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 PerspectiveCynthia A. Harding, M.P.H.Los Angeles County Department of Public HealthMaternal, 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.HMichael Lu, MD, MPH
3 Today’s Presentation Infant Mortality in Los Angeles County Preconception HealthLife Course Theory and FrameworkThe Life Course Framework in Los Angeles County
6 Antelope Valley (AV) Relatively isolated 4,903 live births in 2002 Mother’s race/ethnicity:17% African American46% Hispanic33% WhiteIncome of 1 in 8 households less than Federal Poverty Level (1 in 5 in LAC).
7 Increasing Infant Mortality in AV 1999-2002 Countywide IM rates were 4.9 to 5.5 fromAV IM rate more than doubled between 1999 and 2002In 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:Focus GroupsFetal Infant Mortality Review (FIMR)PPORLAMBCommunity Collaboration
10 Preliminary Findings Among the 53 infant deaths: 68% died in first 28 days (42% died in 24 hrs)75% pre-term births75% low birth weight21% Teens (< 20 years)43% were African Americans
11 Focus Group Findings Women Providers Transportation to prenatal care Health concerns not taken seriouslyStereotyped as single welfare momsSatisfaction with care after deliveryProvidersWomen entering late into prenatal careDifficulty in accessing high risk prenatal careSerious 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 smallLate or no prenatal careNot first lossPsycho-social issuesTransportation barriersReferral to high risk and specialty care difficult and therefore not occurring
14 Perinatal Periods of Risk Age at DeathPostPostFetalFetalNeonatalNeonatalneonatalneonatalBirth weight<1500 g<1500 g1500+ g1500+ g
16 Perinatal Periods of Risk Age at DeathneonatalFetalNeonatalPostBirth weight<1500 g1500+ g
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 defect100% 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 defect85% of mothers had at least one risk factor for poor birth outcomes
19 Potential Community/PH Interventions PPOR Focus AreaPotential Community/PH InterventionsMaternal Health/PrematurityPreconceptual HealthHealth BehaviorsPerinatal CareMaternal CarePrenatal CareReferral SystemHigh Risk OB CareNewborn CarePerinatal ManagementPerinatal SystemPediatric SurgeryInfant HealthSleep PositionBreast-FeedingInjury PreventionData Source: Birth Cohort Data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
21 Los Angeles Mommy and Baby Survey (LAMB) Population-based survey of recently delivered women residing in AVSelf-administered survey on experiences before, during, and after pregnancyPrenatal careHealth behaviorsOther risk factors
22 LAMB Findings: Moms with poor birth outcomes tend to have: No insurance before pregnancyPrevious low birth weight/preterm infantHigh blood pressure (before/during pregnancy)Inadequate prenatal careEarly labor pain, water broke earlyReported feeling less happy during pregnancySmoked during pregnancyDescribed their neighborhood as unsafe
23 Psychosocial Experiences Antelope ValleyDid 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 Increase capacity to serve high risk families Decrease barriers to careCollaborate with and educate local health care providersConduct outreach to African American women, their families and community5. Continue LAMB countywide
26 Translating Data to Action Findings presented at Antelope Valley Best Babies Collaborative meeting (AVBBC)Over 50 community partners reviewed and identified intervention strategiesShort-term and Long-term interventions identified
27 Areas for Strategic Intervention Maternal Health/Prematurity1. Preconception care2. Interconception care3. Prenatal care4. High risk Ob care?Infant Health1. Safety issues(sleep position, injuryprevention, etc)2. Breast-feeding3. Family and parenting issues?
28 12 Short-term Interventions 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/Prematurity1. Preconception care2. Interconception care3. Prenatal care4. High risk Ob care1. Safety issues(sleep position, injuryprevention, etc)2. Breast-feeding3. Family and parenting issuesProvide 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
29 From Proposals to Policy Service Expansion and LinkagesAntelope Valley Best Babies CollaborativeFaith-Based EffortsBetter hospital discharge planningBetter linkage to MCAH ProgramsNurse Family PartnershipBlack Infant HealthCPSP
31 Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2005
32 Preconception Health Efforts Perinatal SummitHealthy Births Through Healthy Communities: Connecting Leadership to Achieve a Unified Commitment to ActionCountywide LAMBMaternal Health/Prematurity
33 Los Angeles County Preconception Health Collaborative California Family Health CouncilLA Best Babies NetworkLA County Department of Public HealthMarch of DimesPHFE – WIC ProgramPerinatal Advisory Council – Leadership, Advocacy, and ConsultationVA Greater Los Angeles Healthcare System33
35 Integration with Public Health Practice Workforce EducationData BriefsEvaluation
36 Community Engagement Integration with family planning clinics Reproductive Life Plan ToolkitPolicy Briefs:Pregnancy and Family Friendly Workplace PoliciesBreastfeeding-Friendly Workplace Policy Briefs
37 Community Engagement Palm cards, posters, and DVDs I Want my 9 Months Don’t U DareAre You Ready for a Makeover?Nine Questions to ask Before Becoming PregnantFolic Acid is Good for Me / Folic Acid is Good for UsCommunity grants and awardsAdvocacy network
39 Preconception Health Council of California Networking and resourcesPublic Health and Clinical PracticeIncrease access to preconception carePolicy developmentEliminate disparities
40 Life Course Theory Conceptual framework Multidisciplinary model for studying lives, social contexts and social changePopulation focused
41 Life Course ConceptsTimelineTimingEnvironmentEquity
42 How Risk Reduction and Health Promotion Strategies influence Health Development20Health Development406080Age (Years)HPRRRisk Reduction StrategiesHealth Promotion StrategiesRRRisk FactorsOptimal TrajectoryTrajectory Without RR and HP StrategiesProtective FactorsHPFrom: Halfon, N., M. Inkelas, and M. Hochstein The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):
43 L I F E C O U R S EL I F E C O U R S EL I F E C O U R S E
44 The Life Course Perspective (Lu, 2003) Protective factorsRisk factors
45 A 12-Point Plan to Address MCH Across the Life Course Improving Health Care Services1. Provide interconception care2. Increase access to preconception care3. Improve the quality of prenatal care4. Expand health care access over the life course Strengthening Families and Communities5. Strengthen father involvement in families6. Enhance service coordination and systems integration7. Create reproductive social capital in communities8. Invest in community mental health, social support, and urban renewalAddressing social and economic inequities9. Close the education gap10. Reduce poverty11. Support working mothers and families12. Undo racism
47 LAC MCAH Programs Change Life Course Health Trajectories PostpartumDepressionPerinatal MentalHealthTask ForceTeenPregnancyRacismPartnership toEliminateDisparities inInfant MortalityNFPAdapted 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.
48 A Life Course Perspective at Los Angeles County MCAH Programs Nurse Family PartnershipCPSP ProgramSIDS ProgramBlack Infant HealthChildren’s Health Outreach InitiativeCLPPPLAMB 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 AssociationAction Learning Collaborative (ALC) an 18 month program of PEDIMW.K. Kellogg Foundation Funded
50 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.
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, 2003-2007 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 AmericansRising infant mortality rates among African Americans4.2% of live births, 200714.8% 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 CountyIdentify and distribute existing educational materials related to infant mortality and racism.Convene trainings and discussion groups for SPA 1 and 6 providers and community membersDesign a project website
56 AccomplishmentsHealth brief on health disparities among African American infants in LACBackground 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 publicJournal articles, presentations, and information related to infant mortality and undoing racism
58 AccomplishmentsMonthly peer parent grief/support group for bereaved parents and families who suffered a fetal or infant death in LACEnglish and Spanish speaking parents support each other through grief processInterconception health educationPublic Health Nurse coordinates
59 Accomplishments Health Care Disparities: Closing the Gap Workshop MCAH Programs and Commission to End Health Care Disparities convenedTraining by Evelyn L. Lewis & Clark, MD, MA, NMA/Cobb Research InstituteKeynote Speakers: Supervisor Mark Ridley Thomas; Jonathan Fielding, MD, MPH; and Tonya Lewis LeeLos 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 Accomplishments Staff and Community Education “Undoing Racism” Training“Healthy Babies, Healthy Futures: Preventing Prematurity” curricula
61 Recommendations Small core membership Expect differences Remember that change is difficultSmall changes add upInvest in communication
62 Future Efforts Universal assessment and linkage to resources Partnering with Neighborhood Revitalization ProjectsPartnership with CitiesHealth in all policies
63 Los Angeles CountyDepartment of Public HealthMaternal, Child, and Adolescent Health ProgramsCynthia A. Harding, M.P.H. Director
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