Expecting Something Better Jacobs Institute of Women’s Health May 18-19, 2005 Washington, DC Misra and Grason, 2005

Achieving Safe Motherhood: Applying a Life Course and Multiple Determinants Perinatal Health Framework Dawn Misra, University of Michigan School of Public Health and Holly Grason, Johns Hopkins Bloomberg School of Public Health Misra and Grason, 2005

Introduction Safe Motherhood “…ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth.” (www.safemotherhood.org) Maternal mortality has dropped but rates remain above many other nations. New recognition of significance of maternal morbidities. Misra and Grason, 2005

Background Women postponing childbearing Older mothers at increased risk of maternal morbidity and mortality. Chronic diseases increase with age. Longer duration of chronic disease increases toll. Healthy older mothers experience increased rates of antenatal and intrapartum complications. Misra and Grason, 2005

Background Overweight and obesity increasing over past 25 years and has risen each year. Increased rates overweight and risk for overweight among children and adolescents. Misra and Grason, 2005

Background Obese women at increased risk for maternal morbidity and mortality. Pregnancy may contribute to obesity in women and hence future morbidity and mortality. Misra and Grason, 2005

Background Maternal age and obesity trends lead to focus on role of chronic disease. Pregnancy may exacerbate chronic disease. May be long term effects of pregnancy complications on women’s health. Misra and Grason, 2005

Framework Proposed framework for perinatal health integrating life span with multiple determinants. Perinatal encompassed both maternal and offspring outcomes Focus here will be maternal outcomes. Misra and Grason, 2005

Misra, Guyer, and Allston, 2003

Misra and Grason, 2005

Framework Focus on distal and proximal factors that represent exposures beyond prenatal period alone. Emphasizes that strategies to address these factors must be across life course, preconceptional and interconceptional childhood and adolescence Misra and Grason, 2005

Why have we not shifted efforts towards life course perspective? Public health and clinical professionals wedded to notion that prenatal care is fundamental to continued improvements. Financing of health care and funding of public health interventions have engendered continued entrenchment in prenatal care model. Misra and Grason, 2005

Strategies Our Purpose Framework provides strong rationale for life course perspective BUT demands attention to strategies that will overcome existing barriers. Empower women to care for health needs during pregnancy but not revert to overmedicalizing pregnancy. Misra and Grason, 2005

H. Grason. Applying a Lifespan Approach to Safe Motherhood Interventions. Presented at “Expecting Something Better” Jacobs Institute conference. Washington, DC. May 2005. H. Grason, Achieving Safe Motherhood: Applying a Lifecourse and Multiple Determinants Framework to Perinatal Health, 2005.

H. Grason. Applying a Lifespan Approach to Safe Motherhood Interventions. Presented at “Expecting Something Better” Jacobs Institute conference. Washington, DC. May 2005. Misra and Grason, 2005

Strategy Options Information strategies Administrative strategies Financing strategies Provider strategies Non-governmental strategies Environmental Misra and Grason, 2005

Information Strategies To reach population at risk, providers, and those who influence larger system. Examples Interventions to package information differently. Use different venues for communicating info to women across lifespan Information transfer across health specialties for individual women and over time Data-driven policy change Utilizing publicly reported performance data Misra and Grason, 2005

Administrative Strategies Changing current categorical, disease- and population-defined organizational schemes and practices of state and local health agencies. Examples Chronic disease activities are administered independent of MCH programming. Could configure differently to reflect multiple deteriminants and life course framework. Implementing targeted interventions in non-traditional settings such as colleges and workplaces. Need new linkages between public health efforts and institutions where women spend their time. Misra and Grason, 2005

Provider Strategies Medical specialists beyond obstetricians (e.g. endocrinologists, cardiologists) could attend to pregnancy and childbirth issues. Pediatricians could enhance and extend prevention counseling. Approaches: Medical school and residency training changes. Pursue changes that do not depend on clinicians. Coaches of sports teams? Personal trainers? Misra and Grason, 2005

Nongovernmental Strategies Could be community based Church congregations Girl Scouts Methods used frequently include mass market media. “Entertainment Education” -- Integrating purposeful messages into media and entertainment sources. Research demonstrating effectiveness in behavior change. Examples New Zealand integrating nutrition information into TV shows. Food on the Run program training high schoolers about nutrition, physical activity and media advocacy. Misra and Grason, 2005

Environmental Strategies These strategies often implemented through regulation. Very effective in addressing tobacco use. Growing interest in urban planning and community design as ways to influence physical activity. Misra and Grason, 2005

Obesity Strategies by Life Stage Figure 3 Girls in Childhood Adolescent Girls Young Women in their 20s Misra and Grason, 2005

Obesity Strategies by Life Stage Girls in Childhood Communities Making environments where children live safe and amenable to physical activity. More opportunities for girls in sports. Provider settings Role of genetic and familial factors assessed by pediatricians. Anticipatory guidance and health monitoring of body weight by pediatricians. Misra and Grason, 2005

Obesity Strategies by Life Stage Girls in Childhood School setting Foods offered in school settings. Exercise opportunities. Including obesity prevention information in health education curricula. Example: Breastfeeding Education for K-12 Misra and Grason, 2005

Obesity Strategies by Life Stage Adolescent Girls Different influences (peers rather than only families) on behavior and different activities and places where spend time. School settings Include peer support groups. Include health education messages about links between obesity and problems with maternal and infant health. Breastfeeding education. Misra and Grason, 2005

Obesity Strategies by Life Stage Adolescent Girls Provider settings Need to begin to focus on woman-centered information transfer approach. Pediatric histories need to be relayed to family practice and internal medicine physicians and reproductive health providers. Misra and Grason, 2005

Obesity Strategies by Life Stage Young Women in their 20s Woman centered lifecourse approach calls for different foci of interventions and venues for communication than for young girls and teens. College campuses Workforce Misra and Grason, 2005

Obesity Strategies by Life Stage Young Women in their 20s Provider settings Might expand provider base for health interventions to include coaches, athletic club/gym staff. Assuring information transfer across providers and over time continues to be important. Young women change providers often. Use multiple providers at once. Tailoring chronic disease management to pregnancy. Misra and Grason, 2005

Conclusions Lifespan approach demands attention to consistency and continuity with respect to health information and health care. As continuity of care no longer appears possible, patient-based approaches complemented by population-based approaches to reach women across life course are critical for Safe Motherhood. Misra and Grason, 2005