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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

2 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

3 Today’s Presentation  Infant Mortality in Los Angeles County  Preconception Health  Life Course Theory and Framework  The Life Course Framework in Los Angeles County

4 Los Angeles, California

5 Infant Death Rate*

6 Antelope Valley (AV)  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).

7 Increasing Infant Mortality in AV  Countywide IM rates were 4.9 to 5.5 from  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

8 Highest Rates in African Americans  African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002

9 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

10 Preliminary Findings 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

11 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

12 Fetal Infant Mortality Review (FIMR)  National FIMR forms to review 2002 AV infant deaths (N=53)  PHNs conducted home interviews, abstracted hospital and provider records.

13 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

14 Perinatal Periods of Risk <1500 g g Fetal Neonatal Post neonatal Age at Death Birth weight

15 PPOR Findings

16 Perinatal Periods of Risk <1500 g g neonatal Fetal Neonatal Post neonatal Age at Death Birth weight

17 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

18 FIMR/PPOR Findings (continued)  13 Infant Deaths (> 1500 g, 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

19 PPOR Focus Area Potential Community/PH Interventions Maternal Health/Prematurity Preconceptual Health Health Behaviors Perinatal Care Maternal Care Prenatal Care Referral System High Risk OB Care Newborn Care Perinatal Management Perinatal System Pediatric Surgery Infant Health Sleep Position Breast-Feeding Injury Prevention Data Source: Birth Cohort Data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.

20 LA County MCAH Programs

21 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

22 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

23 Psychosocial Experiences Antelope Valley Did not have enough money for food13% Described pregnancy as a hard time22% Diagnosed with a mental health problem4% Moved to a new address32% Had a lot of bills that couldn't be paid24% Self-reported ever experiencing discrimination34% Discriminated due to race21% Discriminated when getting housing12%

24 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

25 From Data to Action

26  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

27 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

28 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.

29 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

30 Who Needs to Help?? Healthy Moms & Babies

31 Infant Death Rate by Race/Ethnicity Antelope Valley,

32 Preconception Health Efforts Perinatal Summit Healthy Births Through Healthy Communities: Connecting Leadership to Achieve a Unified Commitment to Action Maternal Health/ Prematurity Countywide LAMB

33 Los Angeles County 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

34 34 Long-Range Project Goals  Policy/advocacy  Increase and improve postpartum care  Decrease: –Unintended pregnancies –Pre-pregnancy obesity –Infant mortality –Low birth weight

35 Integration with Public Health Practice  Workforce Education  Data Briefs  Evaluation

36 Community Engagement  Integration with family planning clinics  Reproductive Life Plan Toolkit  Policy Briefs:  Pregnancy and Family Friendly Workplace Policies  Breastfeeding-Friendly Workplace Policy Briefs

37 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 38 WIC Offers Wellness “WOW” Program

39 Preconception Health Council of California  Networking and resources  Public Health and Clinical Practice  Increase access to preconception care  Policy development  Eliminate disparities

40 Life Course Theory  Conceptual framework  Multidisciplinary model for studying lives, social contexts and social change  Population focused

41 Life Course Concepts 1.Timeline 2.Timing 3.Environment 4.Equity

42 How Risk Reduction and Health Promotion Strategies influence Health Development From: Halfon, N., M. Inkelas, and M. Hochstein The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3): Trajectory Without RR and HP Strategies 020 Health Development Age (Years) HP RR Risk Reduction Strategies Health Promotion Strategies Optimal Trajectory Protective Factors HP RR Risk Factors

43

44 The Life Course Perspective (Lu, 2003) Protective factors Risk factors

45 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 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

46 Life Course Tool Box

47 Adapted from Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Maternal and Child Health Journal 2003; 7: LAC MCAH Programs Change Life Course Health Trajectories NFP Teen Pregnancy Racism Partnership to Eliminate Disparities in Infant Mortality Perinatal Mental Health Task Force Postpartum Depression

48 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

49 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

50 Los Angeles County PEDIM ALC 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.

51 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

52 Infant Death Rate by Service Planning Area, LA County, Source: California Department of Public Health, Center for Health Statistics, OHIR Vital Statistics Section,

53 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, % of live births, 2007

54 Discrimination Experienced by Mothers in LA County, by Race/Ethnicity SOURCE: Los Angeles County Department of Public Health, 2005 Los Angeles Mommy and Baby Survey

55 Los Angeles County 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

56 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

57 Accomplishments  Website launched in August 2010  Available to general public  Journal articles, presentations, and information related to infant mortality and undoing racism

58 Accomplishments  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

59 Accomplishments 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

60 Staff and Community Education  “Undoing Racism” Training  “Healthy Babies, Healthy Futures: Preventing Prematurity” curricula Accomplishments

61 Recommendations  Small core membership  Expect differences  Remember that change is difficult  Small changes add up  Invest in communication

62 Future Efforts  Universal assessment and linkage to resources  Partnering with Neighborhood Revitalization Projects  Partnership with Cities  Health in all policies

63 Los Angeles County Department of Public Health Maternal, Child, and Adolescent Health Programs Cynthia A. Harding, M.P.H. Director


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