol/L. As a comparison, NHANES lev-els were 72 nmol/L among pregnant womenand 90 nmol/L among nonpregnantwomen. However, > 25% of pregnantwomen from the general U.S. populationhad DAP levels exceeding the median levelsmeasured in the present study. Thus, the

prenatal DAP concentrations associated withcognitive deficits in offspring in the presentinvestigation were within the range of con-centrations found in the general population.

ConclusionPrenatal but not postnatal exposure to OPpesticides was associated with poorer intellec-tual development in 7-year-old children froman agricultural community. Maternal urinaryDAP levels in this sample, although higherthan general U.S. levels, were nonethelesswithin the range of the distribution levels.These findings suggest that some U.S.women in the general population may experi-ence OP pesticide exposure at levels that areassociated with poorer cognitive developmentin offspring in the present study. n

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References

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Clinicians often face significant hurdles inidentifying and diagnosing pesticide poi-soning. Though farmworkers may presentsymptoms associated with pesticide exposure,there are few accessible diagnostic tests thatcan identify the particular type and quantity ofpesticides present in the body. On October 11,2011, the Environmental Protection Agency(EPA) will convene a meeting of clinicians,researchers, industry leaders, farmworker advo-cates, and other stakeholders to discuss thedevelopment of biomarkers and other tools foruse in diagnosing exposure to pesticides.

Accurate diagnosis of pesticide poisoningis necessary to ensure that patients areappropriately treated and receive workers’

compensation if they are entitled to it.Additionally, accurate diagnosis is essential toinforming public health surveillance efforts.Several toxic pesticides have lost registrationin the United States largely because of theinformation available to EPA through surveil-lance of pesticide poisonings.

The American Public Health Association(APHA), clinical organizations and otheradvocates have asked the EPA to require thatpesticide registrants (chemical companies)develop and provide an effective biomarkeras part of the registration process. For moreinformation on this topic, see APHA PolicyResolution – Requiring Clinical Diagnostic Toolsand Biomonitoring of Exposures to Pesticides

http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1400.

The October meeting will allow stakeholdersto examine the issue of biomarkers and discussthe scientific and policy issues involved in theirdevelopment. Migrant Clinicians Network, theNational Farm Medicine Center and Farm -worker Justice are active participates in thisimportant conversation with the goal ofadvancing clinical practice to improve farm-worker health and workplace safety. TheOctober meeting will be help at the Office ofPesticide Programs in Arlington, VA. Informationabout the October meeting is posted on theEPA website at http://www.epa.gov/pesticides/ppdc/testing/ index.html n

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Clinical Diagnostic Tools and Biomonitoring of Pesticide Exposures:EPA to hold October 11, 2011 meeting

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Migrant Clinicians NetworkP.O. Box 164285 • Austin, TX 78716

Non Profit Org.

U.S. Postage

P A I DPERMIT NO. 2625

Austin, TX

Acknowledgment: Streamline is published bythe MCN and is made possible in part throughgrant number U30CS09742-02-00 fromHRSA/Bureau of Primary Health Care. Its con-tents are solely the responsibility of the authorsand do not necessarily represent the officialviews of HRSA / BPHC. This publication may bereproduced, with credit to MCN. Subscriptioninformation and submission of articles shouldbe directed to the Migrant Clinicians Network,P.O. Box 164285, Austin, Texas, 78716. Phone:(512) 327-2017, Fax (512) 327-0719. E-mail:jhopewell@migrantclinician.org

Marie Napolitano, PhD, RNChair, MCN Board of Directors

Karen Mountain, MBA, MSN, RN Chief Executive Officer

Jillian Hopewell, MPA, MADirector of Education, Editor

Editorial Board — Marco Alberts, DMD, DeSotoCounty Health Department, Arcadia, FL;Matthew Keifer, MD, MPH, National FarmMedicine Center (NFMC), Marshfield ClinicResearch Foundation, Marshfield, WI; KimL. Larson, PhD, RN, MPH, East CarolinaUniversity, Greenville, North Carolina

Exploring Social Justice forVulnerable Populations: TheFace of the ImmigrantThe Second Annual Rita M. McGinley SymposiumSeptember 29-30, 2011Pittsburg, PADuquesne University School of Nursinghttp://www.duq.edu/social-justice/agenda.cfm

Clinical Diagnostic Tools andBiomonitoring of PesticideExposuresOctober 11, 2011Arlington, VAhttp://www.epa.gov/pesticides/ppdc/testing/index.html

24th Annual EastCoast Migrant Stream ForumOctober 20-22, 2011West Palm Beach, FLNorth Carolina Community Health CareAssociationwww.ncchca.org

American Public HealthAssociation 139th AnnualMeeting and Exposition October 29-November 2, 2011 Washington, DC American Public Health Association www.apha.org

National Advisory Council onMigrant Health MeetingHotel Albuquerque at Old TownNovember 8-9, 2011Albuquerque, NM

21st Annual Midwest Migrant Stream ForumNovember 10-12, 2011Albuquerque, NMNational Center for Farmworker Healthwww.ncfh.org

2011 Global Health Conference:Advancing Health Equity inthe 21st CenturyNovember 13-15, 2011Montreal, CanadaGlobal Health Education Consortiumhttp://www.2011globalhealth.org

calendar

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