3 rd National Summit on Preconception Health and Health Care Improving Preconception Health in a New Era of Health Care June , 2011 Preconception Health: a Gateway to Improving the Health of Women Across the Lifespan Tamara Wrenn, MA, CCE, CIMT, CWC Executive Director, Just Us Women Productions, LLC Senior Consultant, Practice Matters

Achieving Success The objective of this abstract is to demonstrate the existing capacity for using the Life Course Perspective (LCP) framework to catapult preconception health care to the next level. 2

National MCH System Challenges The birth rate for U.S. teenagers fell 6 percent in The 2009 preliminary estimate of registered births for the United States was 4,131,019, or 3 percent less than in The rate in 2009 was 39.1 births per 1,000 teenagers 15–19 years, down from 41.5 in 2008 and 8 percent lower than in The low birth weight in 2009 was 8.16% compared to 2008 at 8.18% The birth rate for women aged 40 – 44 rose in 2009—the only age group to have an increase—up 3 percent from 9.8 births per 1,000 women in 2008 to 10.1, the highest rate since The preterm birth rate declined in 2009 to 12.18% of all births for the third straight year, from 12.33% in Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. Accessed June, *All 2009 data is preliminary birth data

National MCH Systems Challenges Infant Mortality The preliminary infant mortality rate for 2009 was 6.42 infant deaths per 1,000 live births. This represents a decrease of 2.6 percent from the preliminary 2008 rate of With the exception of 2002 and 2005, the infant mortality rate has statistically remained the same or decreased significantly each successive year from 1958 through The 2009 preliminary infant mortality rate for black infants was infant deaths per 1,000 live births, compared with per 1,000 live births in The infant mortality rate for white infants decreased in 2009 by 4.0 percent, from 5.54 infant deaths per 1,000 live births in 2008 to 5.32 in The mortality rate for black infants was 2.4 times the rate for white infants. 4 Centers for Disease Control and Prevention. National Center for Health Statistics. VitalStats. Accessed June, *All 2009 data is preliminary birth data

National MCH Systems Challenges Healthy People 2020Healthy People 2010 Low Birth Weight 7.8 percent5 percent Pre-term birth 11.4 percent7.6 percent First Trimester Prenatal Care 77.9 percent90 percent Infant Mortality 6 percent4.5 percent Neonatal Mortality percent Primary Cesarean births percent Repeat Cesareans 81.7 percent (18.3 percent) 63 percent (27 percent) In November 2008, the March of Dimes released its first annual “Premature Birth Report Card,” Giving the Nation an overall “D” grade. Health People 2010 Data: National Vital Statistics System Mortality and Natality (NVSS-M, NVSS-N), CDC, NCHS. June 2011 Healthy People 2020 Data: National Vital Statistics System (NVSS), CDC, NCHS, June 2011

Working Definition Preconception Care Preconception care is a set of interventions that identify and modify biomedical, behavioral, and social risks to a woman’s health and future pregnancies. It includes both prevention and management, emphasizing health issues that require action before conception or very early in pregnancy for maximal impact. The target population for preconception care is women of reproductive age, although men are also targeted by several components of preconception care. The overarching goal of preconception care is to provide: 1) screening for risks, 2) health promotion and education, and 3) interventions to address identified risks. Source: National center on Birth Defects and Developmental Disabilities,

Recommendations to Improve Preconception Health and Health Care 1.Individual responsibility across the lifespan 2.Consumer awareness 3.Preventive visits 4.Intervention for identified risks 5.Interconception care 6.Pre-pregnancy checkup 7.Health insurance coverage for women with low incomes 8.Public health programs and strategies 9.Research 10.Monitoring improvements Johnson K, Posner SF, Biermann J, et. al. 2006

Traditional Perinatal Care Continuum Preconception Antepartum Labor and birth Postpartum Primary care Labor and birth Well baby care Interconceptional period Postpartum visit Prenatal care ? Source: Practice Matters

Life Course Perspective The life course perspective conceptualizes birth outcomes as the end product of not only the nine months of pregnancy, but the entire life course of the mother leading up to the pregnancy. Suggests that a complex interplay of – biological, – behavioral, – psychological, – and social protective and risk factors contributes to health outcomes across the span of a person’s life. 9

10 We Are the Life Course

Implications for Strategic Planning Preconception Health and Health Care Theory (early programming/timing) – LCP points to the importance of the earliest experiences and exposures (early programming) and of critical or sensitive periods throughout life, in shaping the health of individuals and populations. Strategic Planning/Practice – Critical/sensitive periods of development Preconception Early childhood Adolescence Interconceptional Intergenerational Fine & Kotelchuck, 2010

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Implications for Strategic Planning Preconception Health and Health Care Theory (longitudinal approach/timeline) – Health develops over a person’s lifespan and across generations. Strategic Planning/Practice – Linkages to systems and services at critical life stages – Addressing the needs of family members and support systems simultaneously – Following the cohort from birth through the senior years to impact generations 13Fine & Kotelchuck, 2010

New MCH Life Course Continuum (Axis 1) Source: Practice Matters

Implications for Strategic Planning Preconception Health and Health Care Theory (health equity and environment) – “LC seeks to explain health disparities across populations and communities – …avoidable differences in health among groups of people who have different levels of social and economic advantages or disadvantages (e.g., …low income or education, members of a racial or ethnic group historically discriminated against). Braveman and Barclay (2009) Strategic Planning/Practice – Upstream approach to addressing the social determinants of health – Health equity strategies that focus on linkages that address socio-economic factors; education, employment, housing, family support systems. – Develop policies at the federal, state and local level that remove barriers and obstacles; address racism 15Fine & Kotelchuck, 2010

MCH Life Course Organization Social Determinants of Health Ladder (Axis 2) Public Policy Initiatives Economic Empowerment Zones Health Insurance Policies Housing Policy Community Environmental Impact Environmental Groups Food & Fitness Organizations Affordable Housing Organizing Organizational Impact PCAP/MOMS and WIC Chronis disease prevention/ Treatment Job Readiness Group/ Interpersonal Impact Centering Pregnancy ® Mother’s GroupsConsumer Involvement Organization Individual Impact Midwifery Care OB/GYN Medical Home Individual behavior change – reproductive/well- ness life plan Depression Screening & Treatment 16

Policy Implications for Preconception Health Care within a Life Course Framework Life Course Perspective Cost Effective Continuum of care Disease prevention Comprehensive health promotion Addresses socio-economic and environmental health disparities Current trajectory of funding Traditional Health Care High Health Care Costs Fragmented System Disease Management Emphasis on Clinical Care Emphasis on Individual Behavior Silo focused systems and services 17

Moving Forward into a New Era of Health Care 18

Examples of Developing an Agenda for Change Maternal and Child Health Life Course Research Network (MCH LCRN)-September 2010, the Center for Healthier Children, Families and Communities was awarded a three-year grant from the federal Maternal and Child Health Bureau (MCHB) to develop a Maternal and Child Health Life Course Research Network (MCH LCRN). RESEARCH/EDUCATION AMCHP/CityMatCH Women’s Preventive Health-With funding from the Centers for Disease Control and Prevention’s Division of Reproductive Health (DRH) and the Health Resources and Services Administration’s Maternal and Child Health Bureau (MCHB), AMCHP and CityMatCH aim to build state and local capacity to promote safe motherhood and enhance women’s health before, during and after pregnancy. POLICY The reviews of federal Healthy Start as a community-based core service centered program have focused on its impact on birth outcomes and the delivery of varied case management services to at-risk women living in vulnerable communities across our nation. The true success of federal Healthy Start has been the fact that this network of projects is successfully emerging as a delivery system for addressing not just community needs specific to maternal and child health but for enhancing access to a continuum of care and social supports for vulnerable populations that include comprehensive preventive services, women’s health, and care coordination of chronic diseases both in clinic and other group settings and in participant homes (National Healthy Start Association, Federal Healthy Start Initiative: A National Network for Effective Home Visitation and Family Support Services, 2010). PRACTICE/PROGRAM PLANNING 19

Real Time Examples of LCP Programs and Funding Opportunities Contra Costa Health Services – The Life Course Initiative, a 15 year Family, Maternal, and Child Health Initiative The Building Blocks Collaborative – partnership of Alameda County organizations and the Alameda County Public Health Department Northern Manhattan Perinatal Partnership, Inc. Harlem Children’s Zone Life Course Initiative for Healthy Families – Wisconsin Partnership Program Magnolia Place Community Initiative – Unities Children’s Bureau with 70 plus other private and public organizations Promise Neighborhoods Programs Community Transformation Grants 20

Limitations Additional research and program evaluation on the long term efficacy of this methodology; Limited integration of preconception health and LCP at an academic level; and, the continuation of silo focused traditional approaches to improving perinatal outcomes. 21

Key Points Preconception health is a gateway for broader conversations about women’s wellness. Health practices and policies with an individual focus have finite success. Researchers have been advocating for broadening the spectrum of improving health using life course for over a decade. 22

Resources Rethinking MCH: The Life Course Model as an Organizing Framework: A Fine, M Kotelchuckn Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care: Unites States: a report of the CDC/ATSDR Preconception Care work group and the select Panel on Preconception Care. MMWR Morb Mortal Weekly Report Rep 2006; 55:1 -23 Contra Costa Health Services The Building Blocks Collaborative HRSA/MCHB Life Course Resource Guide Promise Neighborhoods Community Transformation Grants Northern Manhattan Perinatal Partnership Harlem Children’s Zone Lifecourse Initiative for Health Families partnership-program/lihf-request-for-proposals/1405http:// partnership-program/lihf-request-for-proposals/1405 Magnolia Place Community Initiative community-initiative.htmlhttp:// community-initiative.html 23

Achieving Health Equity by: Building a Social Movement, Investing in Ideas, Executing Tasks, Returning Results! Linking Women to Health, Power and Love Across the Life Span 24

Thank you for your time and attention! Tamara Wrenn, MA, CCE, CIMT, CWC