Cynthia A. Harding, M.P.H. Los Angeles County Department of Public Health

1. 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

2. 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

3. Today’s Presentation • Infant Mortality in Los Angeles County • Preconception Health • Life Course Theory and Framework • The Life Course Framework in Los Angeles County

4. Los Angeles, California

5. Infant Death Rate*1990-2002

6. 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).

7. 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

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

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

10. 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

11. Focus Group Findings • Women • 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

12. National FIMR forms to review 2002 AV infant deaths (N=53) PHNs conducted home interviews, abstracted hospital and provider records. Fetal Infant MortalityReview (FIMR)

13. 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

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

15. PPOR Findings

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

17. 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

18. 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

19. Data Source: Birth Cohort Data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.

20. LA County MCAH Programs

21. 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 Los Angeles Mommy and Baby Survey (LAMB)

22. 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 LAMB Findings:

23. Psychosocial Experiences

24. 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

25. From Data to Action

26. 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 Translating Data to Action

27. 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 ?

28. 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

29. 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 From Proposals to Policy

30. Who Needs to Help?? Healthy Moms & Babies

31. Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2005

32. Perinatal Summit Healthy Births Through Healthy Communities: Connecting Leadership to Achieve a Unified Commitment to Action Preconception Health Efforts Countywide LAMB Maternal Health/ Prematurity

33. Los Angeles CountyPreconception 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

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

35. Integration withPublic Health Practice • Workforce Education • Data Briefs • Evaluation

36. Community Engagement • Integration with family planning clinics • Reproductive Life Plan Toolkit • Policy Briefs: • Pregnancy and Family Friendly Workplace Policies • Breastfeeding-Friendly Workplace Policy Briefs

37. 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 Community Engagement

38. WIC Offers Wellness “WOW” Program WIC Offers Wellness PHFE-WIC 888-942-2229 WOW

39. 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

40. Conceptual framework Multidisciplinary model for studying lives, social contexts and social change Population focused Life Course Theory

41. Timeline Timing Environment Equity Life Course Concepts

42. RR Risk Reduction Strategies Risk Factors HP Health Promotion Strategies Trajectory Without RR and HP Strategies Optimal Trajectory RR RR HealthDevelopment RR HP HP HP Protective Factors 0 20 40 60 80 Age (Years) How Risk Reduction and Health Promotion Strategies influence Health Development 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.

43. 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

44. Protective factors Risk factors The Life Course Perspective(Lu, 2003)

45. 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 A 12-Point Plan to Address MCH Across the Life Course

46. Life Course Tool Box http://www.citymatch.org/lifecoursetoolbox/

47. 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.

48. 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

49. 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

50. 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.