1. The Maternal and Child Health Life Course Model: Introduction and Opportunities for Public Health Nutrition
Milton Kotelchuck, PhD, MPH
Harvard Medical School
Massachusetts General Hospital
Center for Child and Adolescent Health Policy
October 12, 2010

2. 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

3. Ideas and Slides Freely Adapted
From my Colleagues
Amy Fine
Michael Lu
Cheri Pies
Deborah Allen
Neal Halfon

4. Richmond & Kotelchuck, 1983

5. 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

6. Life 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.”
Pediatrician in Hawaii
Pauline Stitt, MCHB 1960

7. 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

8. 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

9. Low birth weight
US,
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

10. Adequate/adeq+ prenatal care
US,
Adequacy is measured using the Adequacy of Prenatal Care Utilization Index, which classifies prenatal care received into 1 of 4 categories (inadequate, intermediate, adequate, and adequate plus) by combining information about the timing of prenatal care, the number of visits, and the infant's gestational age.
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: Retrieved February 21, 2010, from

11. 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

12. 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

13. Need for Change The old MCH/PH practices are not working sufficiently
New 21st Century Science emerging
New or renewed scientific/causal theory emerging

14. 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))

15. 15

16. LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Pregnancy
Age

17. LCHD and Birth Outcomes
White
Reproductive Potential
African
American
Pregnancy
Age

18. Life Course Perspective
This may be particularly important for all of us in MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health programs and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women and families not only during pregnancy, but before and between pregnancies and indeed, across their entire life course.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 18

19. 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

20. 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

21. 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

22. Epigenetics
What is fascinating to me about all this fetal programming business is this phenomenon called epigenetics. Epigenetics is basically volume control for genes. You can turn up or down, or switch on or off gene expressions based on your prenatal exposures. And you can do that simply by putting a chemical group – in this case it’s a simple methyl group – CH3 with one carbon and 3 hydrogen atoms – if you put a methyl group right in front of the DNA, which blocks the gene from ever being expressed. Whereas if you take away that methyl group, then the gene is allowed to freely express itself. Generally speaking, methylation turns off or silences gene expression, whereas de-methylation turns on gene expression.
So prenatal stress can determine the amount of glucocorticoid receptors that gets expressed inside the brain simply by methylating or demethylating the DNA. This is fascinating to me because you can now have two people with the exact same genetic code, but they can have very different output of stress hormones depending on whether the genes are turned on or off, which has to do with whether or not their DNA’s are methylated or demethylated, which has to do with whether or not their moms were stressed out during pregnancy, attesting to the important and potentially lifelong impact of maternal stress during pregnancy on children’s health and development.
Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003 22

23. Prenatal Programming of Childhood Obesity
A second example of early programming I will give you is about childhood obesity. 23

25. Neurons to Neighborhoods Early 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

26. Drawing by Tom Prentiss
In: Cowan MW The development of the brain. Scientific American 113;
Als, H. 1986

27. Human Brain Development - Synapse Formation
Language
Sensing Pathways (vision, hearing)
Higher Cognitive Function
Conception -6 -3 3 6 9 1 4 8 12 16
Months
Years
AGE
C. Nelson, in From Neurons to Neighborhoods, 2000.

29. 2004 National Research Council and Institute of Medicine Report

30. 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.

31. 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

32. 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

33. Barker Hypothesis Birth Weight and Insulin Resistance Syndrome
Odds ratio adjusted for BMI
Barker 1993

34. Barker Hypothesis Birth Weight and Hypertension
Law 1993

35. Barker Hypothesis Birth Weight and Coronary Heart Disease
Age Adjusted Relative Risk
Rich-Edwards 1997

38. 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

39. 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

41. 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

42. 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:

43. Life Course Perspective
This may be particularly important for all of us in MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health programs and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women and families not only during pregnancy, but before and between pregnancies and indeed, across their entire life course.
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30. 43

44. MCH Life Course Could it be true?
Could we really transform disparities into equity?
The WHO Nutrition Standards

46. WHO Multicentre Growth Reference Study Background / 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?)

47. 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

48. 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]

49. 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

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

51. WHO Multicentre Growth Reference Study Major Conclusions
Inter-cultural variability only 4% of variance
All growth retardation reflects environmental insults
Overall (genetic / cultural) longitudinal continuity for human growth and motor development under optimal conditions
Breastfeeding established as norm for growth standards
Supports social justice orientation

52. Education and Training
MCH Life Course Paradigm Shift MCH Life Course Conference June 2008, Oakland CA MCH Life Course Model Topics to be Addressed
Theory
Research
Practice
Policy
Education and Training
Kotelchuck, Lu, Pies, 2008

53. 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

54. HRSA/MCHB Concept Paper
Rethinking MCH: The Life Course Model as an Organizing Framework
Amy Fine
Milton Kotelchuck
October 2010

55. Life Course Perspective
A way of looking at life not as disconnected stages, but as an integrated continuum
And the new paradigm is called the life course perspective. Simply stated, the life course perspective is a way of looking at life not as disconnected stages, but as an integrated continuum. It’s a conceptual framework, some might call it a paradigm shift, that recognizes that each stage of life is influenced by all the life stages that preceded it, and it in turn influence all the life stages that follow it.
M. Lu, 2010 55

56. 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

57. 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

58. 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

59. 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.

60. 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

61. 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

62. 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

63. 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

64. 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

65. MCH Research MCH Life Course Research Network
To overcome these disciplinary and institutional silos, the MCHB recently funded the MCH Life Course Research Network. The goal of the life course research network is to advance MCH life course research, and to maximize the impact of that research on MCH practices, programs and policies. UCLA will serve as the administrative and communication hub, but this cannot be a UCLA thing. By creating a network, we are hoping to breakdown disciplinary and institutional silos, and to engineer collaborative innovations. 65

66. 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
…..

67. 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

68. Multiple time points for intervention
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

69. 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

70. 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

71. Public Health Nutrition Life Course Initiatives
Within public health/clinical programs
Across programs
MCH Life Course organizations
Policy level

72. 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)

73. Alameda County Building Blocks Collaborative Medical Care Housing Jobs
Childcare
Medical Care
Jobs
Healthy Food
Alameda
County
Building
Blocks
Collaborative
Clean Air
Parks and Activities
Policy Makers
To the west coast
Education
Economic Justice
Preschool
Safe Neighbor-hoods
Residents
Transportation 73 73

74. MCH Life Course Policy
Many needed public health nutrition life course reforms require policy level initiatives
Creating a policy agenda

75. 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

76. “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, PhD Nobel Laureate in Economics, 2000

77. But we have to make the case that we get much greater return on investment of healthcare dollars by investing in early development, that if we really want to bend the curve on healthcare costs we have to invest early, beginning before birth, or better yet, 77

78. 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 78

79. 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

80. MCH Life Course Partnerships
Generate new political will to implement the MCH life course models

81. 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

82. 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

83. 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

84. 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

85. 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

86. 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

87. 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

88. MCH Life Course Resources
CityMatCH
MCHB
Future MCHB Web site

89. Richmond & Kotelchuck, 1983 89