Post on 02-Jan-2016
description
PPP MEMBERS Maternal and Child Health programs
Title V- Federal block grant dollars to PA Dept of Health, which makes grants to 10 county and municipal health departments
and Healthy Start programs funded directly by
DHHS to 7 programs in PA
CONCEPTS AND LANGUAGE
OCDEL focus on early childhood from an educational perspective
MCH professionals focus on early childhood from a maternal/pregnancy/pre-pregnancy perspective
POSSIBILITIES
We serve the same people Our results are not as good as we’d like Collaboration should help improve our results If we do better, our clients should do better,
and there should be opportunities to increase funding
LIFE COURSE PERSPECTIVE FRAMEWORK
The current most promoted concept for thinking about maternal and child health
Designed to address the extremely resistant problem of racial disparities in infant mortality
IN THE BEGINNING
Adverse Childhood Experiences Study
Thanks to Dr. Ron Voorhees, M.D., M.P.H., Acting Director, Allegheny County Health Department. Several slides from his presentation on ACE, presented October 26, 2011 to PPP follow.
RELATIONSHIP OF CHILDHOOD ABUSE AND HOUSEHOLD DYSFUNCTION TO MANY OF THE LEADING CAUSES OF DEATH IN ADULTS: THE ADVERSE CHILDHOOD EXPERIENCE (ACE) STUDY
Vincent J. Felitti, Robert F. Anda, Dale Nordenberg, David F. Williamson, Alison M. Spitz, Valerie
Edwards, Mary P. Koss, James S. Marks
American Journal of Preventive Medicine, 1998; 14(4) 245-258
ADVERSE CHILDHOOD EXPERIENCES
More than 17,000 Kaiser patients were asked to recall their childhood experiences
Health conditions in the present were tabulated
ACE STUDY - CATEGORIES OF ADVERSE CHILDHOOD EXPERIENCES (ACE)
Psychological abuse
Physical abuse
Sexual abuse
Substance abuse in home
Mental illness in parent
Violence against mother
Incarceration of parent
KAISER HMO ENROLLEES HAD AT LEAST ONE TYPE OF ADVERSE CHILDHOOD EXPERIENCE:
0 Categories
49.5%
4 Categories
6.2%3 Categories
6.9 %
2 Categories
12.5%
1 Category
24.9%
Data from Felitti, et. al.
GROWING UP WITH ADVERSE CHILDHOOD EXPERIENCES INCREASES THE RISK FOR MANY LATER ADVERSE HEALTH CONDITIONS – RANGING FROM SMOKING TO OBESITY TO DEPRESSION AND SUBSTANCE ABUSE.
FOUR OR MORE ACES DOUBLE THE RISK FOR BEING A SMOKER
1.1 1.5 2.22.0
Data from Felitti, et. al.
Odds Ratio (relative to
0 ACEs)
Number of ACE Categories
ACES INCREASE RISK FOR CHRONIC BRONCHITIS/EMPHYSEMA
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
1.6 1.62.2
3.9
ACES INCREASE THE RISK OF STROKE
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
0.9 0.71.3
2.4
ACES INCREASE RISK OF ISCHEMIC HEART DISEASE
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
0.90.91.4 2.2
ACES INCREASE THE RISK OF CANCER
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
1.2 1.2 1.0 1.9
ACES INCREASE REPORTING OF HAVING AN STD
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
1.4 1.5 1.9 2.5
ACES INCREASE RISK OF HAVING HAD OVER 50 SEXUAL PARTNERS
0
2
4
6
8
10
12
14
1 2 3 >=4
Number of ACE Categories
Od
ds
Rat
io (
Rel
ativ
e to
0
cate
go
ries
)
Data from Felitti, et. al.
1.7 2.3 3.1 3.2
ACES INCREASE THE RISK FOR DEPRESSION ALMOST FIVE TIMES
1.5 2.42.6
4.6
Data from Felitti, et. al.
Odds Ratio (relative to
0 ACEs)
Number of ACE Categories
FOUR ACES INCREASE THE RISK FOR USING ILLICIT DRUGS 4.7 TIMES; EVEN ONE ALMOST DOUBLES THE RISK:
Data from Felitti, et. al.
1.72.9
3.64.7
Odds Ratio (relative to
0 ACEs)
Number of ACE Categories
ACES INCREASE THE RISK FOR ALCOHOLISM
Data from Felitti, et. al.
2.0
7.4 4.9
4.0
Odds Ratio (relative to
0 ACEs)
Number of ACE Categories
ACES INCREASE THE RISK FOR SUICIDE ATTEMPT OVER 12 TIMES:
1.8
3.0
6.6
12.2
Data from Felitti, et. al.
Odds Ratio (relative to
0 ACEs)
Number of ACE Categories
SOCIOECONOMIC IMPACT OF CHILD ABUSE AND NEGLECT
David Zielinski (Duke University) estimated that almost 20% of unemployed adults report abuse or neglect as child
Adult victims of maltreatment:have less education
have more physical and mental health problems that interfere with their work
are twice as likely to be below federal poverty level
are twice as likely to be on Medicaid
DISPARITIES IN INFANT MORTALITY
Not so long ago, maternal and child health workers believed that just getting women in for at least ONE prenatal visit would make a difference in the rates of infant mortality
The science has changed; our understanding has deepened
Focus has shifted to racial disparities and why they are so persistent
WHY?
Many studies have shown that the factors that might explain the racial disparities, don’t!
Genetics Behavior Prenatal Care SES Stress Infection
MULTIPLE RISK FACTORS
Explain less than 10% of the variation in low birth weights between white and African-American babies
EARLY PROGRAMMING
Emphasis on importance of sensitive developmental periods in utero or early life during which future reproductive potential becomes programmed
KNOWLEDGE IS INCREASING
In the last 20 years, David Barker, MD, PhD, FRS, studied what happens to a low birth weight baby
Health consequences in adult life, such as heart disease and diabetes
Mother’s consistent prenatal stress affects her hormones, which in turn, affects the baby’s brain development
Epigenetics =another continuing aspect of study (trust me!!)
STILL MORE COMPLEXITY
Cumulative pathways All that happens throughout the life of the
mother, and her mother (not to mention what we’re learning about dads!)
THESE ARE NOT MUTUALLY EXCLUSIVE!
Early programming and cumulative pathways affect the life course over generations
WHAT TO DO?12 POINT PROGRAM
Improving Health care Services Provide interconception care to women with
prior adverse pregnancy outcomes Increase access to preconception care for
women Improve the quality of prenatal care Expand health care access over the life
course
STRENGTHENING FAMILIES AND COMMUNITIES
Strengthen father involvement in families Parental resilience
Enhance service coordination and systems integration
Create reproductive social capital in communities
Invest in community building and urban renewal
ADDRESSING SOCIAL AND ECONOMIC INEQUITIES
Close the education gap Knowledge of parenting and child development
Reduce poverty Support working mothers and families Undo racism
OPPORTUNITIES ABOUND!
Break down barriers Talk and work with one another Recognize commonalities Keep hope alive
REFERENCES
Barker, David, http://www.thebarkertheory.org contains complete references
Lu, Michael and Neil Halfon, “Racial and Ethnic Disparities in Birth Outcomes: A Life-Course Perspective,” Maternal and Child Health Journal, Vol. 7, No. 1, March 2003”
Lu, Michael, “Strong Roots Healthy Fruit: Transforming Generations through the Life Course Perspective,” June 29, 2010, Philadelphia Department of Public Health, Division of Maternal and Child Health, DVD presentation
Ronald E. Voorhees, MD, MPH, “Improving Health: First Things First,”
PPP, October 26, 2011, Power Point Presentation