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 1999-2002
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:
Focus Groups
Fetal Infant Mortality Review (FIMR)
PPOR
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 Providers 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
Age at Death
Post
Post
Fetal
Fetal
Neonatal
Neonatal
neonatal
neonatal
Birth weight
<1500 g
<1500 g
1500+ g
1500+ g

15. PPOR Findings

16. Perinatal Periods of Risk
Age at Death
neonatal
Fetal
Neonatal
Post
Birth weight
<1500 g
1500+ 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 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. Potential Community/PH Interventions
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 food
13%
Described pregnancy as a hard time
22%
Diagnosed with a mental health problem 4%
Moved to a new address
32%
Had a lot of bills that couldn't be paid
24%
Self-reported ever experiencing discrimination
34%
Discriminated due to race
21%
Discriminated when getting housing
12%

24. Recommendations 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

25. From Data to Action

26. Translating Data to Action
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

27. Areas for Strategic Intervention
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 ?

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/
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

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, 1996-2005

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

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 33

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. WIC Offers Wellness “WOW” Program
PHFE-WIC

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
Timeline
Timing
Environment
Equity

42. How Risk Reduction and Health Promotion Strategies
influence Health Development 20
Health Development 40 60 80
Age (Years) HP RR
Risk Reduction Strategies
Health Promotion Strategies RR
Risk Factors
Optimal Trajectory
Trajectory Without RR and HP Strategies
Protective Factors HP
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):

43. L I F E C O U R S E
L I F E C O U R S E
L I F E C O U R S E

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. LAC MCAH Programs Change 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.

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, 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 Americans
Rising infant mortality rates among African Americans
4.2% of live births, 2007
14.8% 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 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. 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 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