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Repositioning MCH in America: Where We Are…Where We Need to Go

April 8-9, 2009 Cornhusker Marriott Hotel 333 South 13th Street Lincoln, Nebraska. 2009 Nebraska Public Health Conference Prevent, Promote, Protect: Working Toward a Healthier Nebraska. Repositioning MCH in America: Where We Are…Where We Need to Go. Mario Drummonds, MS, LCSW, MBA

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Repositioning MCH in America: Where We Are…Where We Need to Go

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  1. April 8-9, 2009 Cornhusker Marriott Hotel 333 South 13th Street Lincoln, Nebraska 2009 Nebraska Public Health Conference Prevent, Promote, Protect: Working Toward a Healthier Nebraska Repositioning MCH in America: Where We Are…Where We Need to Go Mario Drummonds, MS, LCSW, MBA CEO, Northern Manhattan Perinatal Partnership, Inc.

  2. Acknowledgements • Dr. Michael Lu • Dr. Neal Halfon • Dr. Maxine Hayes • Dr. Jimmie Collins

  3. Presentation Objectives • Define the current political & public health climate that rationalizes reinventing MCH • Discuss the new leadership mandate and vision for a new MCH system of care • Communicate the MCH policy and programmatic choices for Nebraska & America

  4. Where Are We?

  5. National MCH System Challenges • A Recent CDC National Center for Health Statistics Report Revealed: • U.S. Teen Birth Rate (15-19) Increased from 41.9 births per 1000 in 2006 to 42.5 in 2007 • Total U.S. Births rose in 2007 to over 4,317,199-Highest Number of birth ever registered in the United States

  6. National MCH System Challenges • The Cesarean Delivery rate rose 2% in 2007, to 31.8%, marking the 11th consecutive year of an increase • Nearly 40% of Births were to Women Over 30 years of Age and Unmarried • Percentage of Low Birth weight Babies Declined Slightly between 2006 and 2007, from 8.3% to 8.2% -first decline

  7. National MCH System Challenges • In November 2008, the March of Dimes released its first annual “Premature Birth Report Card,” Giving the Nation an overall “D” grade

  8. Infant Mortality Rates 1. Singapore 2.7 14. Switzerland 4.9 2. Hong Kong 2.9 15. Australia 4.9 3. Japan 3.0 16. Canada 5.3 4. Sweden 3.2 17. Netherlands 5.3 5. Norway 3.8 18. Greece 5.4 6. Finland 3.8 19. Belgium 5.4 7. Czech Republic 4.1 20. Portugal 5.6 8. Denmark 4.2 21. United Kingdom 5.6 9. France 4.4 22. Israel 5.8 10. Spain 4.4 23. Ireland 5.9 11. Germany 4.4 24. New Zealand 6.1 12. Italy 4.6 25. Cuba 6.2 13. Austria 4.8 26. United States 6.8

  9. Infant Mortality Rate by State, 2002-2004 2010 Target = 4.5 D.C. N Per 1,000 live births 9.0 or more 8.0 - 8.9 7.0 – 7.9 6.0 – 6.9 Less than 6.0 (4) (8) (11) (16) (12) Source: NVSS, NCHS, CDC.

  10. Cities With The Highest IMR -- District of Columbia -- Norfolk -- Detroit -- Baltimore -- Atlanta -- Chicago -- Newark -- Philadelphia -- Cleveland -- Milwaukee

  11. Infant Mortality Rates In The U.S. (2003)

  12. Racial & Ethnic DisparitiesInfant Mortality, 2005 Deaths Per 1,000 Live Births Year 2010 Goal NCHS 2008

  13. Racial & Ethnic DisparitiesLow Birth Weight < 2500g2005 Percent of Live Births Year 2010 Goal

  14. 6,000 African-American infant deaths a year could be prevented if the IMR of African-Americans was lowered to the level of whites.

  15. Healthy People 2010Infant Mortality Per 1,000 Live Births Year 2010 Goal NCHS 2008

  16. Healthy People 2010Low Birthweight Per 1,000 Live Births Year 2010 Goal NCHS 2008

  17. Obesity Trends Among U.S. AdultsBRFSS, 1990 No Data <10% 10%–14%

  18. Obesity Trends Among U.S. AdultsBRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20%

  19. Obesity Trends Among U.S. AdultsBRFSS, 2000 No Data <10% 10%–14% 15%–19% ≥20%

  20. No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Obesity Trends Among U.S. AdultsBRFSS, 2003

  21. No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. AdultsBRFSS,1990, 1995, 2005 (*BMI 30, or about 30 lbs overweight for 5’4” person) 1995 1990 2005

  22. Maternal Obesity: 2-3x Risk of C-Section Potential mechanisms:  maternal pelvic soft tissue which narrows diameter of birth canal  dystocia  macrosomic infant Cephalopelvic disproportion Maternal obesity:  intrapartum meconium staining, cord accidents Gestational diabetes (but  C-section independent of diabetes) Conclusion: Obesity alone is a risk factor for C-section Chu et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007

  23. Maternal Obesity: Congenital Anomalies  neural tube defects x1.9  anencephaly x1.5  spina bifida x 2.2  cv anomaly x1.2  cleft palate x1.2  anorectal atresia x1.5  hydracephaly x1.7  limb reduction anomaly x1.3 Stothard et al. Maternal overweight and obesity and the risk of congenital anomalies. JAMA 2009

  24. Maternal Obesity & Risk of Stillbirth 2x  risk of stillbirth Possible mechanisms:  gestational DM  hypertension Other factors Conclusion: obese women should undergo weight reduction prior to pregnancy Chu et al. Maternal obesity and the risk of stillbirth: a metaanalysis. Am J Obstet Gyn 2007

  25. Obesity in Pregnant Women • Diabetes (2.6X higher) • Maternal blindness • Maternal limb amputation • Maternal renal failure • Increased risk of miscarriage • Increased risk of birth defects • Fetus exposed to an environment of high serum glucose • Fetus exposed to environment of nutritional deficiency (folate) Leddy et al. Rev Obstet Gynecol. 2008 Stothard et al. JAMA. 2009

  26. Maternal Mortality Source: OECD Health Data 2008

  27. National MCH System Strengths & Policy Initiatives • Children’s Health Insurance Bill Signed in Law by President Obama -another 4.1 million children covered– more than 11 million children now served in US

  28. National MCH System Strengths & Policy Initiatives • Expansion of Preconception and Interconceptional Care • Proposed Obama Administration Increase in MCH Block Grant Funding

  29. National MCH System Strengths & Policy Initiatives • Proposed Increase in Early Head Start & Head Start Funding over the Next Five Years • Growth of Life Course Theory in 2003 and its Potential to Influence MCH Practice in America

  30. National MCH System Strengths & Policy Initiatives • Proposed Obama Administration Investments in Nurse Family Partnership & Harlem Children’s Zone Replication Nationally • Growing Discussion & Appreciation for the Social Determinates of Health as Explainer of Racial Disparities in Health and the Solution to them

  31. What Is To Be Done?

  32. How Do We Reposition MCH in America? What Should MCH Look Like by 2030? Change in Vision; Structure; Financing, Policy, Program Design Needed:

  33. America’s MCH Vision • Recognize that Women Produce & Reproduce Life in America • Reproduction & Nurturing of Human Capital Key to Survival of the Nation! • Prenatal, Preconception and Interconception Care should be Linked Together as Part of a Comprehensive Solution to Women’s Health

  34. America’s MCH Vision • Focus on the Health of Women Beyond Pregnancy • Women’s Health is Housing Policy, Economic Development Policy, Environmental Policy, Education Policy, etc.

  35. Structure/Leadership • The Way MCH Services are Delivered in America is Currently Fragmented! • HRSA, MCHB, CDC, ACYF, NIH, etc. • Immediately Create a Deputy Secretary for MCH Position

  36. Structure/Leadership • Reports Directly to DHHS Secretary Nominee, Kathleen Sebelius • Charge-support systems building & Integration at Federal, State and Local Levels • Incentivize MCH Innovation throughout system

  37. Structure/Leadership • Consolidating Women & Children’s Health Assets into One Agency can Save Money and Increase Operating Efficiencies • Utilize President Obama’s newly created White House Council on Women and Girls as a Vehicle to Coordinate Women’s Health Policy and Financing Across Federal & State Agencies

  38. Financing • Health of Women Across the Life Course has to be a key component of any Health Care Reform Agenda in Washington

  39. Financing • If President Obama’s Health Care Reform Package stalls in Congress, these are some Tactical Solutions: • Soda or Tobacco Tax to create a women’s health funding stream for Interconceptional care • Medicaid Family Planning Waivers

  40. Financing • Private Employer-Based Plans • Community Health Centers • Healthy Start • Title X Family Planning Clinics • Title V Agencies

  41. Policy/Program Design • To achieve the vision above the MCH system in America today must strive to become more integrated assuring access, quality and coordination of affordable care across a woman’s life course!

  42. Operationalize Life Course Theory: • Show how health departments & MCH organizations change strategy, organizational structure, and integrate program interventions across the time-line and swim upstream addressing social determinates of health, thus improving women’s health

  43. Pediatric Office 2.0 Parenting Support Early Intervention Early Child Mental Health Services Home-visiting network Early HeadStart & HeadStart Child Care Resource & Referral Agency Developmental Services Lactation Support Preventive Care Acute Care Pediatric Office Developmental Services Chronic Care

  44. Pediatric Office Pediatric Office 3.0 Evaluation (IDEA Sector Surveillance Community Services and Resource Sector Screening Pediatric Services Sector Assessment Peds/HPlan/PHSector IDEA Regional Center for Developmental Disabilities Mid-Level Assessment Center Preventive Care Other Specialized Services Acute Care Developmental Services Chronic Care COORDINATION CENTER Child Care/Family Resource Center Program Surveillance Program

  45. Spectrum of Work for MCH Life Course OrganizationBuilding Public Health Social Movement Early Childhood Young Adult Women over 35 Birth Pre-teen Teen 45

  46. First-time MotherhoodNew Parent Initiative Purpose: Develop, implement, evaluate and disseminate novel social-marketing approaches that: • Concurrently increase awareness of existing preconception/interconception, prenatal care, and parenting services/programs, • Address the relationship between such services, health/birth outcomes, and a healthy first year of life.  • Include women and men who are from populations disproportionately affected by adverse pregnancy outcomes in their community including racial/ethnic minorities as well as their providers.

  47. First-time MotherhoodNew Parent Initiative HRSA’s Maternal and Child Health Bureau was allotted approximately $4.8 million for this activity through the ConsolidatedAppropriations Act 2008 (P.L. 110-161) . State-based Awards • 2009: AZ, CA, CT, FL, MA, NC, NE, NV, OR, PA, UT, WI • 2010: AZ, CA, CT, FL, MA, ME, NC, NE, NV, OR, PA, UT, WI

  48. Integrate MCH Core Services & Chronic Disease Management: The Ties that Bind • Millions of women have chronic health conditions during and prior to pregnancy • Maternal Weight, Obesity, Mental Health Issues Point to developing an Integrative MCH/Chronic Disease Strategy

  49. Integrate MCH Core Services & Chronic Disease Management: The Ties that Bind • 40,000 women in NYC have gestational diabetes • Focus on developing Interconceptional Protocols to address women with previous pregnancies that ended in adverse outcomes

  50. Integrate MCH Core Services & Chronic Disease Management: The Ties that Bind • Fully fund and execute CDC’s 10 Recommendations to Improve Preconception Health & Health Care • Develop a Work Team between MCHB & CDC to share evidence-based practices, develop evaluation protocols and share funding streams to integrate care

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