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
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
Today’s Presentation
 Infant Mortality in Los Angeles County
 Preconception Health
 Life Course Theory and Framework
 The Life Course Framework in Los
Angeles County
Los Angeles, California
Infant Death Rate*
1990-2002
10.00
9.00
U.S.
Deaths per 1,000 live births
8.00
LACounty
7.00
CAState
6.00
5.00
4.00
3.00
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
* Th e in fan t d eath rat e is d efin ed as th e to t al n u mb er o f d eath s p er 1 ,0 0 0 liv e b irth s
So u rce: Ca lifo rn ia Dep artmen t o f Health Serv ic es, Cen ter fo r Hea lth St atis ti cs, Vi ta l St atis ti cs, 1 9 9 3 to 2 0 0 2
2001
2002
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).
Increasing Infant Mortality in AV
1999-2002
12
 Countywide IM rates were
4.9 to 5.5 from 1999-2002
10.6
9.4
per 1,000 Live Births
10
8
6.2
6
5.4
5.5
5.4
5.0
4.9
4
2
LAC Overall Rate
 AV IM rate more than
doubled between 1999 and
2002
 In 2002, there were 4903
live births and 53 infant
deaths in AV*
AV Rate
0
1999
2000
2001
2002
* Small numbers cause large changes in rates
Highest Rates in African Americans
35.0
30.0
32.7
AfricanAmerican
Hispanic
White (Non-Hispanic)
Antelope ValleyRate
 African American
rate increased from
11.0 in 1999 to
32.7/1,000 live
births in 2002
28.4
Per 1,000 Live Births
25.0
19.0
20.0
15.0
11.0
10.0
7.7
5.7
6.6
5.6
5.0
3.5
2.7
2.2
0.0
1999
2000
2001
Source: California Department of Health Services, Center for Health Statistics, Vital Statistics, 1999 to 2002
2002
5.5
Our Response:
 Four promising practices integrated to
address the problem:
1. Focus Groups
2. Fetal Infant Mortality Review (FIMR)
3. PPOR
4. LAMB
 Community Collaboration
Preliminary Findings
Among the 53 infant deaths:
68%
75%
75%
21%
43%
died in first 28 days (42% died in 24 hrs)
pre-term births
low birth weight
Teens (< 20 years)
were African Americans
Focus Group Findings
 Women




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
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.
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
Perinatal Periods of Risk
Age at Death
Fetal
<1500 g
1500+ g
Neonatal
Post
neonatal
PPOR Findings
SPA 12
<1500 g
1500+ g
Comparison Group 3
Fetal
Neonatal
PostNeonatal
Fetal
Neonatal
PostNeonatal
3.4
5.5
0.8
2.2
1.5
0.4
(N=17)
(N=27)
(N=4)
(N=45)
(N=30)
(N=7)
2.8
1.8
2.6
1.2
0.8
0.6
(N=14)
(N=9)
(N=13)
(N=25)
(N=17)
(N=12)
-
Total Births = 4,934
Total Births = 20,139
Total Fetal-Infant Mortality Rate = 17.0
Total Fetal-Infant Mortality Rate = 6.8
Excess Rate
Fetal
Neonatal
PostNeonatal
1.2
4.0
0.5
1.6
1.0
2.0
=
Total Excess Rate = 10.3
1. Fetal-Infant Mortality Rate is defined as death per 1,000 live births plus fetal deaths (Total Births).
2. Data Source: Birth, Fetal Death, and Death data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
3. The Comparison Group is defined as non-Hispanic w hite mother aged 20 and above w ith more than 12 years of education and resided in Los Angeles County.
Data Source: Birth Cohort data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
Perinatal Periods of Risk
Age at Death
Fetal
<1500 g
1500+ g
Neonatal
Post
neonatal
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
FIMR/PPOR Findings (continued)
 13 Infant Deaths (> 1500 g, 29-365 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
Potential
Community/PH
Interventions
PPOR Focus Area
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.
LA County MCAH Programs
Maternal Health/
Prematurity
Women’s health
Preconceptional/
Interconceptional care
Family Planning,
Preconception
Health Collaborative
Maternal Care
Prenatal care
Referral system
High risk OB care
BIH, NFP, PCG,
CPSP
Newborn Care
Perinatal management
Neonatal care
Newborn follow-up
BIH, CHI, CPSP,
NFP, PCG
Infant Health
Sleep position
Breast-feeding
Injury prevention
BIH, CPSP, CLPPP,
SIDS, NFP, PCG
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
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
Psychosocial Experiences
Antelope Valley
Did not have enough money for food
Described pregnancy as a hard time
Diagnosed with a mental health problem
Moved to a new address
Had a lot of bills that couldn't be paid
Self-reported ever experiencing
discrimination
Discriminated due to race
Discriminated when getting housing
13%
22%
4%
32%
24%
34%
21%
12%
Recommendations
1. Increase capacity to serve high risk families
2. Decrease barriers to care
3. Collaborate with and educate local health care
providers
4. Conduct outreach to African American women,
their families and community
5. Continue LAMB countywide
From Data to Action
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
Areas for Strategic Intervention
1. Preconception care
Maternal
Health/
Prematurity
2. Interconception care
?
3. Prenatal care
4. High risk Ob care
1. Safety issues
Infant Health
(sleep position, injury
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
?
12 Short-term Interventions
1. Preconception care
Maternal
Health/
Prematurity
2. Interconception care
3. Prenatal care
4. High risk Ob care
1. Safety issues
(sleep position, injury
Infant Health
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
1.Increase access to high-risk Ob care and
related ancillary services, such as labs;
access is particularly difficult for Medi-Cal
recipients.
2.Arrange faith-based youth services to
provide health services.
3.Promote “100 Acts Kindness” for pregnant
women.
4.Increase access to transportation for
pregnant moms and advocate politically
for trans. improvement.
5.Arrange male support groups to address
the ”Role of Men”.
6.Present this data to local Ob and pediatric
providers and staff to increase awareness.
7.Provide comprehensive assessment for
newborns, especially for high risk ones.
8.Provide immediate information and planned
follow-up for high-risk infants/moms.
9.Provide newborn infant care classes to new
moms before they are discharged from the
hospital.
10.Establish a 24-hour lactation team.
11.Provide education for breastfeeding and
infant care during prenatal care.
12.Bring providers and volunteers together to
identify best practices.
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
Who Needs to Help??
Healthy
Moms &
Babies
Infant Death Rate by Race/Ethnicity
Antelope Valley, 1996-2005
Afr ican Am e r ican
As ian/Pacific Is lande r
His panic
35.0
Total
32.7
30.0
Infant Deaths per 1,000 Live Births
White
28.4
25.0
19.1
20.0
19.0
17.6
16.5
15.1
14.3
15.0
11.0
9.5
10.0
5.0
0.0
1996
1997
1998
1999
2000
2001
Ye ar
2002
2003
2004
2005
Preconception Health Efforts
Perinatal Summit
Healthy Births Through Healthy
Communities: Connecting Leadership to
Achieve a Unified Commitment to Action
Countywide LAMB
Maternal
Health/
Prematurity
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
Long-Range Project Goals
 Policy/advocacy
 Increase and improve postpartum care
 Decrease:
– Unintended pregnancies
– Pre-pregnancy obesity
– Infant mortality
– Low birth weight
34
Integration with
Public Health Practice
Workforce Education
Data Briefs
Evaluation
Community Engagement
 Integration with family planning
clinics
 Reproductive Life Plan Toolkit
 Policy Briefs:
 Pregnancy and Family
Friendly Workplace Policies
 Breastfeeding-Friendly
Workplace Policy Briefs
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
WIC Offers Wellness
“WOW” Program
38
Preconception Health Council of California
Networking and resources
Public Health and Clinical Practice
Increase access to preconception care
Policy development
Eliminate disparities
http://everywomancalifornia.org/index.cfm
Life Course Theory
 Conceptual framework
 Multidisciplinary model for studying
lives, social contexts and social change
 Population focused
Life Course Concepts
1.
2.
3.
4.
Timeline
Timing
Environment
Equity
How Risk Reduction and Health Promotion Strategies
influence Health Development
Risk Factors
RR
Risk Reduction Strategies
HP
Health Promotion Strategies
Trajectory Without RR and HP
Strategies
Optimal Trajectory
RR
RR
RR
HP
HP
HP
Protective Factors
0
20
40
Age (Years)
60
80
From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly
78(3):447-497.
The Life Course Perspective
(Lu, 2003)
Protective factors
Risk factors
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
Life Course Tool Box
http://www.citymatch.org/lifecoursetoolbox/
LAC MCAH Programs Change
Life Course Health Trajectories
Postpartum
Depression
Perinatal Mental
Health
Task Force
Teen
Pregnancy
Racism
NFP
Partnership to
Eliminate
Disparities in
Infant Mortality
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.
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
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
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.
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
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, 2003-2007
Geographic Areas of Focus
 Service Planning
Areas with the
highest rates of infant
mortality among
4.2% of live
African Americans births, 2007
 Rising infant
mortality rates among
African Americans
14.8% of live
births, 2007
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
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
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
Accomplishments
 Website
launched in
August 2010
 Available to
general public
 Journal articles,
presentations,
and information
related to infant
mortality and
undoing racism
http://www.lapublichealth.org/mch/LACALC/LACALC_index.htm
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
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
Accomplishments
Staff and Community Education
 “Undoing Racism” Training
 “Healthy Babies, Healthy Futures:
Preventing Prematurity” curricula
Recommendations

Small core membership

Expect differences

Remember that change is difficult

Small changes add up

Invest in communication
Future Efforts
 Universal assessment and linkage to resources
 Partnering with Neighborhood Revitalization
Projects
 Partnership with Cities
 Health in all policies
Los Angeles County
Department of Public Health
Maternal, Child, and Adolescent
Health Programs
Cynthia A. Harding, M.P.H.
Director
charding@ph.lacounty.gov