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

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 Countywide IM rates were 4.9 to 5.5 from 1999-2002 AV IM rate more than doubled between 1999 and 2002 In 2002, there were 4903 live births and 53 infant deaths in AV* * Small numbers cause large changes in rates

Highest Rates in African Americans African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002

Our Response: Four promising practices integrated to address the problem: Focus Groups Fetal Infant Mortality Review (FIMR) PPOR LAMB Community Collaboration

Preliminary Findings Among the 53 infant deaths: 68% died in first 28 days (42% died in 24 hrs) 75% pre-term births 75% low birth weight 21% Teens (< 20 years) 43% were African Americans  

Focus Group Findings Women Providers 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 Post Post Fetal Fetal Neonatal Neonatal neonatal neonatal Birth weight <1500 g <1500 g 1500+ g 1500+ g

PPOR Findings

Perinatal Periods of Risk Age at Death neonatal Fetal Neonatal Post Birth weight <1500 g 1500+ g

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 Potential Community/PH Interventions 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

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 13% Described pregnancy as a hard time 22% Diagnosed with a mental health problem 4% Moved to a new address 32% Had a lot of bills that couldn't be paid 24% Self-reported ever experiencing discrimination 34% Discriminated due to race 21% Discriminated when getting housing 12%

Recommendations Increase capacity to serve high risk families Decrease barriers to care Collaborate with and educate local health care providers 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 Maternal Health/ Prematurity 1. Preconception care 2. Interconception care 3. Prenatal care 4. High risk Ob care ? Infant Health 1. Safety issues (sleep position, injury prevention, etc) 2. Breast-feeding 3. Family and parenting issues ?

12 Short-term Interventions Increase access to high-risk Ob care and related ancillary services, such as labs; access is particularly difficult for Medi-Cal recipients. Arrange faith-based youth services to provide health services. Promote “100 Acts Kindness” for pregnant women. Increase access to transportation for pregnant moms and advocate politically for trans. improvement. Arrange male support groups to address the ”Role of Men”. Present this data to local Ob and pediatric providers and staff to increase awareness. Maternal Health/ Prematurity 1. Preconception care 2. Interconception care 3. Prenatal care 4. High risk Ob care 1. Safety issues (sleep position, injury prevention, etc) 2. Breast-feeding 3. Family and parenting issues Provide comprehensive assessment for newborns, especially for high risk ones. Provide immediate information and planned follow-up for high-risk infants/moms. Provide newborn infant care classes to new moms before they are discharged from the hospital. Establish a 24-hour lactation team. Provide education for breastfeeding and infant care during prenatal care. Bring providers and volunteers together to identify best practices. Infant Health

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

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 33

Long-Range Project Goals Policy/advocacy Increase and improve postpartum care Decrease: Unintended pregnancies Pre-pregnancy obesity Infant mortality Low birth weight

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 PHFE-WIC 888-942-2229

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 Timeline Timing Environment Equity

How Risk Reduction and Health Promotion Strategies influence Health Development 20 Health Development 40 60 80 Age (Years) HP RR Risk Reduction Strategies Health Promotion Strategies RR Risk Factors Optimal Trajectory Trajectory Without RR and HP Strategies Protective Factors HP 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.

L I F E C O U R S E L I F E C O U R S E L I F E C O U R S E

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 Partnership to Eliminate Disparities in Infant Mortality NFP 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 African Americans Rising infant mortality rates among African Americans 4.2% of live births, 2007 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