The Maternal and Child Health Life Course Model: Introduction and Opportunities for Public Health Nutrition Milton Kotelchuck, PhD, MPH Harvard Medical.

The Maternal and Child Health Life Course Model:

Introduction and Opportunities for Public Health Nutrition

Milton Kotelchuck, PhD, MPHHarvard Medical School

Massachusetts General Hospital Center for Child and Adolescent Health Policy

October 12, 2010

Goal of Presentation

• Provide an understanding for the current new emphasis on life course and social determinant models

• Introduce the MCH Life Course paradigm and briefly note its scientific underpinnings

• Review its theoretical principles• Present an MCH Life Course strategic framework for the

Title V MCH Bureau• Provide examples of MCH Life Course related public

health research, program and policy, partnership initiatives • And explore barriers and opportunities for MCH life course

use by public health nutritionists

Ideas and Slides Freely Adapted From my Colleagues

Amy Fine Michael LuCheri Pies

Deborah Allen Neal Halfon

Richmond & Kotelchuck, 1983

75th Anniversary of Title V of the Social Security Act

• MCHB will initiate a new strategic planning effort – using MCH Life Course and Social Determinants as its guiding framework

• October 20, 2010

Life Course is not new to MCHLife Course is not new to MCH

“MCH does not raise children, it raises adults.  All of tomorrow's productive, mature citizens are located someplace along the MCH continuum.  They are at some point in their creation either being conceived or born or nurtured for the years to come.  There is very little genuine perception that mature people come from small beginnings, that they've had a perilous passage every moment of the way.  All the population, everybody of every age were all at one time children.  And they bring to their maturity and old age the strength and scars of an entire lifetime.”

Pauline Stitt, MCHB 1960

Why a new strategic approach?

• MCH health status is not improving -- existing MCH programmatic approaches are not sufficiently effective

• The current balance of clinical & public health practices relative to social environmental practices and policies seems out of kilter

• There is substantial new life course research to guide new initiatives

• Reasserts the Children’s Bureau/Title V MCH leadership mandates

• New political and programmatic opportunities• Prior 5 year strategic plan expired and on life supports

MCH Populations Health Status Not Improving

• Perinatal health is not improving – IM stagnant; LBW rising; PTB raising; C-sections increasing

• Child Health Status is not improving– Obesity rates sky rocketing

• Maternal Health Status is unknown – Too much post-partum weight gain, rising rates of diabetes– High rates of parental depression

• Family Health is straining– Less family stability

• MCH racial/ethnic disparities remain and may be rising• US International health status rankings declining

• We have to do something different

Low birth weightUS, 1996-2006

Low birth weight is less than 2500 grams (5 1/2 pounds). Source: National Center for Health Statistics, final natality data. Retrieved February 22, 2010, from www.marchofdimes.com/peristats.

Adequate/adeq+ prenatal careUS, 1992-2002

Footnotes available in notes section.Source: National Center for Health Statistics, final natality data. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994; 84: 1414-1420. Retrieved February 21, 2010, from www.marchofdimes.com/peristats.

Failure of Enhanced Prenatal Care to Reduce Racial Disparities or

Improve Birth Outcomes• “You can’t cure a life time of ills in nine

months of a pregnancy”• Failure of late 20th Century movement to

reduce Infant Mortality through increased access to comprehensive prenatal care (WIC)

• Renewed search for understanding of disparities

• New scientific knowledge• Paradigm shift in MCH – to MCH Life Course

Current programmatic approaches• Pay insufficient attention to social and

environmental/root causes of illnesses• Focus on increasing access to medical

care, quality of health care services (while reducing costs), changing individuals’ behavior, building service systems for treatment of specific chronic conditions

• Utilize life stage not life course approaches, with limited child to adult to aging adult continuities

Need for Change

• The old MCH/PH practices are not working sufficiently

• New 21st Century Science emerging

• New or renewed scientific/causal theory emerging

MCH Life Course Scientific Basis

• The challenge is to understand how the social environment gets built into or embodied into our physical bodies – which manifests itself in our health and disease status.

• To bridge the world of our intuitive social understanding of the causes of ill health (poverty, malnutrition) with our understanding of its clinical manifestations and treatment

• To better link downstream with upstream health (or to move downstream further downstream (root causes))

MOD slide 1

Life Course Perspective

Poor Birth Outcome

Good Birth Outcome

White

AfricanAmerican

Puberty Pregnancy0 5Age

LCHD and Birth Outcomes

Pregnancy

White

AfricanAmerican

Reproductive Potential

Age

LCHD and Birth Outcomes

Pregnancy

White

AfricanAmerican

Reproductive Potential

Age

Life Course Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

The MCH Life Course Perspective: Moving from Research and Theory to Practice

• There is a convergence of similar life course frameworks in related health fields– Reproductive life course models– Child development models– Chronic Illness models

• The knowledge base for the MCH Life Course Perspective is strong and getting stronger

Underlying Scientific Basis for Life Course Models

• Reproductive Health– Cumulative Stress Impact / Weathering– Early Programming (Epigenetics / Set Points)– Intergenerational Reproductive Health Effects

• Child Health and Development– Brain Development / Developmental Sciences– Early Childhood Interventions– Chronic Illness / Obesity Onset – Teratogens

• Chronic Disease Models– Fetal Origins of Adult Diseases

New Science Underlying MCH Life Course: Reproductive Health

• Cumulative Impact– Cumulative multiple stresses over time can

have a profound direct impact on health and development, and an indirect impact through associated behavioral or health service seeking change (Weathering)

• Early Programming– Early experiences can “program” an

individual’s future health and development, either directly in a disease or condition or in a vulnerability to a disease in the future

Epigenetics

Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

Prenatal Programming of Childhood Obesity

Neurons to NeighborhoodsEarly Environments Matter and

Nurturing Relationships are Essential

• Parents and other regular caregivers in children’s lives are “active ingredients” of environmental influence during early childhood

• Children’s early development depends on health and well being of parents

• Early experiences affect the brain (the focus on the 0-3 period begins too late and ends too soon)

• A wide range of environmental hazards threaten the developing central nervous system

• The capacity exists to increase the odds of favorable development outcomes through planned interventions

Drawing by Tom Prentiss

In: Cowan MW 1979. The development of the brain. Scientific American 113; 113-133

Als, H. 1986

Human Brain Development - Synapse Formation

Con

cept

ion

Months YearsAGE

-6 -3 0 3 6 9 1 4 8 12 16

Sensing Pathways

(vision, hearing)

Language

Higher Cognitive Function

C. Nelson, in From Neurons to Neighborhoods, 2000.

2004 National Research Council and Institute of Medicine Report

IOM/NRC Definition of Children’s Health (2004)

“Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.”

From Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

WHO Definition of Community Health

• A healthy city or community is…”one that is continually creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all the functions of life and in developing their maximum potential”

Hancock and Duhl, WHO Healthy Cities Papers No.1, 1988

Life Course Chronic Disease Epidemiology

Adolescent Origins of Adult Diseases

Childhood Origins of Adult Diseases

Fetal Origins of Adult Diseases

• High blood pressure• Diabetes Mellitus• Coronary Heart Disease• Cancer• Obesity

The Barker Hypothesis: Historical Cohort Analysis

Barker HypothesisBirth Weight and Insulin Resistance Syndrome

0

2

4

6

8

10

12

14

16

18

<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5

Birthweight (lbs)

Odds ratio adjusted for BMI

Barker 1993

Barker HypothesisBirth Weight and Hypertension

155

160

165

170

Syst

olic

Pre

ssur

e (m

mH

g)

<=5.5 5.6-6.5 6.6-7.5 7.6-8.5 >8.5

Birthweight (lbs) Law 1993

Barker HypothesisBirth Weight and Coronary Heart Disease

0

0.25

0.5

0.75

1

1.25

1.5

<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0

Birthweight (lbs)

Age Adjusted Relative Risk

Rich-Edwards 1997

Center for Healthier Children,Center for Healthier Children,Families & CommunitiesFamilies & Communities

Adverse childhood events and Adverse childhood events and adult ischemic heart disease adult ischemic heart disease

0

0.5

1

1.5

2

2.5

3

3.5

0

1

2

3

4

5,6

7,8

Dong et al, 2004Adverse Events

Od

ds

Ra

tio

Center for Healthier Children,Center for Healthier Children,Families & CommunitiesFamilies & Communities

Adverse childhood events and Adverse childhood events and adult depressionadult depression

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0

1

2

3

4

5+

Adverse EventsChapman et al, 2004

MCH Life Course Model

Posits a new scientific paradigm for the MCH field

Addresses enduring health issues with new perspectives (e.g.,disparities)

Requires new longitudinal and holistic approaches to MCH programs, policy and research

Provides an integrated framework for facilitating the MCH policy agenda

Links the MCH community to adult and elderly health and social service policy development

Social Determinants

• The social determinants of health are those factors which are outside of the individual; they are beyond genetic endowment and beyond individual behaviors. They are the context in which individual behaviors arise and in which individual behaviors convey risk. The social determinants of health include individual resources, neighborhood (place-based) or community (group-based) resources, hazards and toxic exposures, and opportunity structures.

Camara Jones, 2010

Health Equity

Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity.

Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice.

World Health Organization Commission on Social Determinants of Health

Human Rights

….these commitments (human rights) provide a useful framework for shaping national laws and policies, provide a useful tool for ensuring accountability and point to approaches useful for promoting public health.

Gruskin and Dickens, 2006, American Journal of Public Health; 96:1903-1905

Life Course Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

MCH Life Course

• Could it be true?

• Could we really transform disparities into equity?

• The WHO Nutrition Standards

WHO Multicentre Growth Reference StudyBackground / Context

• Current growth curves developed from 1930’s Fels longitudinal studies (White middle class sample)

• Should there be separate norms for each cultural / racial group?

• Fierce debate among MCH Epidemiologists, especially given major LBW racial disparities in U.S.

• Issue arose in Guatemalan INCAP study of the effects of malnutrition on mental development (since Guatemalans were shorter, why use U.S. norms?)

WHO Multicentre Growth Reference Study Purpose of Study

• Goal: to assess optimal child growth (and motor development) and create

standards usable throughout the world

• Distinction between standards and norms– Ideal vs.. actual growth curves

WHO Multicentre Growth Reference Study

Methods I• Sample selected for optimal growth

– All upper middle class families– All infants exclusively breastfed for four + months– All full-term births, with no birth defects

• Longitudinal (0 – 24 months) and cross-sectional samples (18 – 71 months)

– N=1743 longitudinal, N=6697 cross-sectional (N=8440)

• Six sites chosen around the world – U.S. (Palo Alto), Ghana (Accra), Oman (Muscat), India

(South New Delhi), Brazil (Pelatos), Norway (Oslo), [China dropped out]

WHO Multicentre Growth Reference Study

Methods II• Standardized measurement protocols, very well

trained and supervised staff• Physical measurement recorded

– Length / height, weight, weight for height, BMI– Monthly thru12 months, bi-monthly thru 24 months, then 4 times

thru age 5

• Motor development milestones– Sitting with support; hands and knees crawling; standing with

assistance; standing alone; walking with assistance; walking alone

– Measured at same age as above thru 24 months, plus utilized mother’s reports

• All measurements were home-based

WHO Multicentre Growth Reference Study Detailed Results

• Physical Growth (standards)– Essential similar everywhere (data combined)– Only 3.4% inter-site variations; 70% intra-site variability;

26% error• Motor Development

– No sex differences– 5/6 of motor developments sequential– No relationship between infant size and motor

development• Birth Characteristics

– Modest variations 3,300 mean birth weight (3.1-3.6 Kg range)

– 3.2% LBW (vs.. national estimates (up to 30% in India)), shows powerful impact on SES on birth outcomes

WHO Multicentre Growth Reference Study Major Conclusions

1. Inter-cultural variability only 4% of variance

2. All growth retardation reflects environmental insults

3. Overall (genetic / cultural) longitudinal continuity for human growth and motor development under optimal conditions

4. Breastfeeding established as norm for growth standards

5. Supports social justice orientation

• Theory

• Research

• Practice

• Policy

• Education and Training

MCH Life Course Paradigm ShiftMCH Life Course Conference

June 2008, Oakland CA

MCH Life Course Model Topics to be Addressed

Kotelchuck, Lu, Pies, 2008

MCH Life Course Theory

• There is no formal or official MCH Life Course theory

• Indeed, it is unclear if the correct word is even theory or perspective or model or paradigm

• But without theory there is no guide practice and policy

• Life Course theory must be surmised from existing literature

HRSA/MCHB Concept Paper

Rethinking MCH: The Life Course Model as an Organizing Framework

Amy Fine

Milton Kotelchuck

October 2010

Life Course Perspective

A way of looking at life not as disconnected stages, but as an

integrated continuum

M. Lu, 2010

Life Course Development

Life course development provides a framework to understand how multiple determinants of health interact across the life span and across generations to produce health outcomes

Halfon, 2007

MCH Life Course Goals

• To optimize health across the lifespan for all people; and

• To eliminate health disparities across populations and communities

Draft, Fine and Kotelchuck 2010

Key concepts of the MCH Life- course Model

• Today’s experiences and exposures determine tomorrow’s health

• Health trajectories are particularly affected during critical or sensitive periods

• The broader environment – biologic, physical, and social – strongly affects the capacity to be healthy

• Inequality in health reflects more than genetics and personal choice.

Amy Fine, Milt Kotelchuck, 2009

Key concepts of the MCH Life- course Model

• Timeline conveys movement along a continuum and cumulative impacts over time.

• Timing reflects the importance of the earliest experiences and exposures and of critical periods throughout life.

• Environment recognizes the importance of family and community in shaping health, including the physical, social, and economic environment in which people live, grow and develop.

• Equity refers to the importance of addressing disparities in health and development across populations.

MCH Life Course core concepts

• MCH life course, social determinants, and social justice models are complementary and synergistic

• Move beyond, but include, medical/clinical care; they are not safety net programs

• Life course not as disconnected stages, but as an integrated continuum; we are one

• Not deterministic but transformational and interactive trajectories

• Equitable valuation of life at every age

MCH Life Course

• Our challenge is to transform this new MCH Life Course theory and research into new MCH practice and policies

• MCHB Strategic Planning Initiative

MCH Bureau Life Course Initiatives• Commitment of Dr. Peter Van Dyck to use MCH

life course theory as a strategic planning framework for the Bureau

• Multiple MCH Bureau-wide and Senior Leadership meetings and presentations

• State Needs Assessment Conference, and a State Title V Directors’ workgroup

• Several new MCHB Life Course initiatives • Amy Fine and Milt Kotelchuck engaged to

develop a Life Course concept paper to help kick off their new Strategic Planning initiative

Developing an MCHB strategic agenda for change

• Strengthening the life course knowledge base

• Developing new program and policy strategies

• Enhancing political will

Draft, Fine and Kotelchuck, 2010

MCH Life Course Research

• Research growing, but more is needed • Barriers to longitudinal life course research

– Limited longitudinal analytic capacity– Scattered longitudinal data bases– Disciplinary and institutional silos– Virtually no measures of life-course trajectories,

cumulative risks, cumulative experiences– Confidentiality legal infrastructure not in place– Few longitudinal data/life course training opportunities

• New MCHB initiatives

MCH ResearchMCH Life Course Research

Network

Public Health Nutrition Research Needs

and MCH Life Course• Basic obesity research

– Intergenerational transmission of obesity/GDM– Early cellular/genetic transformations– Micronutrients

• Childhood dietary history and intervention impacts – Longitudinal and programmatic research– Epidemiologic research

• Public Policy and Public Health root cause analyses

• …..

MCH Life Course Practice and Policies

• The ultimate challenge – transforming life course to concrete programs and policies

• The most difficult MCH Life Course task

• Requires more than renaming existing programs

• The science of MCH practice is the hardest science

• MCH learning community needed

MCH Life Course Model Barbara Ferrar’s Overview of its Meaning for

Practice

• Multiple time points for intervention

• Expanded settings for intervention

• Policy is important at local, state and national levels

MCH Life Course Practice

• The MCH Life Course Theory suggests a greater attention to four key continuities or discontinuities in health and health care that impact on achieving optimal health– Longitudinal continuity– Vertical ( or programmatic) continuity– Horizontal (or contextual) continuity– Holistic continuity

Public Health Nutrition Discontinuities

• Longitudinal– Public Health nutrition more thoughtful than other MCH areas (about

upstream causes; longitudinality of impacts)– Limited downstream intervention effectiveness (TV monitoring itself;

Adolescent diets) – Poor longitudinal nutrition records

• Vertical or programmatic– WIC ends, where do the children or mothers go?– Limited primary care to tertiary care handoffs

• Horizontal– Limited ties between physicians and schools– Difficulties of recruiting parents to community nutrition resources

• Holistic– You are what you eat– Too many intervention overloads

Public Health NutritionLife Course Initiatives

• Within public health/clinical programs

• Across programs– MCH Life Course organizations

• Policy level

MCH Nutrition Life Course Interventions (examples)

• Pediatric practice quality care improvement initiatives (NICHQ)

• Birmingham Sunday Greens

• Numerous multi-pronged community-based Obesity reduction campaigns

• Michelle Obama’s LetsMove.gov efforts

• Delaware Nemours Obesity Reduction Initiative (5,2,1,Almost None)

Healthy Food

Education

Residents

Parks and

Activities

Housing

Economic Justice

AlamedaCountyBuildingBlocks

Collaborative

Childcare

Preschool

Transportation

Policy Makers

Jobs

Safe Neighbor-hoods

Clean Air

Medical Care

MCH Life Course Policy

• Many needed public health nutrition life course reforms require policy level initiatives

• Creating a policy agenda

Policy Implications for the Government Sector

• Avoid the allure of categorical solutions

• Focus on upstream population needs

• Assure that needed programmatic collaboration happens

• Partner with all sectors

• Install visionary leadership

• Invest in data for policy decisions

Debbie Allen, 2008

“Policies that seek to remedy deficits incurred in early years are much more costly than early investments wisely

made, and do not restore lost capacities even when large costs are incurred. The

later in life we attempt to repair early deficits, the costlier the remediation

becomes.”

James J. Heckman, PhDNobel Laureate in Economics, 2000

Policy concepts deriving from the MCH Life-course Model

• Refocus the organization and delivery of MCH clinical and population health services

• Enhance linkages between health services and other child and family services and supports sectors (e.g., educational, social services)

• Rebuild and redirect social, economic and physical environments to support and promote the health of the population (e.g. building community capacity to support health)

Fine, Kotelchuck et al, 2009

MCH Life Course Policy Initiative

• Realigning Health Services and Systems

• Integrating Health and Other Service Systems for Women, Children and Families

• Building Community Capacity to Support Health

• Creating National and Federal Agenda to Address Social Determinants of Health

Draft, Kotelchuck and Fine 2010

MCH Life CoursePartnerships

• Generate new political will to implement the MCH life course models

MCH Partners/Political Will

• MCH Bureau (and HRSA) Staff

• The broader MCH “family”

• Other health and non-health federal agencies

• Non-traditional stakeholders

• Local community and political stakeholders

Draft, Fine and Kotelchuck, 2010

MCH Life Course Training and Education Tasks

• Integrate MCH life course models into MCH training programs

• Leadership training

• Retool the current MCH workforce

• Enhance MCHB leadership competencies/long term training to prepare future MCH leadership

New Needed MCH Life Course Skills/Capacities

• Coalition building and collaboration

• Advocacy

• Longitudinal data capacity

• Community-based participatory research

• Enhanced needs assessment capacities

• And many other skills

Possible MCH Life Course Barriers for Public Health Nutritionists

• Difficulty of balancing social determinant with clinical nutrition models of care (RD vs. PH Nutritionist)

• Lack of capacity for addressing “non-health” aspects of population nutrition

• Limited success of primary prevention / upstream involvement

• Isolation from other health, welfare, education and community development systems

• Difficulty of balancing new life course opportunities versus existing programmatic mandates

MCH Life Course Strengths for Public Health Nutritionists

• There is already strong motivation for social justice • There is a strong longitudinal and social determinant

orientation for PHN• Long programmatic history of Public Health Nutrition-MCH

life course initiatives • There are strong links between basic/epidemiologic

sciences and public health practices• PHN is a multi-disciplinary field• The new initiatives may help PHN gain new allies (and

vice versa), new political will to address upstream health issues, be less isolated and part of broader MCH/Public health agenda

• The MCH Life Course is not new to you

MCH Bureau Strategic Planning and Leadership

• MCHB has a critical leadership role in fostering the MCH life course paradigm shift

• The life course perspective, along with the social determinants, and social justice models, offers MCHB the opportunity to reinvigorate its Children’s Bureau legacy and political mandate – to address all factors that impact on children’s health and well-being

• It provides a federal and national leadership opportunity to broadly improve the health and well being of mothers, children and families

75th Anniversary of Title V of the Social Security Act

• MCHB will initiate a new strategic planning effort – using MCH Life Course and Social Determinants as its guiding framework

• October 20, 2010

MCH Life Course Resources

• CityMatCH http://www.citymatch.org/lifecoursetoolbox/

• MCHB • http://mchb.hrsa.gov/lifecourseresources.htm

• Future MCHB Web site

Richmond & Kotelchuck, 1983