1. University of North Texas Health Science Center at Fort Worth 3rd Annual North Texas Health Forum Reducing Infant Mortality in Tarrant County Understanding the Life Course Approach to Reducing Infant Mortality Audra D. Robertson, MD, MPH Brigham and Women’s Hospital Harvard Medical School April 8, 2010

2. Babies born to Black women in the US, Texas, and Tarrant County are more than twice as likely to die in the first year of life compared to babies born to White women. In Boston, three times as likely.

3. Infant mortality is a significant indicator of a community’s health and social welfare

4. Understanding the Life Course Approach to Reducing Infant Mortality 1.Defining the disparity  Review national, state, local data to identify the disparity 2. Understanding the cause of the disparity  Preterm Birth  Risk versus Care 3. Addressing the disparity  Understanding the life course approach  Stress and preterm birth ▪ Barker Hypothesis, Allostatic Load, Weathering  Implementing a Life Course Approach 4. Discussion

5. Definitions  Infant death: Death of an infant in the 1 st year of life  Infant mortality rate: Number of infant deaths per 1,000 live births.  Term birth: Birth from 37 to 41 completed weeks of gestation.  Preterm birth: Birth before 37 weeks  Very preterm birth: Birth before 32 weeks  Late preterm birth: Birth from 34 to 36 weeks

6. Decline in the Infant Mortality Rate in the US by Race, Decline in the Infant Mortality Rate in the US by Race, 1980-2000 DHHS NCHS National Vital Statistics Reports, 2002

7. United States, Table 1: Health 2008 IMR: Deaths per 1,000 live births

8. National, State, and Local Infant Mortality Rates and the Racial Disparity (2006) HP 2010 HP 2010 1 National Center for Health Statistics, 2007 2 Massachusetts Dept of Public Health, 2008 3 Texas Dept of State Health Services and Tarrant County Public Health, 2009 4.5 Black White 2.4x 2.3x 2.3x3.7x

9. A Case of Infant Mortality  A healthy 34 year-old African American woman presented to a teaching hospital with bleeding and abdominal pain at 27 weeks gestation  Despite current medical intervention, she delivered a ounce boy prematurely  He lived 24 days  The mother has yet to recover emotionally from this loss

11. US IMR by Race 1995 and 2005 2 National Center for Health Statistics, 2010 All Races………………………………….……. White..……………………………………..….. Black ……………………………………………. Native American …………………………… Asian ……………………………………………. Hispanic ………………………………………… Mexican …..………………………………… Puerto Rican …………………………….… Cuban ……………………………………….. Central and South American …………. 1995 7.6 6.3 14.6 9.0 5.3 6.3 6.0 8.9 5.3 5.5 2005 6.9 5.7 13.6 8.1 4.9 5.6 5.5 8.3 4.4 4.7

12.  Hispanic groups have lower socioeconomic status, but better than expected health and mortality outcomes  Explanation (unknown)  Healthy migrant effect  Return migration effect  Social capital, resiliency  Reasons for this paradox are likely to be multifactorial and social in origin  Outcomes worsen after acculturation

13. 1.Defining the disparity  Review national, state, local data to identify the disparity 2. Understanding the cause of the disparity  Preterm Birth  Risk versus Care 3. Addressing the disparity  Understanding the life course approach  Stress and preterm birth ▪ Barker Hypothesis, Allostatic Load, Weathering  Implementing a Life Course Approach 4. Discussion

14. Infant Death (Death in 1 st year of life) Neonatal (<28 days of life) Birth defect Premature birth Postnatal (28 days – 11 months) Birth defect Sudden Infant Death (SIDS)

15. CDC/NCHS National Vital Statistics System, 2008 46%

16.  Estimated total annual health care charges for babies born in the US: Estimated $52 Billion (for 4.3 million live births)  Total cost for babies born premature $26 Billion (for 546,000 preterm births)  Average health care cost for a baby born healthy $4,551  Average health care cost for a baby born premature $49,000 The Cost of Preterm Births Source: March of Dimes 2009, AHRQ Healthcare Costs and Utilization 2007, and Institute of Medicine 2006

17. Premature Birth & Low Birth Weight Risk Gene Environment Poverty Education Stress Immune/ Inflammatory Neuro- Endocrine Generational Effect Bias Care Differences in access to care Differences in care received The root causes of the disparity

18.  Collins and David NEJM 1997  Examined LBW of African-born blacks living in U.S., U.S. born African Americans, and U.S. born whites.  LBW among African-born blacks closer to U.S. born whites, but by 2 nd generation black to white gap started to emerge.

19. Collins and David NEJM 1997

20. Premature Birth & Low Birth Weight Risk Gene Environment Poverty Education Stress Immune/ Inflammatory Neuro- Endocrine Generational Effect Bias Care Differences in access to care Differences in care received The root causes of the disparity

21. Premature Birth & Low Birth Weight Risk Gene Environment Poverty Education Stress Immune/ Inflammatory Neuro- Endocrine Generational Effect Bias Care Differences in access to care Differences in care received The root causes of the disparity

22.  Collins et al. 1997  Women with 16 years or more Education  Small-for-Dates Rate ▪ African-Americans2.8% ▪ Whites1.2% ▪ Odds Ratio2.9 (CI 1.4-4.5)

23. Adapted from D. Williams

24. Premature Birth & Low Birth Weight Risk Gene Environment Poverty Education Stress Immune/ Inflammatory Neuro- Endocrine Generational Effect Bias Care Differences in access to care Differences in care received The root causes of the disparity

25. Premature Birth & Low Birth Weight Risk Gene Environment Poverty Education Stress Immune/ Inflammatory Neuro- Endocrine Generational Effect Bias Care Differences in access to care Differences in care received The root causes of the disparity

26. 1.Defining the disparity  Review national, state, local data to identify the disparity 2. Understanding the cause of the disparity  Preterm Birth  Risk versus Care 3. Addressing the disparity  Understanding the life course approach  Stress and preterm birth ▪ Barker Hypothesis, Allostatic Load, Weathering  Implementing a Life Course Approach 4. Discussion

27.  Health is shaped by the biological, behavioral/social and psychosocial pathways operating throughout life, as well as across generations  Study of independent, cumulative and interactive effects of biological, social and psychological risk factors/exposures during gestation, childhood, adolescence, young adulthood and later adult life on women's health and birth outcomes Kuh D and Hardy R. A Life Course Approach to Women’s Health. 2002

28. Understanding the exposure–outcome associations across an individual lifespan accounting for:  critical or sensitive period of exposure  exposure trajectory  intensity of exposure over time (accumulation) Kuh D and Hardy R. A Life Course Approach to Women’s Health. 2002

29. Embryo Child Adolescence Young Adult / Adult Pre-conception Prenatal Inter-conception View life, not in stages, but as integrated continuum Begin to understand critical/sensitive periods of risk as well as cumulative effects i.e. Barker Hypothesis e.g. Environmental Pollution e.g. Mental Health

30.  Reproductive capacity begins with menarche and ends with menopause  Yet, reproductive health begins in utero and is influenced by:  Life circumstances such as neighborhood environment, relationship interactions and social support structures  An individual's stress coping skills and disposition Mishra G, Cooper R, and Kuh D. Maturitas 65;2:2010 (92-97)

32.  A large body of evidence supports maternal psychosocial stress as an independent and significant risk factor for preterm birth 1  Evidence supports a correlation between maternal psychological stress and the placental–adrenal endocrine axis 2  Research implicates CRH as a contributor to the initiation of labor in term and preterm birth 3 1 Hedegaard, 1993; Hobel, 2003; Ruiz, 2003; Zambrana, 1999 2 Lockwood, 1999; Wadhwa et al, 2001 3 Holzman, 2001; McGrath, 2002; Moawad, 2002

35.  The fetal origins of adult disease  Biologic Programming Exposures during critical periods of growth and development in utero may “program” the structure or function of organs, tissues, or body systems  Previous Theory  adult lifestyle model  social causation Barker DJP. Fetal and infant origins of adult disease. London: British Medical Publishing Group, 1992.

36. Physiologic Response StressRecovery “Stressed”  Increased cardiac output  Increased available glucose  Enhanced immune function  Growth of neurons “Stressed Out”  Hypertension, CV disease, MI  Obesity, glucose intolerance & insulin resistance  Infection & inflammation  Atrophy & death of neurons Time No Recovery Physiologic Response Adapted from M. Lu and B McEwen

37.  Homeostasis: remaining stable by constancy  Allostasis: fluctuation of the physiologic systems within the body to meet demands from external forces, causes activation of neural, neuroendocrine and neuroendocrine-immune mechanisms  Allostatic Load: the physiologic “cost” of an individuals reaction to repeated challenge (thus chronic exposure to fluctuating or heightened neural or neuroendocrine responses) McEwen BS. Ann N Y Acad Sci. 1998

38.  An individual may age prematurely because of exposure to chronic stress early in life  Stress Age versus Chronologic Age  Geronimus and Weathering  associated with adverse pregnancy outcomes and hypertension among black and poor women  McEwen and Allostatic load  the cumulative wear and tear that the body experiences as a result of daily life Geronimus AT.Ethn Dis 1992 and McEwen Metabolism 2003

39.  The Barker Hypothesis of the fetal origins of adult disease  The HPA axis remains plastic throughout life and is molded and remodeled by environmental exposures  Animal studies support that chronic stress can program the fetal brain’s reaction to novel stressors  Stress exposure up-regulates gene expression of CRH which may create exaggerated physiologic responses to stressors  Thus, programming future stress responses Rosen JB et al. Behav Neurosci 1996.

40. Risk Reduction and Health Promotion Strategies to Improve Birth Outcomes Young Adult/ AdultAdolescence White African American Perinatal Reproductive Potential Life Course African American Childhood Age 0 Adapted from Lu and Halfon. Matern Child Health J. 2003;7:13-30. Risk Factors Protective Factors

41. Adapted from McGinnis et al., Health Affairs 2002

42. Strategies to Reduce Infant Mortality using a Life Course Approach Address the root cases Chronic Maternal Stress Preterm birth and low birth weight birth Address social determinant of health Incorporate a life course approach to scientific investigation, program integration, and policy development Embryo Child Adolescence Young Adult / Adult

43. Atwood K et el. Am J of Pub Health 1997. 87(10):1603-6. Richmond and Kotelchuck. from Oxford Textbook of Public Health. 1991 Prevention Priorities Knowledge Base Political Will Social Strategy

44.  Reduce the number of high-risk pregnancies  Preconception Health  Optimal Social Determinants of Health  Optimal Reproductive Life Plan  Reduce LBW and preterm birth  Health promotion  Optimal PNC (e.g. progesterone for previous PTB, group prenatal care)  Improve birthweight specific survival  Access to quality OB care and high volume NICU -> Regionalized care  Reduce death from sudden infant death syndrome  Support services, parent education, and health promotion

45. 1. Provide inter-conception care to women with prior adverse pregnancy outcomes 2. Increase access to preconception care for African American women 3. Improve the quality of prenatal care 4. Expand healthcare access over the life course 5. Strengthen father involvement in African American families 6. Enhance service coordination and systems integration 7. Create reproductive social capital in African American communities 8. Invest in community building and urban renewal 9. Close the education gap 10. Reduce poverty among Black families 11. Support working mothers and families 12. Undo racism Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes: A life-course approach. Ethnicity and Disease. 2008

46. Acknowledgments o Richard Kurz, PhD UNT HSC School of Public Health o Mario Drummonds, MS, LCSW, MBA CEO, Northern Manhattan Perinatal Partnership, Inc and Practice Matters o Tamara Wrenn, MA, CCE, CIMT Senior Consultant, Practice Matters o Michael Lu, MD, MPH UCLA School of Public Health o David Williams, PhD Harvard School of Public Health o Richard David, MD o James Collins Jr, MD, MPH

47. University of North Texas Health Science Center at Fort Worth 3rd Annual North Texas Health Forum Reducing Infant Mortality in Tarrant County Understanding the Life Course Approach to Reducing Infant Mortality Audra D. Robertson, MD, MPH Brigham and Women’s Hospital Harvard Medical School April 8, 2010