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. Directorcharding@ph.lacounty.gov