An Expanded Approach to Maternal and Child Health: Preconception Health in the Context of a Life Course Perspective Cynthia A. Harding, M.P.H. Los Angeles County Department of Public Health Maternal, Child and Adolescent Health Programs
An Expanded Approach to Maternal and Child Health: Preconception Health in the Context of a Life
Course Perspective
Cynthia A. Harding, M.P.H.
Los Angeles County Department of Public Health
Maternal, Child and Adolescent Health Programs
Special Thanks to
• Shin Margaret Chao, Ph.D., M.P.H.
• Giannina Donatoni, Ph.D., M.T.(A.S.C.P.)
• Angel Hopson, M.S.N., M.P.H., R.N.
• Milton Kotelchuck, Ph.D., M.P.H.
• Neal Halfon, M.D., M.P.H
• Michael Lu, MD, MPH
Today’s Presentation
Infant Mortality in Los Angeles County
Preconception Health
Life Course Theory and Framework
The Life Course Framework in Los Angeles County
Los Angeles, California
Infant Death Rate*1990-2002
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Dea
ths
per
1,0
00 l
ive
bir
ths
U.S.
LA County
CA State
S o u r ce: Ca lif o r n ia D ep ar tm en t o f H ealth S er v ic es, Cen ter f o r H ea lth S t atis ti cs, V i ta l S t atis ti cs, 1 9 9 3 to 2 0 0 2
* Th e in f an t d eath r at e is d ef in ed as th e to t al n u m b er o f d eath s p er 1 ,0 0 0 liv e b ir th s
Antelope Valley (AV)
Relatively isolated
4,903 live births in 2002Mother’s race/ethnicity:
17% African American46% Hispanic33% White
Income of 1 in 8 households less than Federal Poverty Level (1 in 5 in LAC).
Increasing Infant Mortality in AV
1999-2002
4.95.4 5.5
5.4
5.0
6.2
9.4
10.6
0
2
4
6
8
10
12
1999 2000 2001 2002
per
1,00
0 L
ive
Bir
ths
LAC Overall Rate
AV Rate
Countywide IM rates were 4.9 to 5.5 from 1999-2002
AV IM rate more than doubled between 1999 and 2002
In 2002, there were 4903 live births and 53 infant deaths in AV*
* Small numbers cause large changes in rates
Highest Rates in African Americans
African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002
19.0
28.4
32.7
5.7 5.6
7.7
3.5
5.5
11.0
6.6
2.7 2.2
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1999 2000 2001 2002
Per 1
,000 L
ive Bi
rths
African American Hispanic
White (Non-Hispanic) Antelope Valley Rate
Source: California Department of Health Services, Center for Health Statistics, Vital Statistics, 1999 to 2002
Our Response:
Four promising practices integrated to address the problem:
1. Focus Groups
2. Fetal Infant Mortality Review (FIMR)
3. PPOR
4. LAMB Community Collaboration
Preliminary Findings
Among the 53 infant deaths:
68% died in first 28 days (42% died in 24 hrs)75% pre-term births75% low birth weight 21% Teens (< 20 years)43% were African Americans
Focus Group Findings
Women Transportation to prenatal care Health concerns not taken seriously Stereotyped as single welfare moms Satisfaction with care after delivery
Providers Women entering late into prenatal care Difficulty in accessing high risk prenatal care Serious concern and commitment to collaborate
Fetal Infant MortalityReview (FIMR)
National FIMR forms to review 2002 AV infant deaths (N=53)
PHNs conducted home interviews, abstracted hospital and provider records.
What did we learn from FIMR ?
Babies born too soon and too small Late or no prenatal care Not first loss Psycho-social issues Transportation barriers Referral to high risk and specialty care
difficult and therefore not occurring
Perinatal Periods of Risk
<1500 g<1500 g
1500+ g1500+ g
FetalFetal NeonatalNeonatal PostPost
neonatalneonatal
Age at Death
Birth w
eight
PPOR Findings
Fetal NeonatalPost-
NeonatalFetal Neonatal
Post-Neonatal
Fetal NeonatalPost-
Neonatal
3.4 5.5 0.8 2.2 1.5 0.4(N=17) (N=27) (N=4)
-(N=45) (N=30) (N=7) =
2.8 1.8 2.6 1.2 0.8 0.6(N=14) (N=9) (N=13) (N=25) (N=17) (N=12)
Total Births = 4,934 Total Births = 20,139
Total Fetal-Infant Mortality Rate = 17.0 Total Fetal-Infant Mortality Rate = 6.8 Total Excess Rate = 10.3
1.
2.
3.Data Source: Birth Cohort data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
Fetal-Infant Mortality Rate is defined as death per 1,000 live births plus fetal deaths (Total Births).
<1500 g
1500+ g
1.2
SPA 12 Comparison Group3 Excess Rate
The Comparison Group is defined as non-Hispanic w hite mother aged 20 and above w ith more than 12 years of education and resided in Los Angeles County.
Data Source: Birth, Fetal Death, and Death data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
4.0 0.5
1.6 1.0 2.0
Perinatal Periods of Risk
<1500 g<1500 g
1500+ g1500+ g
neonatalFetalFetal NeonatalNeonatal PostPost
neonatal
Age at Death
Birth w
eight
FIMR/PPOR Findings
Presented at community meeting in 2005
27 Neonatal Deaths (<1500 g, 0-28 days)
37% of infants had either a documented infection or congenital birth defect
100% of mothers had at least one risk factor for poor birth outcomes
FIMR/PPOR Findings (continued)
13 Infant Deaths (> 1500 g, 29-365 days)
Over half the infants had issues related to safety and 46% had a congenital birth defect
85% of mothers had at least one risk factor for poor birth outcomes
PPOR Focus AreaPotential
Community/PH Interventions
Maternal Health/Prematurity
Preconceptual HealthHealth BehaviorsPerinatal Care
Maternal CarePrenatal CareReferral SystemHigh Risk OB Care
Newborn CarePerinatal ManagementPerinatal SystemPediatric Surgery
Infant HealthSleep PositionBreast-FeedingInjury Prevention
Data Source: Birth Cohort Data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Women’s healthPreconceptional/ Interconceptional care
Prenatal careReferral systemHigh risk OB care
Perinatal managementNeonatal care Newborn follow-up
Sleep positionBreast-feedingInjury prevention
Family Planning,Preconception
Health Collaborative
BIH, NFP, PCG, CPSP
BIH, CHI, CPSP, NFP, PCG
BIH, CPSP, CLPPP, SIDS, NFP, PCG
LA County MCAH Programs
Los Angeles Mommy and Baby Survey (LAMB)
Population-based survey of recently delivered women residing in AV
Self-administered survey on experiences before, during, and after pregnancy
– Prenatal care
– Health behaviors
– Other risk factors
LAMB Findings:Moms with poor birth outcomes tend to have:
No insurance before pregnancy
Previous low birth weight/preterm infant
High blood pressure (before/during pregnancy)
Inadequate prenatal care
Early labor pain, water broke early
Reported feeling less happy during pregnancy
Smoked during pregnancy
Described their neighborhood as unsafe
Psychosocial ExperiencesAntelope
Valley
Did not have enough money for food 13%Described pregnancy as a hard time 22%Diagnosed with a mental health problem 4%Moved to a new address 32%Had a lot of bills that couldn't be paid 24%Self-reported ever experiencing discrimination 34%Discriminated due to race 21%Discriminated when getting housing 12%
Recommendations
1. Increase capacity to serve high risk families
2. Decrease barriers to care
3. Collaborate with and educate local health care providers
4. Conduct outreach to African American women, their families and community
5. Continue LAMB countywide
From Data to Action
Findings presented at Antelope Valley Best
Babies Collaborative meeting (AVBBC)
Over 50 community partners reviewed and
identified intervention strategies
Short-term and Long-term interventions
identified
Translating Data to Action
Maternal Health/
Prematurity
1. Preconception care
2. Interconception care
3. Prenatal care
4. High risk Ob care
Infant Health
1. Safety issues
(sleep position, injury
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
?
?
Areas for Strategic Intervention
Maternal Health/
Prematurity
1. Preconception care
2. Interconception care
3. Prenatal care
4. High risk Ob care
Infant Health
1. Safety issues
(sleep position, injury
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
12 Short-term Interventions 1.Increase access to high-risk Ob care and
related ancillary services, such as labs; access is particularly difficult for Medi-Cal recipients.
2.Arrange faith-based youth services to provide health services.
3.Promote “100 Acts Kindness” for pregnant women.
4.Increase access to transportation for pregnant moms and advocate politically for trans. improvement.
5.Arrange male support groups to address the ”Role of Men”.
6.Present this data to local Ob and pediatric providers and staff to increase awareness.
7.Provide comprehensive assessment for newborns, especially for high risk ones.
8.Provide immediate information and planned follow-up for high-risk infants/moms.
9.Provide newborn infant care classes to new moms before they are discharged from the hospital.
10.Establish a 24-hour lactation team.11.Provide education for breastfeeding and
infant care during prenatal care.12.Bring providers and volunteers together to
identify best practices.
From Proposals to Policy
Service Expansion and Linkages Antelope Valley Best Babies Collaborative Faith-Based Efforts Better hospital discharge planning Better linkage to MCAH Programs
Nurse Family Partnership Black Infant Health CPSP
Who Needs to Help??
Healthy Moms & Babies
Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2005
15.1
17.619.1
11.0
19.0
28.4
32.7
16.5
14.3
9.5
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Infa
nt
Death
s p
er
1,0
00 L
ive B
irth
s
African American Asian/Pacific Islander Hispanic White Total
Preconception Health Efforts
Perinatal SummitHealthy Births Through Healthy Communities: Connecting Leadership to Achieve a Unified Commitment to Action
Maternal Maternal Health/ Health/
PrematurityPrematurity
Countywide LAMB
Los Angeles CountyPreconception Health Collaborative
California Family Health CouncilLA Best Babies Network
LA County Department of Public HealthMarch of Dimes
PHFE – WIC ProgramPerinatal Advisory Council –
Leadership, Advocacy, and ConsultationVA Greater Los Angeles Healthcare System
34
Long-Range Project Goals
Policy/advocacy Increase and improve postpartum care Decrease:
– Unintended pregnancies– Pre-pregnancy obesity– Infant mortality– Low birth weight
Integration withPublic Health Practice
Workforce Education
Data Briefs
Evaluation
Community Engagement
Integration with family planning clinics
Reproductive Life Plan Toolkit
Policy Briefs: Pregnancy and Family
Friendly Workplace Policies Breastfeeding-Friendly
Workplace Policy Briefs
Community Engagement Palm cards, posters, and DVDs
I Want my 9 Months
Don’t U Dare
Are You Ready for a Makeover?
Nine Questions to ask Before Becoming Pregnant
Folic Acid is Good for Me / Folic Acid is Good for Us
Community grants and awards
Advocacy network
38
WIC Offers Wellness “WOW” Program
Preconception Health Council of California
Networking and resourcesPublic Health and Clinical PracticeIncrease access to preconception carePolicy developmentEliminate disparities
http://everywomancalifornia.org/index.cfm
Life Course Theory
Conceptual framework
Multidisciplinary model for studying lives, social contexts and social change
Population focused
Life Course Concepts
1. Timeline
2. Timing
3. Environment
4. Equity
How Risk Reduction and Health Promotion Strategies How Risk Reduction and Health Promotion Strategies influence Health Developmentinfluence Health Development
From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.
Trajectory Without RR and HP Strategies
0 20
Hea
lth
Dev
elo
pm
ent
40 60 80Age (Years)
HP
RR Risk Reduction Strategies
Health Promotion Strategies
Optimal Trajectory
Protective Factors
HP HPHP
RR
RR
RR
Risk Factors
The Life Course Perspective(Lu, 2003)
Protective factors
Risk factors
A 12-Point Plan to Address MCH Across the Life Course
Improving Health Care Services 1. Provide interconception care 2. Increase access to preconception
care 3. Improve the quality of prenatal
care4. Expand health care access over
the life course Strengthening Families and
Communities 5. Strengthen father involvement in
families
6. Enhance service coordination and systems integration
7. Create reproductive social capital in communities
8. Invest in community mental health, social support, and urban renewal
Addressing social and economic inequities
9. Close the education gap10. Reduce poverty11. Support working mothers and
families12. Undo racism
Life Course Tool Box
http://www.citymatch.org/lifecoursetoolbox/
Adapted from Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes:a life-course perspective. Maternal and Child Health Journal 2003; 7:13-30.
LAC MCAH Programs ChangeLife Course Health Trajectories
NFP
TeenPregnancy
Racism
Partnership toEliminate
Disparities inInfant Mortality
Perinatal MentalHealth
Task Force
PostpartumDepression
A Life Course Perspective at Los Angeles County MCAH Programs
Nurse Family Partnership CPSP Program SIDS Program Black Infant Health Children’s Health Outreach Initiative CLPPP LAMB and LA HOPE
The Partnership to Eliminate Disparities in Infant Mortality (PEDIM)
PEDIM a joint project of CityMatCH, the Association of Maternal and Child Health Programs and the National Healthy Start Association
Action Learning Collaborative (ALC) an 18 month program of PEDIM
W.K. Kellogg Foundation Funded
Los Angeles County PEDIM ALC
VisionEliminate racial inequities contributing to infant mortality in LAC urban areas, based on a life course perspective.
MissionIncrease capacity at the community, State, and local levels to address the impact of racism on birth outcomes and infant health in urban areas of LAC.
Los Angeles County PEDIM ALC
CA Department of Public Health; MCAH Program
LAC Department of Public Health; MCAH Programs
Shields for Families
March Of Dimes
South Los Angeles Health Projects
University of Southern California
Healthy African American Families
Antelope Valley Black Infant Health Program
Los Angeles Best Babies Network
Infant Death Rate by Service Planning Area,LA County, 2003-2007
Source: California Department of Public Health, Center for Health Statistics,OHIR Vital Statistics Section, 2003-2007
Geographic Areas of Focus
Service Planning Areas with the highest rates of infant mortality among African Americans
Rising infant mortality rates among African Americans
4.2% of live births, 2007
14.8% of live births, 2007
Discrimination Experienced byMothers in LA County, by Race/Ethnicity
SOURCE: Los Angeles County Department of Public Health,2005 Los Angeles Mommy and Baby Survey
Los Angeles CountyPEDIM ALC Strategies
Develop quarterly briefs on racism and its relationships to birth outcomes in Los Angeles County
Identify and distribute existing educational materials related to infant mortality and racism.
Convene trainings and discussion groups for SPA 1 and 6 providers and community members
Design a project website
Accomplishments
Health brief on health disparities among African American infants in LAC
Background on infant mortality and statistics by mother’s race/ ethnicity in the eight Service Planning Areas of LAC
Accomplishments Website
launched in August 2010
Available to general public
Journal articles, presentations, and information related to infant mortality and undoing racism
http://www.lapublichealth.org/mch/LACALC/LACALC_index.htm
AccomplishmentsMonthly peer parent
grief/support group for bereaved parents and families who suffered a fetal or infant death in LAC
English and Spanish speaking parents support each other through grief process
Interconception health education
Public Health Nurse coordinates
AccomplishmentsHealth Care Disparities: Closing the Gap Workshop MCAH Programs and Commission to End Health Care
Disparities convened
Training by Evelyn L. Lewis & Clark, MD, MA, NMA/Cobb Research Institute
Keynote Speakers: Supervisor Mark Ridley Thomas; Jonathan Fielding, MD, MPH; and Tonya Lewis Lee
Los Angeles County Board of Supervisors proclamation, April 6, 2010 is “ Disparities in Infant Mortality Awareness Day”
ALC Co-leads Shin Margaret Chao, PhD, MPH and Angel Hopson, MSN, MPH, RN with Supervisor Mark Ridley Thomas
Staff and Community Education “Undoing Racism” Training “Healthy Babies, Healthy Futures:
Preventing Prematurity” curricula
Accomplishments
Recommendations
Small core membership
Expect differences
Remember that change is difficult
Small changes add up
Invest in communication
Future Efforts
Universal assessment and linkage to resources Partnering with Neighborhood Revitalization
Projects Partnership with Cities Health in all policies
Los Angeles CountyDepartment of Public HealthMaternal, Child, and Adolescent Health Programs
Cynthia A. Harding, M.P.H. [email protected]