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The following is a continuation of a chapter reprinted by permission from 21st Century Obstetrics Now! (David
Stewart, PhD, and Lee Stewart, CCE, Editors), National Association of Parents & Professionals for Safe
Alternatives in Childbirth, 1977. (p. 387)
See here for "Why Women Must Meet The Nutritional Stress of Pregnancy" Part I
See here for "Why Women Must Meet The Nutritional Stress of Pregnancy" Part II
Medical Mismanagement--
The Prevailing Obstetrical Care
The rational observer would assume that, in the light of the wealth of scientific data and implications of basic principles
of internal medicine and neurology, maternal nutrition would receive top public health priority. A neuro chemist and physician
who extensively researched the relationship between prenatal nutrition and fetal development observed an inherent paradox
in our feigned concern for infant and childhood health. He declared:
In this country, major biomedical efforts have pinpointed a number of fatal diseases for eradication, including
poliomyelitis, cancer, and cardiovascular disorders. There has been a particular emphasis on diseases that affect children,
and the news media often report cases that elicit immediate and generous response from individuals and organizations. But
the oldest and most persistent scourge of mankind, which most often affects children and destroys their life opportunities--the
triad of hunger, poverty, and ignorance--is largely forgotten by the community...One would assume that medicine devoted to
the care of women and children would be the most advanced part of medical research and practice. Yet nothing could be further
from the truth...Why is there so much indifference to this subject of hunger, malnutrition, and starvation, when children
and pregnant women, who generate instinctive sympathy and concern from almos everyone, are the most severely affected victims?[76]
While veterinarians, farmers, and ranchers have clearly defined standards for the management of pregnant animals, no such
standards exist for humans.
Notwithstanding the reluctance of obstetricians, who seldom receive much training in nutrition [as of 1977], to incorporate
sound prenatal nutrition as a fundamental aspect of prenatal care, it staggers the imagination to attempt to justify their
insistence on drugs and restrictive diets, especially since such regimens have been linked to reproductive pathology. One
survey [as of 1977] showed that only 5% of obstetricians believe that appetite suppressants are unsafe among obese gravid
women .[124] Among the obstetricians surveyed, 57% stated that they prescribe the drugs for "overweight" patients. In another
survey only 57% of the obstetricians surveyed rejected the concept that the fetus behaves parasitically in extracting its
nutrients regardless of the mother's nutritional intake.[125] It was not surprising that only 5% of them seemed to be aware
of the protectie effects of applied, scientific nutrition.
One nutritionist stated:
Obstetricians seem to think that a low calorie diet to keep the mother's weight down is of prime importance. Many
doctors [as of 1977] even threaten to hospitalize women in the last trimester if they gain more weight than prescribed. Some
patients I have seen have said their doctors have prescribed a ridiculous (weight gain) of 12-14 pounds! The doctors still
prescribe a low salt diet and blindly use diuretics to hopelessly attempt to prevent swelling...The restrictive diets these
women are given daily are the most damaging regimen possible, to both mother and especially the developing fetus. Critical
fetal brain development during this period can never be attained, besides the other possible damaging effects to maternal
health and fetal development. It is frightening to see all these drugs the obstetricians still daily prescribe. You
think they would have learned from Thalidomide that drugs and development don't mix, but it seems they want to recreate that
horror in the 70's.
The practice of weight control, salt restriction, low calorie diets, and drug use during pregnancy is still the biggest problem
with the obstetrical care in the (San Francisco) Bay Area, and probably the entire U.S. These obsolete ideas are still being
practiced daily, despite constant warnings from the nutritional researchers...The only answer is to inform all pregnant
women of the risks they will encounter if they follow their obstetrician's philosophy, and to recommend they either find an
obstetrician who has adopted the most recent methods (they are few and far between) or advise them to talk to a nutrition
consultant or a university nutrition researcher in their area.[126]
"There are a number of phenomena which we have accepted as 'normal in pregnancy' which I have realized were nutrition-related
and which I do not see in my practice any more ... Mothers who are properly nourished do not get stretch marks, and they do
not seem to have acceleration of dental caries or softening of the gums. I do not see loss of hair, splitting of nails, softening
of bones, anemia, postpartum hemorrhage, or failures of nursing. In addition, after the 4th month, most mothers feel normal
as far as energy output."
(One physician's observations after adopting an effective nutrition program for his pregnant patients.)
A concerned supporter of good prenatal nutrition explained:
The American medical profession appears to have a dragnet out during prenatal care. Or are the medical profession
and drug industry blind regarding the nutritional needs of the expectant mother, or too ignorant or stiff-necked to care?
The doctor, as one mother put it, doesn't have to live with the child whom he has caused to suffer brain damage and deformaties.
So a mother has to use her own judgement. She must discard the doctor's advice for restrict her weight, use drugs, and omit
salt which the baby needs during her prenatal care. Indeed, she should question that doctor's whole professional outlook.
Since the doctor's aducational preparation for his profession does not include nutrition, the expectant mother must learn
for herself about the nutritionally balanced diet. If she omits the empty calories from her diet, she will not put on unneeded
fat. She must remember that weight and water gain is important for a healthy baby.[120]
Since the doctor's educational preparation for his/her profession does not include nutrition, the expectant mother must learn
for herself about a nutritionally balanced diet.
While veterinarians, farmers, and ranchers have clearly defined standards for the management of pregnant animals, no such
standards exist for humans. A professor of animal husbandry stated: "With too little salt in the diet...animals become
unthrifty and in time go to pieces. Cows deliver weak calves, or even lose their calves. Cows may even die from salt starvation...When
thinking about salt in livestock management, keep in mind that it is: 'Profitable to remember, costly to forget'"[127]
In contrast, a widely distributed booklet for pregnant women reads: "(Your doctor) may prescribe medicines to help control
your blood pressure and/or fluid retention."[128] To toxemic women the booklet suggests: "Do not use salt to season your
food, either at the table or in cooking."[128]
A booklet written for diabetics gives similarly pernicious advice. It reads: "Besides insulin, your doctor may want to prescribe
other medications during your pregnancy--a diuretic, for example, if you are retaining fluid excessively...Follow his directions
carefully."[129]
The insistence of weight control during pregnancy by physicians has led to an innumerable number of instances of preventable
iatrogenic maternal and infant morbidity and mortality.
Another area of obstetrics which is completely misunderstood involves weight gain during pregnancy. As in the case with distorted
views on salt metabolism, the use of weight control has led to an innumerable number of instances of preventable iatrogenic
maternal and infant morbidity and mortality.
Weight gain has been shown to be the maternal factor which is most highly correlated with birth weight.[51] Although weight
gain during pregnancy can reflect nutritional status, it is not an accurate indicator of dietary adequacy. One reason that
a dietary history and/or blood constituents analysis are more accurate means of assessing nutritional status is that, as in
the nonpregnant state, a high weight gain can result from a high-calorie diet which is low in essential nutrients. Also,
paradoxically, undernourished (particularly protein-deficient women) can gain a rapid amount of weight in a relatively short
period of time as a result of pathological edema. As has been established herein, the edema in such women is a direct consequence
of lowered colloid osmotic pressure of the plasma protein caused by hypovolemia [36,102] and frequently leads to metabolic
toxemia of late pregnancy.[36]
Since healthy, full-term children are born to women who have a normal pregnancy at a wide range of weight gain (or weight
loss), subjecting a group of women to any particular weight control regimen is unscientific and potentially hazardous.[130]
Hytten discovered that the distribution of weight gain during the last 20 weeks of healthy pregnancies approaches the normal
statistical distribution with a mean weekly gain of one pound.[100] Because of individual differences, it is best for pregnant
women to eat a diet of nourishing foods to appetite without regard for their weight gain.[36]
In a study of approximately 8,000 single live births of 37 to 44 weeks' gestation, Lowe demonstrated the direct and highly
significant relationship between weight gain and birth weight.[35] The correlation between birth weight and maternal weight
gain was 0.94. He showed that the relationship was not continuous, since, at and above approximately 3500 grams (7 pounds
11 ounces), birth weight does not increase as weight gain increases.
Utilizing data from the Collaborative Perinatal study, Singer et al. analyzed the association between weight gain and infant
development.[131] They confirmed the findings of other researchers that age, parity, and many other factors are not related
to birth weight when weight gain is one of the independent variables. The data in Table 39 show that the incidence of low
birth weight is related to weight gain at the .001 significance level.
TABLE 39
CORRELATION BETWEEN
WEIGHT GAIN DURING PREGNANCY
AND INCIDENCE OF LOW BIRTH WEIGHT
 |
|
|
Weight Gain (Pounds)
|
% Low Birth Weight
|
|
Loss
|
17.0
|
|
0-15
|
15.8
|
|
16-25
|
8.2
|
|
26-35
|
4.3
|
|
36 or more
|
3.0
|
|
|
|
They also discovered the relationship between maternal weight gain and infant size and neurological function at one year of
age and that between weight gain and psychiatric, mental and motor function at one year of age and that between weight gain
and phychiatric, mental, and motor function at eight months of age. Table 40 lists infant size and the three exams in descending
order of their degree of association with weight gain. All infant abnormalities except those measured by the neurological
exam are significantly related to birth weight on a statistical basis. Even when the relationship between birth weight and
infant abnormalities was removed from the analysis, low maternal weight gain was found to be associated with infant abnormalities.
TABLE 40
INCIDENCE OF ABNORMAL GROWTH BY WEIGHT GAIN
| |
0-15
Pounds
(%)
|
16-25
Pounds
(%)
|
26-35
Pounds
(%)
|
Over
36 Pounds
(%)
|
|
Weight
|
15.8
|
11.2
|
8.4
|
6.2
|
|
Motor Exam
|
11.3
|
8.0
|
6.8
|
5.2
|
|
Mental Exam
|
12.5
|
9.3
|
8.3
|
7.5
|
|
Height
|
10.1
|
7.5
|
6.5
|
7.3
|
|
Neurologic Test
|
8.8
|
7.5
|
7.9
|
7.1
|
Despite the overwhelming evidence of the potentially pernicious consequences of weight control, which is most devastating
during late pregnancy (at which time fetal brain development is most rapid), obstetricians still unduly restrict weight on
a routine basis. One survey showed that 95% of obstetricians restrict weight gain during pregnancy.[125] A present study
showed similar results.[132] A large number of the women were reprimanded for approaching or exceeding their weight quota.
One woman, who had gained 23 pounds by the ninth month of pregnancy, said: "He (the doctor) yells at me every visit. He
says I eat too much. I just get so depressed. He told me my delivery is going to be harder because of my weight gain."[132]
The only answer is to inform all pregnant women of the risks they will encounter if they follow their obstetrician's philosophy.
The doctor doesn't have to live with the child whom he has caused to suffer brain damage and deformities. A mother has to
use her own judgement. She must discard the doctor's advice to restrict her weight, use drugs, and omit salt. Indeed, she
should question that doctor's whole professional outlook.
More of the text of this chapter follows the letter excerpts.
Excerpts from Letters
The following excerpts of letters indicate that many physicians, instead of ensuring that women satisfy the nutritional stress
of pregnancy, are placing them on regimens which endanger their health and the lives and health of their newborns:
From strictly an economic standpoint, preventive obstetrical care is one of the nation's soundest investments. For each case
of severe mental retardation that is prevented, the economic gain to society is more than $900,000 [1977].
Despite the accepted practices of weight control and salt restriction, there are, fortunately, physicians who do practice
preventive obstetrical care. One physician enumerated the benefits from his emphasis on protective prenatal nutrition:
Letter from a Physician With a Nutrition Program
|
|
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When I initially counsel patients with their first pregnancy visit, nutrition is strongly stressed. I do not mention limiting
weight in any way but instead tell to gain at least 25 to 30 pounds during this pregnancy and that this weight gain will be
a protein weight gain. I give them a list of protein-containing foods and reassure them that much of this weight is to gained
in the first few months of pregnancy. I do not at any time, with any visit, tell the patients that they are gaining too much
but instead stress only good nutrition ... The patients did need constant support from me since attitudes of others around
them tended to express that they were gaining too much weight or that somehow weight gain was harmful in pregnancy. I do
not use diuretics in pregnancy, nor any other medications other than a good prenatal vitamin.
During the time I have been in practice here, I have managed approximately 500 obstetrical patients, I have had two patients
with preeclampsia, both of whom had severe chronic diseases. One of these had systemic lupus erythematosis, the second a
hereditary cholesterol problem. Both of these now have healthy babies. I have had six spontaneous premature infants. One
of these was from a mother who had acute appendicitis in her sixth month of pregnancy. Three of the patients did not start
prenatal care until their sixth month of pregnancy and were severely malnourished when I started with them; two of the patients
had placenta previa, and one patient was a total vegetarian whom I judged was on inadequate sources of vegetable protein.
The remainder of my patients have had normal, healthy children. One patient had a sudden infant death occur at four months
of age. The mother of this baby was an epileptic requiring large doses of Dilantin to control her seizures, and this had
been taken all through her pregnancy. Nearly all of my patients breast-feed their babies, and good nutrition is stressed
throughout the breast-feeding time. Most of them breast-feed for six months or more. The mothers begin their first breast-feeding
on the delivery table and continue to breast-feed every two to four hours throughout the hospital stay. The hospital stay
in my patient group averages 24 hours. Cesarean sections taken as a group are kept for approximately 48 hours ... All cesarean
section mothers nurse their babies.
In answer to the question "Do doctors in our area limit weight gain?" I would say most still do ... As an aside, there are
a number of other phenomena which we accepted as "normal in pregnancy" which I have realized were nutrition-related and which
I do not see in my practice any more ... Mothers who are properly nourished do not get stretch marks, and they do not seem
to have acceleration of dental caries or softening of the gums. I do not see loss of hair, splitting of nails, softening
of bones, anemia, postpartum hemorrhage, or failures at nursing. In addition, after the fourth month of the pregnancy, most
mothers feel normal as far as energy output. We see very quick recoveries after pregnancy, and we do not see failures at
breast-feeding because of nutritional problems in the mother.[126]
|
|
|
|
The testimonies to the adherence of good nutrition are numerous. The following all indicate the benefits of sound prenatal
nutrition:
Testimonials to Nutrition
Why are so few obstetricians attuned to the role of maternal nutrition in protecting the health of the expectant mother and
her unborn? A professor of OB/GYN reflected:
In this current flurry of interest in nutrition in pregnancy, the physician responsible for the care of pregnant
women often finds himself in a difficult position. His knowledge of nutrition in general is deficient, for formal instruction
in nutritional principles is notably absent from medical school curriculae and residency programs ... Thus, when faced with
providing nutritional advice to his patients, he all too frequently finds himself confused.[133]
Because obstetricians are not educated in the field of practical nutrition, they are susceptible to unscientific advertising
claims of the drug industry. As late as 1974, diuretics and appetite suppressants were advertised in major obstetrics journals.[134]
In addition, the medical profession, especially the American College of Obstetricians and Gynecologists (ACOG), have directly
or indirectly sanctioned the use of medical regimens which lead to reproductive pathology. The powerful American College
did not form a Committee on Nutrition until 1972. Their first position paper on maternal nutrition, which is replete with
myths and unscientific speculation, was not published until December 1972.[134] A recent enumeration [as of 1977] of the
ACOG's ten-year goals did not include mention of the implementation of nutrition education for the pregnant woman or standards
for the nutrition education of physicians.{135]
Because of the lack of awareness among health care professionals and the reluctance of most organizations to advocate that
pregnant women follow sound nutritional guidance and refrain from taking drugs (unless absolutely necessary) when such advice
is contrary to that given by a physician, hundreds of thousands of pregnant women unwittingly place themselves and their unborn
at risk. It is not surprising that a major university study showed that approximately one million infants are at risk of
needlessly being brain damaged every year in the U.S.[136] Since the study was basically confined to low-income populations,
it did not consider the large numbers of affluent women who subject themselves and their newborns to needless pathology as
a result of adhering to low-salt and/or low-calorie regimens, controlling their weight gain, and/or taking physician-prescribed
drugs.
An overt expression of the prevailing neglect to recognize the nutritional needs of expectant mothers and their unborn is
human experimentation. Because the medical profession and others have not advanced to the stage of instituting rigorous standards
for the management of pregnancy (as have veterinarians and ranchers), numerous women have been subjected to cruel experimentation.
In a well-publicized study at Columbia University, pregnant women in an area in which the low birth weight rate is 17% were
placed in 2 groups for purposes of comparing the viability of their newborns.[137] In neither group (one group of women received
a 40 gram protein supplement daily; those in the control group received a supplement containing only 6 grams of protein) were
the women given nutrition counseling or warned of the risks of undernourishment. In another study, the women in the control
group, who were known to be consuming an average of less than 40 grams of protein per day, were not informed of the dangers
of their dietary inadequacies.[138] Naturally, the researchers in both studies observed a higher incidence of reproductive
casualty among the controls.
In another "scientific" study, 8 pregnant women were placed on a diet which provided less than 25 grams of protein for a period
of five successive days.[139] It should not have surprised the researchers that their ratio of urinary urea nitrogen to total
nitrogen decreased significantly (p.01), indicating that the women were protein deficient. The urinary urea nitrogen/total
nitrogen ratio in one woman who was placed on a diet which provided only 1500 calories and 20 grams of protein for 15 consecutive
days decreased more than 43%.
The practice of preventive medicine is probably more essential in the field of obstetrics than in any of the other medical
specialties. A child born to a mother who is not exposed to proper obstetrical guidance is at risk of developing mental,
physical, and/or behavioral abnormalities. Emphasizing the social and economic benefits of a practical approach to prenatal
nutrition, the international publisher of perhaps the most widely circulated medically oriented publication, wrote:
"What is most baffling is that these precedents, so important to people in terminal stages of irreversible disease,
seem to have little or no bearing in regard to preventible disorders of infinitely greater incidence and of infinitely greater
economic consequences. Once again, our characteristics as an activist society distort what should be the proper relationship
between preventive and curative medicine. We are prepared, and we are a rich enough country, to afford $500,000,000 to $2
billion to prolong life for a few years in those with irreversibly damaged hearts and kidneys.
"Why, then, the incredible neglect annually of many thousands of pregnant women whose malnutrition causes irreversible
fetal brain damage and physical anomalies in children who will for a lifetime be a burden to themselves, to their families,
and to society? These are preventable conditions due to ignorance and/or lack of the most simple nutritional essentials.
We seem fascinated by our mechanical facilities and technologies. It would seem that if a brain transplant were possible,
our social and psychic orientation is such that we would be prepared to support a Medicare charge of $20,000 to $25,000 per
"transistorized brain" transplant. Why then do we fail to make available a few hundred dollars per pregnancy to assure normal
neurologic and general physical development in the unborn? Supplementation to the point of total nutritional adequacy for
ALL American mothers could probably be achieved for less than the presently anticipated cost for renal dialysis of 13,000
patients [as of 1977]. This is not to suggest that the United States need forego either Medicare coverage for renal dialysis
or for totally implantable artificial hearts but, rather, that it makes good medical sense--indeed, common sense--and good
economics to invest in preventive medicine for the pregnant woman and unborn child--a venture which economically is self-liquidating
and less costly than attempts to correct, as we do now, preventable damage and its heavy economic liability.
"It seems that we still have to learn the simplest lesson of good, preventive medicine. Why?"[140]
From strictly an economic standpoint, preventive obstetrical care is one of our nation's soundest investments. For each case
of severe mental retardation, which frequently results from inadequate maternal nutrition, that is prevented, the economic
gain to society is more than $900,000 [by 1977 prices].[141] Recognizing the extremely high rate of preventable retardation
which occurs in the U.S., a university president declared:
"We must ... prevent the occurrence of gratuitous retardation, that is, of retardation that results, not from genetic
malformation or other unavoidable causes, but rather from social neglect. In order to do this, we must understand the importance
of nutrition, especially the nutrition of the fetus ... It is a gratuitous retardation, imposed on those children whose prenatal
and early nutrition has been defective. Only a society that has lost its respect for human life and its concern for the fulfillment
of each individual can be indifferent to this retardation. If we are to avoid such retardation, we must insure that no mother,
either through poverty or ignorance, malnourishes her children in utero.
"The highest priority in American education today should be the establishment of a national program of nutrition and early
childhood education ... It is the obligation of educators at all levels--in schools, colleges, institutions, social agencies,
and medical institutions--to provide this education. It is the obligation of society to see that no carrying mother or young
child is undernourished because of financial need."[142]
Illustrating a case history of preventable mental retardation, a concerned obstetrician appealed to his colleagues for the
immediate implementation of primary prevention through good nutrition as a routine, integral facet of obstetrical care. He
wrote:
Patient M. was a small Mexican woman who followed her doctor's orders to the letter. A private OB/GYN specialist
in California restricted her to one egg and one glass of milk a week, on the grounds that there is too much salt in milk and
eggs. She was constantly advised at each prenatal visit: "Keep your weight down!" She wanted a healthy baby, so she faithfully
followed her doctor's orders. Result: she gained only 14 pounds in all (from 112 to 126) and went into labor right at term.
This was three months after she had been given a low-salt diet and diuretic pill to take every day; she didn't miss a day.
Her son, J.F., weighed 4 pounds, 15 ounces at birth. His blood sugar dropped to 20 mg. per cent and he had hypoglycemic
convulsions repeatedly. The mother, after a normal blood loss at delivery, went into what her doctor termed "idiopathic [unknown
cause] shock"--which we know was caused by her hypovolemia.
The boy is obviously and grossly mentally retarded and has to attend a special school for brain-damaged children.
At age 15 months he was age three to four months in development and function on the Denver Grid-head drop, crossed eyes,
small head. At age 18 months he still could not pull to stand or walk.
The patient had her second son after prenatal care in my clinic. During this second pregnancy she gained 50 pounds,
had two eggs and a quart of milk every day, meat, vegetables, fruits, cereals, and no salt diuretics, not dietary salt restriction.
She was told on each visit: "Keep eating a good diet--salt your food to taste!" This second child, A., weighed 9 pounds
at birth and is a perfect specimen.
Fellow American physicians, how long are we going to disregard the scientific evidence of the causal relationship
of protein-calorie malnutrition, restriction of salt, and the dangerous use of salt diuretics to complications of pregnancy,
fetal mortality, and damage to the newborn human infant?[143]
JOIN SPUN
To counteract the lack of availability of nutrition education services for pregnant women and the prevailing nonchalance among
health care professionals concerning the application of primary prevention through applied, scientific nutrition, the Society
for the Protection of the Unborn through Nutrition (SPUN) was established. For five years SPUN has represented expectant
mothers in their quest for services designed to make pregnancy a healthy, fulfilling, and everlasting experience. Additionally,
SPUN works directly with health care agencies and providers of medical care toward establishing standards for scientific nutritional
management in American obstetrics.
Note from Joy: Unfortunately, SPUN no longer exists, but I include the information about SPUN for its historical significance.
Membership in SPUN (17 N. Wabash, Suite 603, Chicago, IL 60602) is now available to the general public. The annual membership
fee of $10.00 (which is tax-deductible) entitles members to a subscription to SPUN's newsletter and other publications pertaining
to maternal and infant health care and to numerous services, such as access to audio-visual aids, referrals, and reduced or
waived registration fee for special events.
A new SPUN program on the regional level is to sponsor seminars for the education and certification of community prenatal
nutrition counselors. These individuals will provide SPUN services to women and medical personnel through liason with local
childbirth educators and women's health facilities.
Join with other concerned individuals who are involved with the health of expectant mothers and the growth and development
of their babies.
A BOOK ON NUTRITION
"What Every Pregnant Woman Should Know"
(The Truth About Diets and Drugs in Pregnancy)
A new book dealing with the mismanagement of the nutritional aspects of pregnancy by American obstetricians will be published
by Random House in September 1977. Written by Gail Sforza Brewer, with Tom Brewer, M.D., as medical consultant, it explains
to mothers how they can protect themselves and their unborn from the hazards of nutritional nonchalance during pregnancy.
Menus and recipes for pregnancy are included.
If not available from your local bookstore, order from Publisher:
Random House, 201 E. 50th St., New York, NY 10022
$8.95 (plus 75 cents for postage $ handling)
"If brain transplants were possible, our social and psychic orientation is such that we would be prepared to support a Medicare
charge of $20,000 to $25,000 per "transistorized brain" transplant. Why, then, do we fail to make available a few hundred
dollars per pregnancy to assure normal neurological and general physical development in the unborn? Supplementation to the
point of total nutritional adequacy for ALL American mothers could probably be achieved for less than the presently anticipated
cost for renal dialysis of only 13,000 patients."
21st Century Obstetrics Now! Vol. 2 available here
CITED REFERENCES
1.Stewart, D., and Stewart, L., (eds.), Safe Alternatives in Childbirth, 2nd ed., Chapel Hill, NC: NAPSAC, 1977.
2.McCleary, E., New Miracles of Childbirth, New York: David McKay Co., 1974.
3.SPUN Reports, Oct 1, 1973.
4.Lilienfeld, A., and Parkhurst, E., A study of the association of factors of pregnancy and parturition with the development
of cerebral palsy, Am. J. Hygiene 53:262-282, 1951. (quoting Freud, S., Die infantile cerebrallahmung, Vienna: Alfred Holder,
1897.
5.The women and their pregnancies, quoting Subcommittee on Appropriations of House of Representatives, Depts. of Labor and
HEW Appropriations for 1962, U.S. Dept. HEW, p. 756, 1972.
6.ICEA News, vol 15, no 1, Jan 1976.
7.Berger, G., et al., Regionalized perinatal care: an estimate of its potential effect on racial differences in perinatal
mortality in North Carolhm, NC Med. J. 36:476-479, 1975.
8. Bishop, E., NC Med. J. 36:89-91, 1975.
9.Demographic Yearbook.
10.Abramowicz, M., and Kass, E., Pathogenesis and prognosis of prematurity, N.Eng. J. Med. 275:878-885, 1966.
11.U.S. Vital Statistics - Natality, Nat'l Cte. for Health Statistics, Vols for each of the years, 1950 through 1972.
12. Wynn, M., and Wynn, A., The protection of maternity and infancy, New York: E.H. Baker & Co., 1974.
13. Stickle, G., The health of mothers and babies: how do we stack up?, paper given at 5th Nat'l Volunteer Leadership Conf.,
Dec 1, 1976.
14. Observations on maternity care, and Pediatric health care in the People's Republic, Report to People's Republic of China,
Nat'l Acad. of Sci., 1973.
15. Acosta-Sison, Relation between the state of nutrition of the mother and the birth weight of the fetus: a preliminary study,
J. Philippine Is. Med. Assoc. 9:174-176, 1929.
16. Tompkins, W., The significance of nutritional deficiency in pregnancy: a preliminary report, J. Int'l Col. Surgeons 4:147-154,
1941.
17. Burke, B., et al., Nutrition studies during pregnancy, I. Problem, methods of study and group studied, Am. J. Ob. Gyn.
46:38-52, 1943.
18. Burke, B., et al., Nutrition studies during pregnancy, IV. Relation of protein content of mother's diet during pregnancy
to birth length, birth weight, and condition of infant at birth, J. Ped. 23:506-515, 1943.
19. Burke, B., et al., The influence of nutrition during pregnancy upon the condition of the infant at birth, J. Nutrition
26:569-583, 1943.
20. Antonov, A., Children born during the siege of Leningrad in 1942, J. Ped. 30:250-259, 1947.
21. Smith, C., The effect of wartime starvation in Holland upon pregnancy and its product, Am. J. Ob. Gyn. 53:599-608, 1947.
22. Tompkins, W., and Wiehl, D., Nutritional deficiencies as a causal factor in toxemia and premature labor, Am. J. Ob. Gyn.
62:898-919, 1951.
23. Coursin, D., Maternal nutrition and the offspring's development, Nutrition Today, pp. 12-18, Mar-Apr, 1973.
24. Nutritional supplementation and the outcome of pregnancy, Nat'l Acad. of Sci. 1973.
25. Habicht, J. , et al., Relation of maternal supplementary feeding during pregnancy to birth weight and other sociobiological
factors, in Winick, M., (ed.), Nutrition and fetal development, New York: J. Wiley & Sons, 1974.
26. Lechtig, A., et al., Effect of moderate maternal malnutrition on the placenta,Am.J.Ob.Gyn.123:191-201,1975.
27. Lechtig, A., et al., Effect of improved nutrition during pregnancy and lactation on developmental retardation and infant
mortality, in White, P., and Selvey, N., (eds.), Proceedings of Western Hemisphere Nutrition Congress 1974, Publishing Sciences
Group, 1975.
28. Ebbs, J., et al., The influence of prenatal diet on the mother and child, J. Nutri. 22:515-526, 1941.
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To Be Continued....
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