PRESENTATION TO OCDEL
STAKEHOLDERS
LIFECOURSE PERSPECTIVE
FEBRUARY 20, 2013
Pat Yoder, presenter
PPP MEMBERS

Maternal and Child Health programs
Title V- Federal block grant dollars to PA Dept of
Health, which makes grants to 10 county and
municipal health departments
and
 Healthy Start programs funded directly by
DHHS to 7 programs in PA

CONCEPTS AND LANGUAGE
OCDEL focus on early childhood from an
educational perspective
 MCH professionals focus on early childhood from
a maternal/pregnancy/pre-pregnancy perspective

POSSIBILITIES
We serve the same people
 Our results are not as good as we’d like
 Collaboration should help improve our results
 If we do better, our clients should do better, and
there should be opportunities to increase funding

SO, LET’S TALK!
LIFE COURSE PERSPECTIVE FRAMEWORK
The current most promoted concept for thinking
about maternal and child health
 Designed to address the extremely resistant
problem of racial disparities in infant mortality

IN THE BEGINNING


Adverse Childhood Experiences Study
Thanks to Dr. Ron Voorhees, M.D., M.P.H.,
Acting Director, Allegheny County Health
Department. Several slides from his presentation
on ACE, presented October 26, 2011 to PPP
follow.
RELATIONSHIP OF CHILDHOOD ABUSE AND
HOUSEHOLD DYSFUNCTION TO MANY OF THE
LEADING CAUSES OF DEATH IN ADULTS: THE
ADVERSE CHILDHOOD EXPERIENCE (ACE)
STUDY
Vincent J. Felitti, Robert F. Anda, Dale Nordenberg,
David F. Williamson, Alison M. Spitz, Valerie Edwards,
Mary P. Koss, James S. Marks
American Journal of Preventive Medicine, 1998; 14(4) 245-258
ADVERSE CHILDHOOD EXPERIENCES
More than 17,000 Kaiser patients were asked to
recall their childhood experiences
 Health conditions in the present were tabulated

ACE STUDY - CATEGORIES OF ADVERSE
CHILDHOOD EXPERIENCES (ACE)
Psychological abuse
Physical abuse
Sexual abuse
Substance abuse in home
Mental illness in parent
Violence against mother
Incarceration of parent
KAISER HMO ENROLLEES HAD AT LEAST ONE TYPE OF
ADVERSE CHILDHOOD EXPERIENCE
4 Categories:
3 Categories
6.2%
6.9 %
2 Categories
12.5%
0 Categories
49.5%
1 Category
24.9%
Data from Felitti, et. al.
GROWING UP WITH ADVERSE CHILDHOOD
EXPERIENCES INCREASES THE RISK FOR
MANY LATER ADVERSE HEALTH
CONDITIONS
– RANGING FROM SMOKING
TO OBESITY TO DEPRESSION AND
SUBSTANCE ABUSE.
FOUR OR MORE ACES DOUBLE THE RISK FOR BEING A
SMOKER
Odds Ratio
(relative to 0
ACEs)
1.1
1.5
2.0
Number of ACE Categories
Data from Felitti, et. al.
2.2
ACES INCREASE RISK FOR CHRONIC
BRONCHITIS/EMPHYSEMA
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
3.9
4
2
1.6
1.6
1
2
2.2
0
3
Number of ACE Categories
Data from Felitti, et. al.
>=4
ACES INCREASE THE RISK OF STROKE
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
4
2
0.9
0.7
1
2
1.3
2.4
0
3
Number of ACE Categories
Data from Felitti, et. al.
>=4
ACES INCREASE RISK OF ISCHEMIC HEART
DISEASE
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
4
2
0.9
0.9
1
2
1.4
2.2
0
3
Number of ACE Categories
Data from Felitti, et. al.
>=4
ACES INCREASE THE RISK OF CANCER
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
4
1.2
1.2
1.0
1.9
1
2
3
>=4
2
0
Number of ACE Categories
Data from Felitti, et. al.
ACES
INCREASE REPORTING OF HAVING AN
STD
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
4
2
1.4
1.5
1
2
1.9
2.5
3
>=4
0
Number of ACE Categories
Data from Felitti, et. al.
ACES INCREASE RISK OF HAVING HAD OVER 50 SEXUAL PARTNERS
Odds Ratio (Relative to 0
categories)
14
12
10
8
6
4
2
1.7
2.3
3.1
3.2
3
>=4
0
1
2
Number of ACE Categories
Data from Felitti, et. al.
ACES INCREASE THE RISK FOR DEPRESSION ALMOST FIVE
TIMES
Odds Ratio
(relative to 0
ACEs)
4.6
1.5
2.4
2.6
Number of ACE Categories
Data from Felitti, et. al.
FOUR ACES INCREASE THE RISK FOR USING ILLICIT DRUGS 4.7
TIMES;
EVEN ONE ALMOST DOUBLES THE RISK:
Odds Ratio
(relative to 0
ACEs)
3.6
2.9
1.7
Number of ACE Categories
Data from Felitti, et. al.
4.7
ACES INCREASE THE RISK FOR ALCOHOLISM
Odds Ratio
(relative to 0
ACEs)
7.4
4.9
4.0
2.0
Number of ACE Categories
Data from Felitti, et. al.
ACES INCREASE THE RISK FOR SUICIDE ATTEMPT OVER 12
TIMES:
12.2
Odds Ratio
(relative to 0
ACEs)
6.6
3.0
1.8
Number of ACE Categories
Data from Felitti, et. al.
SOCIOECONOMIC IMPACT OF CHILD ABUSE
AND NEGLECT
David Zielinski (Duke University) estimated that
almost 20% of unemployed adults report abuse or
neglect as child
Adult victims of maltreatment:
have less education
have more physical and mental health problems that interfere with
their work
are twice as likely to be below federal poverty level
are twice as likely to be on Medicaid
DISPARITIES IN INFANT MORTALITY
Not so long ago, maternal and child health
workers believed that just getting women in for
at least ONE prenatal visit would make a
difference in the rates of infant mortality
 The science has changed; our understanding has
deepened
 Focus has shifted to racial disparities and why
they are so persistent

WHY?
Many studies have shown that the factors that
might explain the racial disparities, don’t!
 Genetics
 Behavior
 Prenatal Care
 SES
 Stress
 Infection

MULTIPLE RISK FACTORS

Explain less than 10% of the variation in low
birth weights between white and AfricanAmerican babies
EARLY PROGRAMMING
Emphasis on importance of sensitive
developmental periods in utero or early life
during which future reproductive potential
becomes programmed
KNOWLEDGE IS INCREASING
In the last 20 years, David Barker, MD, PhD, FRS,
studied what happens to a low birth weight baby
 Health consequences in adult life, such as heart
disease and diabetes
 Mother’s consistent prenatal stress affects her
hormones, which in turn, affects the baby’s brain
development
 Epigenetics =another continuing aspect of study (trust
me!!)

STILL MORE COMPLEXITY

Cumulative pathways
All that happens throughout the life of the
mother, and her mother (not to mention what
we’re learning about dads!)
THESE ARE NOT MUTUALLY EXCLUSIVE!

Early programming and cumulative pathways
affect the life course over generations
WHAT TO DO?
12 POINT PROGRAM
Improving Health care Services
 Provide interconception care to women with prior
adverse pregnancy outcomes
 Increase access to preconception care for women
 Improve the quality of prenatal care
 Expand health care access over the life course
STRENGTHENING FAMILIES AND
COMMUNITIES
Strengthen father involvement in families
Parental resilience
 Enhance service coordination and systems
integration
 Create reproductive social capital in communities
 Invest in community building and urban renewal

ADDRESSING SOCIAL AND ECONOMIC
INEQUITIES
Close the education gap Knowledge of parenting
and child development
 Reduce poverty
 Support working mothers and families
 Undo racism

OPPORTUNITIES ABOUND!
Break down barriers
 Talk and work with one another
 Recognize commonalities
 Keep hope alive

REFERENCES




Barker, David, http://www.thebarkertheory.org contains complete
references
Lu, Michael and Neil Halfon, “Racial and Ethnic Disparities in Birth
Outcomes: A Life-Course Perspective,” Maternal and Child Health
Journal, Vol. 7, No. 1, March 2003”
Lu, Michael, “Strong Roots Healthy Fruit: Transforming Generations
through the Life Course Perspective,” June 29, 2010, Philadelphia
Department of Public Health, Division of Maternal and Child Health,
DVD presentation
Ronald E. Voorhees, MD, MPH, “Improving Health: First Things First,”
PPP, October 26, 2011, Power Point Presentation