Institute for Equity in Birth Outcomes Maternal Stress

1. Institute for Equity in Birth Outcomes Maternal Stress Deborah Allen, ScD Boston Public Health Commission

2. Outline • A bit of context • Why the focus on stress • Modeling the impact of stress • Diderichsen model • A simplified model (GEfGW) • Putting the model to work • Programmatic options, downstream and up • Implementation tools • And beyond

3. Context • Long-term dilemma in MCH • Why have past interventions not resolved disparities in birth outcomes • We have focused on • Access to prenatal care • Financing • Geography and transportation • Awareness • Support • Health behaviors • Drugs • Smoking • Diet • Without success at closing the race/ethnicity gaps

4. Boston Birthweight Distributionby Race/Ethnicity (2009) Data Source: Boston resident live births, Massachusetts Department of Public Health Data Analysis: Boston Public Health Commission Research and Evaluation Office

5. Timing of Boston Preterm Births by Race/Ethnicity (2009)

6. Infant mortality

7. The new focus on “life course” • In US and internationally • In relation to specific chronic conditions • In relation to racial/social disparities in health generally • As an explanation for persistent disparities in health outcomes • As a guide to intervention

8. Key elements of a life course approach • A focus on early exposure to risk • Or more broadly, risk at periods of high vulnerability • And on cumulative risk over the life span • Renewed interest in social determinants of health • This is not a new idea but it is rediscovered and reframed periodically • A new emphasis on stress as the link between social experience and health

9. 1) Early exposure to risk • Evidence of the consequences of adverse birth outcomes • Proximal consequences • Distal consequences: the Barker Hypothesis • Some exposures are uniquely dangerous at specific critical periods • Folic acid deficit in first trimester • Alcohol dependency in adolescence

10. Chronic disease in child and adult life may be predicted by early exposures • Concept of “critical periods” has been applied to impact of insults in utero • Cardiovascular disease • Non-insulin dependent diabetes • Hypertension • With acknowledgement of later modifying factors and/or later compounding factors • The case of asthma • Link to maternal prenatal stress • Link to postpartum mother and child stress

11. 2) Cumulative risk • Risk accumulates within lifetime of individual • Long term risk • Synergy across multiple risks • Evidence suggests risk accumulates across generations • “Grandmaternal” birth weight as predictor of infant birth weight • Adds a dynamic dimension to model

12. The case of “weathering” --Boston low birth weight rates

13. 3) Social determinants The causes most often listed for disparities in adverse outcomes across group of children • Components of the ACES • Substance abuse • Family break-up • Parental depression • Child abuse and neglect • Criminal involvement of family member

14. But we need to look at the “causes of causes” • Income • Employment • Education • Interaction with criminal justice system • Food: adequate, safe, healthy • Clean air and water • Housing and neighborhood safety • Social support • Access to health care • Transportation

15. And, linking and interacting with all of the above • Discrimination • Both as a cause of the elements listed above • And as a psychosocial experience, with its own direct consequences for health

16. The reality of continued discrimination • Doleac and Stein, 2010: discrimination in housing sales • Bertrand and Mullainathan, 2002: discrimination in employment • Even when applicant documented widely promoted “self improvement” efforts • Baker et all, 2006: unequal distribution of fast food outlets and supermarkets and of healthy foods within those outlets in St. Louis • Poe-Yamagata and Jones, 2000: discrimination against youth of color at all stages in criminal justice process

17. And finally: 4) Stress • According to the WHO, stress may reflect or be expressed in terms of • Anxiety • Insecurity • Low self-esteem • Social isolation • Lack of control over work and home life • The WHO perspective: It’s not just about money, it is also about the mind-body connection

18. Is there something about being at the low end of the ladder • Not necessarily defined by where the bottom and top of the ladder are • But affected by distance from bottom to top

19. NOTE: Survey question reads, “In your entire lifetime, have any close family members or close friends of yours been killed by violence, like being shot, stabbed, or beaten to death (do not include those include in war)?” DATA SOURCE: Boston Youth Survey, 2008; Harvard Youth Violence Prevention Center through a Cooperative agreement with the Center for Disease Control and Prevention DATA ANALYSIS: Harvard Youth Violence Prevention Center

20. Linking stress to life span health: allostatic load

21. Evidence indicates direct impact of stress – even when no link to direct material deprivation • US and international studies link ambient violence to preterm birth, low birth weight and infant death • Lauderdale, looking at Arabic-named women in CA six months after 9/11, found 2-fold increase in LBW compared with prior year • Increasing evidence that asthma rates (incidence and exacerbation) link to community violence

22. Life course as a guide to intervention • Our strategies must • Reduce early adverse exposures • Disrupt accumulation of risk over time • Address social determinants • Eliminate or reduce impact of stressors

23. A fully realized model (Diderichsen) Figure Source: The Lancet 2002; 359:259 (DOI:10.1016/S0140-6736(02)07418-4) Terms and Conditions

24. A simpler model

25. Change the social determinants • Healthy Start in Housing • Medical-Legal Partnership • CORI reform • Financial literacy • Improved access to benefit programs • One-stop shopping, etc.

26. Reduce psychosocial stress • Centering and other group models • Project LAUNCH • Problem Solving Education • Father/partner engagement • Access to stress reduction programs

27. Avert accumulation of stress/identify and address risk • Centering • Universal newborn home visiting • Enhanced case management • Defending Childhood Initiative/Trauma informed care

28. Promote health/ameliorate illness • Breastfeeding • Improved pregnancy care • Progesterone access • Improved access to LARCs • Primary care/ob linkage to mental health

29. Implementation Tools 1

30. Implementation Tools 2

31. Addressing specific HEILC questions • What tools are being used to screen women before and after pregnancy? What is being used in Boston? Available tools other than Edinburgh? • CES-D, BEC • What best practices are provided to women at risk of depression to prevent poor birth outcomes • PSE, Centering, father involvement, Wrap around in early childhood mental health, trauma informed care • How do you reach the very hard-to-reach mothers? • Newborn home visiting, Healthy Start in Housing, Partnership with Health Care for the Homeless • Does BPHC have an evidenced based curriculum that is being used? • PSE, Centering, Fatherhood • Is BPHC holding any group sessions for maternal stress and how are they dealing (if at all) with the father involvement piece? • Centering, Women’s Circles, Healthy Start in Housing • Group-based and population/community-based strategies to reduce maternal stress? • Centering. wide promotion and support for trauma informed care, summer enrichment • Are there strategies, such as social marketing, being used to increase social capital in order to mitigate the impact of stress? • Social marketing around early childhood mental health, ECMH Parent Council, Healthy Start Consumer Work Group, Violence Prevention and Intervention, Centering • Who provides the services, professional/ paraprofessional, nurse, mental health counselor? • All of the above • Are there interventions that can address cumulative stress vs. pregnancy stress? • Progesterone promotion, HSiH, Early Childhood Mental Health, LARC Loan Pilot Project • Weak on preconceptional care • How to measure depression as related to birth outcomes? • Screening in pediatrics, newborn home visiting • Have you collected data on the sources of stress, including ACEs, or symptoms only? • Healthy Start in Housing, Women’s Health Questionnaire, Early Childhood Mental Health

32. New opportunities • Life course is teaching us humility • It teaches us to identify the stress in women’s lives and to respect their struggles • And acknowledges that there are major social forces at work: health education is not enough; individual resilience has its limits • But it also opens the door • To community organizing approaches • To new partnerships with the women they serve • And to a renewed commitment to equality

33. To be a poor man is hard, but to be a poor race in a land of dollars is the very bottom of hardships. W.E.B. Dubois, The Souls of Black Folk