1. Reinventing Maternal & Child Health: A Life-Course Perspective Michael C. Lu, MD, MPH Associate Professor of Obstetrics, Gynecology, and Public Health UCLA Schools of Medicine and Public Health UCLA Center for Healthier Children, Families and Communities National Center for Infancy & Early Childhood Health Policy MCHB-AIM Child & Adolescent Policy Support Center Alameda County Building Blocks for Healthy Babies, Healthy Families, & Healthy Communities September 10, 2009

5.  The definition of insanity is doing the same thing over and over and expecting different results Benjamin Franklin

6. Acknowledgment  Mario Drummond  Neal Halfon  Milt Kotelchuck  Cheri Pies

7. Acknowledgment

8. Life-Course Perspective  A way of looking at life not as disconnected stages, but as an integrated continuum

9. Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

10. Life Course Perspective  Early programming  Cumulative pathways  Reinventing MCH

11. Early Programming

13. Barker Hypothesis Birth Weight and Coronary Heart Disease Age Adjusted Relative Risk Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.

14. Barker Hypothesis Birth Weight and Hypertension Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in utero and its amplification throughout life. Br Med J 1993;306:24-27.

15. Barker Hypothesis Birth Weight and Insulin Resistance Syndrome Odds ratio adjusted for BMI Barker DJP, Hales CN, Fall CHD, Osmond C, Phipps K, Clark PMS. Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (Syndrome X): Relation to reduced fetal growth. Diabetologia 1993;36:62-67.

16. Maternal Stress & Fetal Programming

17. Prenatal Stress & Programming of the Brain  Prenatal stress (animal model) Hippocampus  Site of learning & memory formation  Stress down-regulates glucocorticoid receptors  Loss of negative feedback; overactive HPA axis Amygdala  Site of anxiety and fear  Stress up-regulates glucocorticoid receptors  Accentuated positive feedback; overactive HPA axis Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain. J Neuroendocrinol 2001;13:113-28.

18. Prenatal Programming of the Hypothalamic-Pituitary-Adrenal Axis Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain. J Neuroendocrinol 2001;13:113-28.

19. Epigenetics Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

20. Epigenetics Same Genome, Different Epigenome R.A. Waterland, R.A. Jirtle, "Transposable elements: targets for early nutritional effects on epigenetic gene regulation," Mol Cell Biol, 23:5293-300, 2003. Reprinted in the New Scientist 2004

21. Prenatal Programming of Childhood Obesity

22. Epidemic of Childhood Overweight & Obesity Source: National Center for Health Statistics, National Health and Nutrition Examination Survey Note: Estimate not available for 1976-1980 for Hispanic; overweight defined as BMI at or above the 95 th percentile ofr the CDC BMI-for-age growth charts Children 6-18 Overweight

23. Prenatal Programming of Childhood Overweight & Obesity

24. Maternal Diabetes & Intrauterine Hyperglycemia Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells) Prenatal& Postnatal Hyperleptinemia Preadipocyte Differentiation Adipocyte Hyperplasia Hypothalamic Leptin Resistance Pancreatic β- Cell Leptin Resistance Hyperphagia Hyperinsulinism Programmed Insulin Resistance Postnatal Hyperinsulinemia Maternal Diabetes & Intrauterine Hyperglycemia Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells) Prenatal& Postnatal Hyperleptinemia Adipocyte Hyperplasia Hypothalamic Leptin Resistance Pancreatic β- Cell Leptin Resistance Hyperphagia Hyperinsulinism Programmed Insulin Resistance Postnatal Hyperinsulinemia Adipogenesis Dysregulation of the Adipoinsular Feedback System Maternal Diabetes & Intrauterine Hyperglycemia Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells) Prenatal& Postnatal Hyperleptinemia Preadipocyte Differentiation Adipocyte Hyperplasia Hypothalamic Leptin Resistance Pancreatic β- Cell Leptin Resistance Hyperphagia Hyperinsulinism Programmed Insulin Resistance Postnatal Hyperinsulinemia Adipogenesis Maternal Diabetes & Intrauterine Hyperglycemia Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells) Prenatal& Postnatal Hyperleptinemia Preadipocyte Differentiation Adipocyte Hyperplasia Hypothalamic Leptin Resistance Pancreatic β - Cell Leptin Resistance Hyperphagia Hyperinsulinism Programmed Insulin Resistance Postnatal Hyperinsulinemia Adipogenesis Prenatal Programming of Childhood Obesity

25. Cumulative Pathways

26. Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/

27. Allostasis: Maintain Stability through Change McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

28. Allostastic Load: Wear and Tear from Chronic Stress McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

29. HPA Axis & Immune System Chikanza 2000

30. Stressed vs. Stressed Out  Stressed Increased cardiac output Increased available glucose Enhanced immune functions Growth of neurons in hippocampus & prefrontal cortex  Stressed Out Hypertension & cardiovascular diseases Glucose intolerance & insulin resistance Infection & inflammation Atrophy & death of neurons in hippocampus & prefrontal cortex

31. Allostasis & Allostatic Load McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002

32. Rethinking Preterm Birth

33. Sequelae of Preterm Birth 75% PerinatalMortality NeurologicDisabilities 50% 12%

34. Racial & Ethnic Disparities Infant Mortality, 2005 Deaths Per 1,000 Live Births NCHS 2008

35. Racial & Ethnic Disparities Preterm Births < 37 Weeks Percent of Live Births NCHS 2008 Year 2010 Goal

36. Racial & Ethnic Disparities Very Preterm Births < 32 Weeks Percent of Live Singleton Births Year 2010 Goal NCHS 2008

37. Rethinking Preterm Birth Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)

38. Preterm Birth & Maternal Ischemic Heart Disease Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth Smith et al Lancet 2001;357:2002-06

39. Reinventing MCH

40. Why Reinvent MCH?

41. Maternal Mortality Source: OECD Health Data 2008

42. Infant Mortality Source: United Nations. Table 4. In: United Nations Demographic Yearbook, 2004. New York, NY: United Nations; 2007:73–93.

43. Racial & Ethnic Disparities Pregnancy-Related Mortality Ratio, 1991-1999 Deaths Per 1,000 Live Births Chang et al MMWR 2003

44. Racial & Ethnic Disparities Infant Mortality, 2005 Deaths Per 1,000 Live Births NCHS 2008

45. Racial & Ethnic Disparities Infant Mortality, Alameda County, 2001-03 Deaths Per 1,000 Live Births Alameda County Health Status Report, 2006: http://www.acgov.org/health/disparitiesStudy.pdf

46. Racial & Ethnic Disparities Low Birth Weight, Alameda County, 2001-03 Percentage of Live Births Alameda County Health Status Report, 2006: http://www.acgov.org/health/disparitiesStudy.pdf

47. How Can This Be?

48. First, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care. Schroeder SA. NEJM 2007;357:1221-8

49. How Can We Do Better? 1.Transform maternal and child healthcare 2.Assure the conditions in which all mothers and children can be healthy

50. 1. Transforming Maternal & Child Healthcare

51. Prenatal Care 1.0 Receptionist Medical Assistant Ultrasound Tech Nurse Manager

52. Prenatal Care 2.0 Oral Health Teratogen Information Services Primary & Specialty Care Social Services Mental Health Nutritional Counseling Receptionist Medical Assistant Ultrasound Tech Nurse Manager High Risk OB Family Support

53. 010203040Years Prenatal Care 3.0 NHVFRC PED Prenatal Care Family Planning Primary Care Reproductive Potential Optimal Health Development Lower Health Development Trajectory Medical Home for Women’s Health Medical Home for Adolescent Health Pediatric Medical Home

54. Old Operating Logic (2.0)New Operating Logic (3.0) Definition of Health Absence of disease and disability Health is a positive concept emphasizing the development of social and personal resources, as well as physical capacities (Ottawa, 1986 & IOM 2004) Goals of Health System Health maintenance and prolonging life of individual Optimizing individual and population health Client ModelIndividualIndividual, community, and population Health Production / Disease Causation Biomedical Biopsychosocial, Life Course Health Development Intervention ApproachDiagnosis and treatment Emphasize disease prevention, health promotion and optimization Time FrameEpisodic CareLifespan: Sensitive, Critical Periods to optimize health trajectories

55. 2. Assure Conditions in Which All Mothers & Children Can Be Healthy

56. Developmental Strategies  Health development (health capital)  Educational development (human capital)  Economic development (material capital)  Family development (relational capital)  Community development (social capital)

57. Educational Development 1.Preconception and prenatal care 2.Parenting education 3.Child care 4.Universal Preschool 5.Early Head Start and Head Start 6.K-12 – small class size, teacher quality, standards 7.After school and summer programs 8.Youth development 9.Health education/physical education 10.Comprehensive school health clinics

58. Racial and Ethnic Disparities Births to Unmarried Mothers Percent of Live Births

59. Family Development 1.Human development (education, employment, legal/social services) 2.Life skills training 3.Reproductive health 4.Violence prevention 5.Marriage counseling/family therapy 6.Economic development 7.Criminal justice system reforms 8.Tax reform 9.Welfare reform 10.Child support reform

60. Economic Development 1.Raise minimum wage 2.Expand Earned Income Tax Credits 3.Strengthen collective bargaining 4.Providing safety net – unemployment, housing, food stamps 5.Providing job training and retraining 6.Assuring universal healthcare 7.Expanding access to family and medical leave, quality childcare, universal preschool 8.Teach financial literacy 9.Extend microloan programs 10.Macroeconomic policies

61. Community Development 1.Economic development 2.Affordable decent housing 3.Delink schools and property tax 4.Community policing 5.Municipal services & infrastructural development 6.Protect clean air and water 7.Promote food quality and safety 8.Mobilize community activism 9.Create social capital 10.Address racism at all levels

62. Healthcare Education Community Development Environment MCH

63.  "We must become the change we want to see.” - MOHANDAS GANDHI

64. NMPP MCH Life- Course Organization

65. Closing the Black-White Gap in Birth Outcomes: A 12-Point Plan Racism

66. MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT (Collins et al, AJPH, 2004)

67. Jones CP. Levels of racism: A theoretical framework and a gardener’s tale. AJPH 2000;90:1212-5

68. Closing the Black-White Gap in Birth Outcomes: A 12-Point Plan 1. Provide interconception care to women with prior adverse pregnancy outcomes 2. Increase access to preconception care for African American women 3. Improve the quality of prenatal care 4. Expand healthcare access over the life course 5. Strengthen father involvement in African American families 6. Enhance service coordination and systems integration 7. Create reproductive social capital in African American communities 8. Invest in community building and urban renewal 9. Close the education gap 10. Reduce poverty among Black families 11. Support working mothers and families 12. Undo racism Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes: A life-course approach. Ethnicity and Disease Forthcoming in 2009.

69. All this will not be finished in the first 100 days. Nor will it be finished in the first 1,000 days, nor in the life of this Administration, nor even perhaps in our lifetime on this planet. But let us begin. John F Kennedy (1961)