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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.

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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
Special Thanks to Preconception Health in the Context of a Life Course Perspective

  • 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
Today’s Presentation Preconception Health in the Context of a Life Course Perspective

  • Infant Mortality in Los Angeles County

  • Preconception Health

  • Life Course Theory and Framework

  • The Life Course Framework in Los Angeles County


Los Angeles, California Preconception Health in the Context of a Life Course Perspective


Infant death rate 1990 2002
Infant Death Rate* Preconception Health in the Context of a Life Course Perspective1990-2002


Antelope valley av
Antelope Valley (AV) Preconception Health in the Context of a Life Course Perspective

  • Relatively isolated

  • 4,903 live births in 2002

    • Mother’s race/ethnicity:

      • 17% African American

      • 46% Hispanic

      • 33% White

  • Income of 1 in 8 households less than Federal Poverty Level (1 in 5 in LAC).


Increasing infant mortality in av 1999 2002
Increasing Infant Mortality in AV Preconception Health in the Context of a Life Course Perspective1999-2002

  • 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
Highest Rates in African Americans Preconception Health in the Context of a Life Course Perspective

  • African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002


Our response
Our Response: Preconception Health in the Context of a Life Course Perspective

  • Four promising practices integrated to address the problem:

    • Focus Groups

    • Fetal Infant Mortality Review (FIMR)

    • PPOR

    • LAMB

  • Community Collaboration


Preliminary findings
Preliminary Findings Preconception Health in the Context of a Life Course Perspective

  • Among the 53 infant deaths:

    • 68% died in first 28 days (42% died in 24 hrs)

    • 75% pre-term births

    • 75% low birth weight

    • 21% Teens (< 20 years)

    • 43% were African Americans


Focus group findings
Focus Group Findings Preconception Health in the Context of a Life Course Perspective

  • 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 mortality review fimr

National FIMR forms to review 2002 AV infant deaths (N=53) Preconception Health in the Context of a Life Course Perspective

PHNs conducted home interviews, abstracted hospital and provider records.

Fetal Infant MortalityReview (FIMR)


What did we learn from fimr
What did we learn from FIMR ? Preconception Health in the Context of a Life Course Perspective

  • 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 Preconception Health in the Context of a Life Course Perspective

Age at Death

Post

Post

Fetal

Neonatal

Fetal

Neonatal

neonatal

neonatal

Birth weight

<1500 g

<1500 g

1500+ g

1500+ g


Ppor findings
PPOR Findings Preconception Health in the Context of a Life Course Perspective


Post Preconception Health in the Context of a Life Course Perspective

Post

Fetal

Neonatal

Fetal

Neonatal

neonatal

neonatal

<1500 g

<1500 g

1500+ g

1500+ g

Perinatal Periods of Risk

Age at Death

Birth weight


Fimr ppor findings

Presented at community meeting in 2005 Preconception Health in the Context of a Life Course Perspective

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


Fimr ppor findings continued
FIMR/PPOR Findings (continued) Preconception Health in the Context of a Life Course Perspective

  • 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


Data Source: Birth Cohort Data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.


LA County MCAH Programs Health Services, Center for Health Statistics, Vital Statistics, 2002.


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

Los Angeles Mommy and Baby Survey (LAMB)


Lamb findings

Moms with poor birth outcomes tend to have: in AV

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

LAMB Findings:



Recommendations
Recommendations in AV

  • Increase capacity to serve high risk families

  • Decrease barriers to care

  • Collaborate with and educate local health care providers

  • Conduct outreach to African American women, their families and community

  • 5. Continue LAMB countywide



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


Areas for Strategic Intervention Collaborative meeting (AVBBC)

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
12 Short-term Interventions Collaborative meeting (AVBBC)

  • Increase access to high-risk Ob care and related ancillary services, such as labs; access is particularly difficult for Medi-Cal recipients.

  • Arrange faith-based youth services to provide health services.

  • Promote “100 Acts Kindness” for pregnant women.

  • Increase access to transportation for pregnant moms and advocate politically for trans. improvement.

  • Arrange male support groups to address the ”Role of Men”.

  • Present this data to local Ob and pediatric providers and staff to increase awareness.

Maternal Health/

Prematurity

1. Preconception care

2. Interconception care

3. Prenatal care

4. High risk Ob care

1. Safety issues

(sleep position, injury

prevention, etc)

2. Breast-feeding

3. Family and parenting issues

  • Provide comprehensive assessment for newborns, especially for high risk ones.

  • Provide immediate information and planned follow-up for high-risk infants/moms.

  • Provide newborn infant care classes to new moms before they are discharged from the hospital.

  • Establish a 24-hour lactation team.

  • Provide education for breastfeeding and infant care during prenatal care.

  • Bring providers and volunteers together to identify best practices.

Infant Health


From proposals to policy

Service Expansion and Linkages Collaborative meeting (AVBBC)

Antelope Valley Best Babies Collaborative

Faith-Based Efforts

Better hospital discharge planning

Better linkage to MCAH Programs

Nurse Family Partnership

Black Infant Health

CPSP

From Proposals to Policy


Who needs to help
Who Needs to Help?? Collaborative meeting (AVBBC)

Healthy Moms & Babies


Infant death rate by race ethnicity antelope valley 1996 2005
Infant Death Rate by Race/Ethnicity Collaborative meeting (AVBBC)Antelope Valley, 1996-2005


Preconception health efforts

Perinatal Summit Collaborative meeting (AVBBC)

Healthy Births Through Healthy Communities: Connecting Leadership to Achieve a Unified Commitment to Action

Preconception Health Efforts

Countywide LAMB

Maternal Health/

Prematurity


Los Angeles County Collaborative meeting (AVBBC)Preconception Health Collaborative

California Family Health Council

LA Best Babies Network

LA County Department of Public Health

March of Dimes

PHFE – WIC Program

Perinatal Advisory Council – Leadership, Advocacy, and Consultation

VA Greater Los Angeles Healthcare System


Long range project goals

Policy/advocacy Collaborative meeting (AVBBC)

Increase and improve postpartum care

Decrease:

Unintended pregnancies

Pre-pregnancy obesity

Infant mortality

Low birth weight

Long-Range Project Goals


Integration with public health practice
Integration with Collaborative meeting (AVBBC)Public Health Practice

  • Workforce Education

  • Data Briefs

  • Evaluation


Community Engagement Collaborative meeting (AVBBC)

  • 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 Collaborative meeting (AVBBC)

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

Community Engagement


Wic offers wellness wow program
WIC Offers Wellness “WOW” Program Collaborative meeting (AVBBC)

WIC Offers Wellness

PHFE-WIC 888-942-2229

WOW


Preconception Health Council of California Collaborative meeting (AVBBC)

  • Networking and resources

  • Public Health and Clinical Practice

  • Increase access to preconception care

  • Policy development

  • Eliminate disparities

http://everywomancalifornia.org/index.cfm


Life course theory

Conceptual framework Collaborative meeting (AVBBC)

Multidisciplinary model for studying lives, social contexts and social change

Population focused

Life Course Theory


Life course concepts

Timeline Collaborative meeting (AVBBC)

Timing

Environment

Equity

Life Course Concepts


RR Collaborative meeting (AVBBC)

Risk Reduction Strategies

Risk Factors

HP

Health Promotion Strategies

Trajectory Without RR and HP Strategies

Optimal Trajectory

RR

RR

HealthDevelopment

RR

HP

HP

HP

Protective Factors

0

20

40

60

80

Age (Years)

How Risk Reduction and Health Promotion Strategies

influence 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.


L I F E C O U R S E Collaborative meeting (AVBBC)

L I F E C O U R S E

L I F E C O U R S E


The life course perspective lu 2003

Protective factors Collaborative meeting (AVBBC)

Risk factors

The Life Course Perspective(Lu, 2003)


A 12 point plan to address mch across the life course

Improving Health Care Services Collaborative meeting (AVBBC)

1. Provide interconception care

2. Increase access to preconception care

3. Improve the quality of prenatal care

4. 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 gap

10. Reduce poverty

11. Support working mothers and families

12. Undo racism

A 12-Point Plan to Address MCH Across the Life Course


Life Course Tool Box Collaborative meeting (AVBBC)

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


LAC MCAH Programs Change Collaborative meeting (AVBBC)

Life Course Health Trajectories

Postpartum

Depression

Perinatal Mental

Health

Task Force

Teen

Pregnancy

Racism

Partnership to

Eliminate

Disparities in

Infant Mortality

NFP

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.


A life course perspective at los angeles county mcah programs
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
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
Los Angeles County PEDIM ALC (PEDIM)

Vision

Eliminate racial inequities contributing to infant mortality in LAC urban areas, based on a life course perspective.

Mission

Increase 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 alc1
Los Angeles County PEDIM ALC (PEDIM)

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
Infant Death Rate by Service Planning Area, (PEDIM)LA County, 2003-2007

Source: California Department of Public Health, Center for Health Statistics,

OHIR Vital Statistics Section, 2003-2007


Geographic areas of focus
Geographic Areas of Focus (PEDIM)

  • 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 by mothers in la county by race ethnicity
Discrimination Experienced by (PEDIM)Mothers in LA County, by Race/Ethnicity

SOURCE: Los Angeles County Department of Public Health,

2005 Los Angeles Mommy and Baby Survey


Los angeles county pedim alc strategies
Los Angeles County (PEDIM)PEDIM 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
Accomplishments (PEDIM)

  • 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


Accomplishments1
Accomplishments (PEDIM)

  • 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


Accomplishments2
Accomplishments (PEDIM)

  • Monthly 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


Accomplishments3
Accomplishments (PEDIM)

Health 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


Accomplishments4
Accomplishments (PEDIM)

Staff and Community Education

  • “Undoing Racism” Training

  • “Healthy Babies, Healthy Futures: Preventing Prematurity” curricula


Recommendations1
Recommendations (PEDIM)

  • Small core membership

  • Expect differences

  • Remember that change is difficult

  • Small changes add up

  • Invest in communication


Future efforts
Future Efforts (PEDIM)

  • Universal assessment and linkage to resources

  • Partnering with Neighborhood Revitalization Projects

  • Partnership with Cities

  • Health in all policies


Los Angeles County (PEDIM)

Department of Public Health

Maternal, Child, and Adolescent Health Programs

Cynthia A. Harding, M.P.H. Director

[email protected]


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