See Them As Women, See Them As Mothers

1. See Them As Women, See Them As Mothers

2. Lift Every Voice (LEV) Program Jeannie Cummings, MA Itika Greene, NP, MPH Suzzette C. Johnson, MSW, MPA Family, Maternal and Child Health Programs: Contra Costa Health Services American Correctional Health Services Association Conference November 4, 2011 “See Them as Women, See Them as Mothers”

3. Lift Every Voice (LEV) Program • Today’s Intention • “See them as women, see them as mothers” • Address how women’s health affects the health of her family and community. • Acknowledgements

4. LEV Presentation Objectives At the end of today’s presentation, participants will: • Learn how a public health program model can be integrated into the criminal justice system in order to better serve women. • Learn how health inequities impact health outcomes among African American and low socioeconomic populations. • Understand preconception health care recommendations to improve reproductive health care for women and improve perinatal outcomes.

5. LEV Mission & Background Mission To inspire, motivate, and empower women to take constructive action to support their mental, emotional, spiritual, and physical well-being. Background • Started in 2005 • Contra Costa County Health Services/Public Health in Family, Maternal and Child Health Programs as part of Perinatal Services Coordination • Concentration in West County Detention Facility

6. LEV Program Description • Home visiting, outreach and case management services • Links to prenatal care, psychosocial support services, and other home visiting programs • Psychosocial education, support, and advocacy • Engages and retains women until delivery of babies • Comprehensive and holistic, culturally sensitive, strength-based, gender-specific, trauma informed • Innovative public health approach within criminal justice system • Systems intervention • “Life Course” Perspective

7. Life Course Perspective • A way of looking at life not as disconnected stages, but as an integrated continuum • Suggests that a complex interplay ofbiological, behavioral, psychological, and social protective and risk factorscontributes to health outcomes across the span of a person’s life Michael C. Lu, MD, MPH, 2011

8. Protective factors Risk factors Life Course Model (Lu, 2003)

9. What is “GOOD” Health? Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. World Health Organization (WHO)

10. What is “GOOD” Health? • Health is a state of well-being with physical, emotional, mental, and spiritual dimensions that serves as an essential foundation for human life with implications for how all other aspects of life are pursued and evolve. • It is also an essential resource to be valued by individuals, families, communities, and our larger global community. Health may vary in how it is defined, qualified, and pursued within diverse communities and for individuals. Barbara C. Wallace, PhD (Toward Equity in Health, 2008)

11. “All members of a community are affected by the poor health status of its least healthy members. Infectious diseases, for example, know no social/ethnic or socioeconomic boundaries.” “Unequal Treatment”, 2003

12. Health Disparities • Health disparities refer to differences in health outcomes (death, illness, injury, and birth-related outcomes). • “A difference in rates of illness, disease, or conditions among different populations.” Turning Point: Collaborating for a New Century in Public Health. The University of Washington School of Public Health and Community Medicine/Robert Wood Johnson Foundation/National Association of County and City Health Officials.

13. Health Inequities • “Health inequities refer to material, social, gender, racial, incomes, and other social and economic inequalities that are beyond the control of individuals and are therefore considered unfair and unjust.” Health Canada, Population & Public Health Branch • “Health inequities are differences in health status and mortality rates across population groups that are systemic, avoidable, unfair and unjust…” and arise from racial and class based inequities. Adapted from Margaret Whitehead and Unnatural Causes

14. Health Equity Health equity means fairness and justice in efforts to achieve the best possible health for everyone, especially for those groups who have systematically faced greater obstacles to being healthy through social disadvantage, discrimination, or marginalization.

15. Social Determinants of Health • The social determinants of health are the conditions in which people are born, grow, live, work, and age, including their experience in and access to the health care system. • Circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. World Health Organization (WHO)

16. Social Determinants of Health:Examples • Socio-economic status • Stress • Early Life • Social Exclusion • Work • Unemployment • Social Support • Addiction • Food • Transportation World Health Organization (WHO)

17. LEV Approaches & Practices • Gender-specific treatment • Trauma-informed care • Motivational interviewing • Family-centered approach • Strength-based • Cultural humility • Eco map

18. A Typical LEV Day • In West County Detention Facility (WCDF) • In the Community • In the Courts, Probation, and Parole • During a Home Visit • In the Hospital • In the FMCH Office

19. Who Are the Women Served by LEV? • Black/African American (44%) • Average Age (23-29) • Education (8-9th grade) • Unstable intimate partners - FOB • Partner abuse/domestic violence • Sexual Abuse • Alcohol, Tobacco and Other Drugs Use (2/3) • Unintended pregnancy • Pre-term labor • Pre-existing medical conditions • Unstable housing

20. Who Are the Women Served by LEV? • History of previous incarceration • History of CPS/CFS involvement • Poverty • Isolation • Mental Health • Depression & Anxiety Disorders • Bi-polar Disorder • PTSD • Trauma • Personality Disorders

21. Behaviors Observed of the Women Served by LEV in WCDF • Entitlement and privilege • Aggression toward staff • Excessive calls to triage • “Getting even” with staff by refusing to take prescribed medication • Misplaced Anger • Pressured and hurried attitude • Lack of social skills • “Child-like” behaviors • Attention seeking behaviors • Depression • Excessive crying

22. LEV & Clients Work Together in Developing an Individualized Care Plan Intake Questions • Where are the children? • Who has custody of the children? • Who are the main caregivers? • Is there an open CFS case? • Is there domestic violence? • What is your plan for the baby? • Previous or current AODS history? • Are you on parole or probation?

23. LEV DVD Part 1

24. Provider Challenges in Working with Incarcerated Women • Compassion Fatigue • Vicarious Traumatization • Dealing with Women’s Anger • Lack of Understanding of Trauma and impact on the women • Lack of Provider Training • Medical Records Come after women have left WCDF

25. Provider Recommendations • Redirect behaviors • Don’t personalize • Talk about the baby • Let the client lead (not too pushy or aggressive) • Empathetic Listening • All female inmates are not alike • Assume Good Will • Talk about healthy life-style changes

26. Lessons Learned • Community partnership expansion and development • Jail health care a ‘window of opportunity’ • Women shut down when feel being judged • Women are a ‘specialized’ population

27. What Can We Do To Make Sure the Women Have Healthy Babies?

28. Prenatal Care • Prenatal care alone is not enough to improve birth outcomes. • In order to improve birth outcomes, interventions must address health equity and the social determinants of health. • Social determinants of health means that where women live, learn, work, and play contribute to their overall health status. Contra Costa FIMR Program, 2010

29. Recommendations for Improving Preconception Health 1. Prevention • Preventive visits: As a part of primary care visits, provide risk assessment and counseling to all women of childbearing age to reduce risks related to the outcomes of pregnancy. 2. Interventions • Interventions for identified risks:Increase the proportion of women who receive interventions as follow up to preconception risk screening, focusing on high priority interventions.

30. Recommendations for Improving Preconception Health 1. Interconception • Interconception care: Use the interconception period to provide intensive interventions to women who have had a prior pregnancy ending in adverse outcome (e.g., infant death, low birthweight or preterm birth). 2. Pre-pregnancy • Pre-pregnancy check ups: Offer, as a component of maternity care, one pre-pregnancy visit for couples planning pregnancy.

31. Chronic Disease Management • Examples (not limited to): • Diabetes • Hypertension • Obesity • Asthma

32. Folic Acid for Men & Women • Men: A study published in Human Reproduction (2008) showed that men who take folic acid lower their risk of having abnormal sperm by 20-30 percent. So men eat foods high in folate, such as fruits & vegetables to help lower the chances of birth defects. • Current recommendation for women: Take folic acid before pregnancy to lower the chance of Neural Tube Defects. • Men & Women: Consume at least 400 micrograms of folic acid daily, in addition to foods high in folate. • Men & Women: Be physically active for at least 30 minutes a day.

33. Oral Health • See a dentist and get teeth cleaned before/during pregnancy. • Pregnancy: dental care can improve the health of the baby. • All pregnant women have dental insurance through Medi-Cal. This includes 60 days postpartum. Source: FMCH Children’s Oral Health Program brochure May 2011

34. Birth Spacing

35. Contraceptive Effectiveness and Continuation Rates Source: Hatcher, RA et al; Contraceptive Technology 19th Edition, 2007

36. Perinatal Depression &Anxiety

37. Every Woman California www.everywomancalifornia.org Information about health considerations for women and their partners before they become pregnant for the first time or between pregnancies (preconception health). Links to resources and tools for health care providers and public health professionals.  Information for women and men who want to learn what they can do to be healthier for themselves and for their families.

38. Discrimination and Disparities in Health Perceptions of discrimination have been shown to account for some of the racial differences in birth outcomes in U. S. data. (Mustillo et al. 2004)

39. Institute of Medicine’s Report: Unequal Treatment, June 2002 The report showed that patient outcomes were affected by the way providers and the system treated them and that people of color were treated differently, so people’s lives were at stake.

40. LEV DVD Part 2

41. Jeannie Cummings, MA LEV Program Coordinator (925) 313-6313 jeannie.cummings@hsd.cccounty.us Itika Greene, NP, MPH FMCH Public Health Nurse Consultant Suzzette C. Johnson, MSW, MPA LEV Program Manager Thank you for your tireless & enthusiastic energy, skills, & focus.

42. QUESTIONS & ANSWERS See Them As Women, See Them As Mothers