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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Misra, Guyer, and Allston, 2003

10. Misra and Grason, 2005

11. 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

12. 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

13. 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

14. 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.

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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