1. Northeast Florida Healthy Start Coalition 2009-2014 Healthy Start Service Delivery Plan: Achieving healthy pregnancies through a life-course approach

2. The Life-Course Model The health and socioeconomic status of one generation directly affects the health status — and reproductive health capital — of the next one.  Interplay of biological, behavioral, psychological and social protective and risk factors contributes to health outcomes across the span of a person’s life  Examine cumulative effect of health status, life events at different stages rather than risks, behaviors and services once a woman becomes pregnant

3. Healthy Start & The Life Course MISSION STATEMENT: The Healthy Start Coalition leads a cooperative community effort to reduce infant mortality and improve the health of children, childbearing women and their families in Northeast Florida. The life-course model broadens the focus of maternal and child health to include both health and social equity. Key factors affecting health outcomes: > socioeconomic status> race and racism > health care> health status > stress> nutrition and weight > birth weight

4. 2009-2014 Healthy Start Service Delivery Plan Tracks progress over the last five years in addressing maternal and infant health needs; guides the development and funding of Healthy Start services through 2014 Life-course framework has both programmatic and policy implications: –Content of case management and related services moves beyond health, e.g. addresses education and poverty –Services organized and delivered in ways that build resiliency and social capital, and reduce dependency (e.g. group activities, self-care). –Requires inter-disciplinary, inter-agency collaboration and cooperation to address the complex needs of at-risk families.

5. Strategies The Healthy Start program: individual case management and risk reduction services, not directly responsible for addressing social determinants. Plan strategies developed on two levels: –What actions can be implemented through Healthy Start? –What partnerships are needed between Healthy Start and other organizations working to address social equity? Looks at four phases: –Infancy –Childhood & Adolescence –Preconception –Pregnancy & Childbirth

6. Health Status & Services INFANT MORTALITY  Declining, but still higher than state and national rates  Black and other nonwhite babies die at 2X the rate  Hispanic infant mortality rising HEALTHY START  Infant Screening rates have declined  More intensive, face-to-face services but fewer served  Fewer substance-exposed newborns served (loss of funding for Azalea Project) BREASTFEEDING: Optimal start & reduces child- and adulthood obesity. Initiation has increased but not duration. No hospitals in NEFL are Baby-Friendly (WHO). SAFE SLEEP: Sudden Unexplained Infant Deaths (SUIDS) leading cause of postneonatal (28-364 days) deaths; most preventable. LOW BIRTH WEIGHT: Disparities in low and very low birth weight place more minority children at risk of life-long physical and development handicaps. NICU stays and costs are rising. 19,268 babies were born in Northeast Florida in 2007, 8% of the births statewide Infancy

7. Social Determinants LOW-INCOME MOTHERS: More moms on Medicaid, fewer graduate HS –43% of moms on Medicaid in 2007 up from 33% in 2003 –16% of babies born to white moms with no HS education; 20% of black moms –25% of moms in Baker County lacked HS education in 2007 SINGLE MOTHERS: Growing number, impact on family income –40% of babies born to single moms; 60% of black babies –Two-parent families earn more money –Fathers’ info on 60% of birth certificates; play vital role in development, economic status ENVIRONMENTAL TOBACCO SMOKE (ETS): Risk factor for SUIDS, asthma — 10% of babies born to mothers who smoked during pregnancy; higher than state — 9% exposed to second-hand smoke 1hr+ a day — White moms smoke at higher rates — Healthy Start: smoking cessation

8. Goals & Strategies REDUCE: Infant mortality, infant mortality disparities, postneonatal mortality, LBW INCREASE: Breastfeeding initiation and duration HEALTHY START STRATEGIES: –Increase screening, initial contact rates. –Provide more-focused education and support –Include fathers in services. –Improve continuity of care (NICU, other prenatal high-risk moms). CRITICAL PARTNERSHIPS: Screening rates: Area hospital council, Florida OB/GYN Society (FOGS) Fathers: Jacksonville Children’s Commission, Jacksonville Urban League, WorkSource, area health departments, Healthy Families programs Hispanic outcomes: Council of Spanish Speaking Organizations, Mayors Hispanic Advisory Council, Spanish Association of North Florida Inc., Jacksonville Hispanic Lions Club, Hispanic media, and Hispanic Chamber of Commerce Breastfeeding: NEF Breastfeeding Collaborative Poverty: Family Foundations, WIC, Healthy People, Healthy Communities

9. Health Status & Services CHILD DEATHS  Accidents are leading cause; homicide is second- leading cause for 15-19 year-olds (2X state rate) OVERWEIGHT  30% of 1 st graders overweight or at-risk  Insufficient physical activity CHILD ABUSE  Regional rates higher than state rates  Leads to future negative behaviors STIs & HIV/AIDS  High rate of teen STIs, especially Duval County  Duval has one of highest rates of teen HIV/AIDS cases TEEN PREGNANCY  Teen pregnancy and repeat births decreased slightly SUBSTANCE ABUSE  Teen rates decreasing, more prevalent among whites HEALTH INSURANCE: Lower rates of Medicaid, Florida KidCare in region HEALTH CARE: Wolfson Children’s Hospital had the most ER visits; Nemour’s provides specialty care SCHOOL HEALTH SERVICES: Funding higher but varies greatly by county, as do health classes and nurses About 329,000 children ages one-19 live in Northeast Florida. Children in the region comprise about 8% of children statewide Childhood & Adolescence

10. Social Determinants POVERTY: 12% of families with children <18, more than 50% of families in Baker County with mom as head of household and kids <age 5 SOCIAL SERVICES: Food Stamp enrollment rising; cash assistance down HOUSING: Older in NEFL; Duval has older housing, higher lead poisoning rates, while almost 90% of Baker County homes have septic tanks SCHOOLS: Students in NEFL fare worse than their counterparts statewide High School Graduation Rate, NEFL & Florida, 2006/2007 & 2007/2008 2006/072007/08 Baker77.977.5 Clay75.377.6 Duval64.365.9 Nassau80.781.5 St. Johns78.389.4 NEFL69.672.5 FLORIDA72.475.4 Source: JCCI 2008 Quality of Life Report, 2006/2007-2007/2008

11. Goals & Strategies REDUCE: Body Mass Index in 1 st Graders, Teen STI Rate, Repeat Teen Pregnancies HEALTHY START: Promote breastfeeding; Address poverty in case management (GED, EITC); Link teen moms to prevention services; Address murder rate, health education through partnerships CRITICAL PARTNERSHIPS : Education: School Board, Achievers for Life, Learning to Finish, AWARE School for Teen Parents, the Jacksonville Community Foundation’s Quality Education for All, Jacksonville Commitment. Poverty: The United Way, Real $ense. School success: Jacksonville Urban League (Head Start), the Early Learning Coalitions, Episcopal Children’s Services, Jax Children’s Commission. Tobacco use: County health departments, SWAT. Uninsured: Department of Children and Families, AHCA. Crime, IM: Jaguars Foundation, Media, JCCI. Teen pregnancy, STI rates: Youth development programs, local churches/faith- based organizations, barbershops, salons. Nutrition, obesity: WIC

12. Health Status & Services PRE-PREGNANCY  Maternal health and prematurity: greatest proportion of fetal & infant deaths  Pre-existing conditions (diabetes and hypertension; STIs; obesity and poor nutrition) are factors UNINTENDED PREGNANCIES:  More than half of pregnancies are unintended UNHEALTHY HABITS:  20% smoked prior to pregnancy  STI rates are 40% higher in NEF (pre- term birth, other poor outcomes)  HIV/AIDS rates are high, especially for black women Preconception In 2007, there were 283,865 women of childbearing age (15-44 years old) residing in Northeast Florida. The number of women age 15-44 years old is expected to reach nearly 300.000 by 2014 BABY SPACING: 25% had birth intervals <18 months - shows lack of contraceptive use, need for family planning services, counseling FAMILY PLANNING: Medicaid waiver underutilized; health departments provide most services OVERWEIGHT: 40% overweight or obese prior to pregnancy; black women impacted more ACCESS TO CARE: One-third are uninsured prior to pregnancy. FOLIC ACID: Only 40% of women take a multi-vitamin with folic acid daily; but 77% know pre-pregnancy consumption reduces birth defects

13. Social Determinants DOMESTIC VIOLENCE: Most victims are women. –60% higher rate of health problems –NEFL consistently exceeds statewide rates –Shelters in the region served 1,400 women and children in 2007-08 NEIGHBORHOOD CRIME & VIOLENCE: Homicide rate in NEFL is 70% higher than state rate –Disproportionately impacts poor and minorities

14. Goals & Strategies REDUCE: Preconception tobacco use, STI rate, INCREASE: Preconception folic acid consumption, interconceptional intervals of 18 months or greater HEALTHY START: Promote multivitamin use; Increase interconceptional counseling, smoking cessation services; Promote use of family-planning waiver; Provide info on family planning services for families, men. CRITICAL PARTNERSHIPS: Family planning, waiver: OB/GYNs, State Agency for Health Care Administration (AHCA). Preconception health, folic acid info: Universities and private colleges (Flagler, JU), community colleges, juvenile justice programs, outward bound, half-way houses, the Tiger SHOP, foster care group homes; WIC; March of Dimes. Tobacco use: Florida Quit Line, Area Health Education Centers (AHECs). Medical homes for uninsured: Hospital Emergency Room Alternatives Program (HERAP).

15. Health Status & Services PREGNANCY  More births to women age 20-24; and fewer to mothers over age 35  St. Johns: most older mothers; Baker & Nassau: most age 17 and under PRENATAL CARE  2x receive late or no prenatal care in NEF black women have highest rates  Women on Medicaid more likely to receive no prenatal care  Most care provided by private doctors C-SECTIONS  Regional rates are higher than the state  Shands Jacksonville has lowest rate in the state; Baptist Medical Center—Nassau has one of the highest Pregnancy & Childbirth There were more than 19,000 deliveries in Northeast Florida in 2007. Fertility rates (births to women age 15-44 years old) in the region rose from 65.9 to 67.9 between 2005 and 2007 SUBSTANCE USE: Impacts Fetal Alcohol Spectrum Disorders, asthma; Tobacco use high in NEF INFECTIONS: Associated with poor birth outcomes PRE-TERM DELIVERIES: Prematurity 2x higher for blacks; Late pre-term deliveries rising. MATERNAL MORTALITY: Consistently higher than state rate, particularly high among non-whites HEALTHY START: Prenatal screening rates low; more intensive, face-to-face services BIRTH CONTROL: Post-partum birth control use low; Higher % of women unable to pay for it in NEF

16. Social Determinants SINGLE MOTHERHOOD: Higher rates of poverty, reduced social support; More than 40% of births in the region were to unmarried mothers in 2007—33% white, 46% Hispanic and 62% of black mothers. FATHERS: Feelings about pregnancy affects role in pregnancy and child’s life. SOCIAL & ENVIRONMENTAL FACTORS: Arguing excessively with partner, financial difficulties, loss of partner or friend, maternal or paternal incarceration, abuse MATERNAL STRESS: Linked to pre-term labor RACISM: Creates disparate affect on black women and contributes to their poor birth outcomes

17. Goals & Strategies REDUCE: Proportion delivering with late or no prenatal care, tobacco use during pregnancy, maternal deaths, single mothers HEALTHY START: Implement outreach in hospital ERs; Promote simplified Medicaid enrollment; Promote breastfeeding; Collaborate with chronic disease prevention; Provide info on consequences, impact of single motherhood; Increase screening rates, initial contacts and intensive, face- to-face services; Provide group prenatal care and case management CRITICAL PARTNERSHIPS C-Section Rates: Delivering hospitals and OBs Tobacco use: American Lung Assn. Birth control: Family planning providers in the community Medicaid eligibility, coverage and enrollment process AHCA & DCF Healthy Start screening: OBs, prenatal care providers Father involvement: Jacksonville Urban League Head Start, county health departments, other community-based initiatives Postpartum obesity: WIC Chronic disease, maternal mortality: Healthy People, Healthy Communities

18. Community Perspectives JCCI Town Hall meetings: five diverse groups (60+ participants) discussed causes and what to do about black infant mortality Focus groups: what does community know? Common themes: –Need for education, information –Impact of stress, lack of trust –Impact of poverty –Lack of awareness, concern among leaders –Need for personal support, community involvement

19. What does the plan tell us? Today’s babies are tomorrow’s mothers and fathers. Significant improvements in infant mortality, low birth-weight and other MCH indicators unlikely to occur unless the health and social status of NEFL residents is addressed across the life-course. We can improve the effectiveness of Healthy Start in impacting individual risks and behaviors in and around pregnancy. There are opportunities to focus and expand the content of case management to address social determinants. Collaboration and partnerships are critical to reducing social and environmental risks, building resiliency and achieving health equity.

20. Partnerships Collaboration essential to address complex needs of families Supports coalition’s commitment to collaboration and to addressing infant mortality within a broader community context. Builds on community engagement efforts: –Friendly Access –Black Infant Health Practice Initiative –Black Infant Health Community Council –Magnolia, Azalea Projects –St. Johns Infant Mortality Task Force

21. Thanks! 2009 Planning Committee Thomas Bryant III, Chair Carolyn Arnister Karen Coleman Rev. Alton Coles Monica Floyd-Cox, RN Linda Hemphill Heather Huffman, RD, IBCLC Dave Malone Lisa Pelle