We Can Do Better: Reinventing Maternal

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We Can Do BetterReinventing Maternal Child
Health in America

• Michael C. Lu, MD, MPH
• Associate Professor
• Department of Obstetrics Gynecology
• David Geffen School of Medicine at UCLA
• Department of Community Health Sciences
• UCLA School of Public Health
• 2008 CityMatCH Conference
• Albuquerque, NM
• September 23, 2008

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Acknowledgment

• Mario Drummond
• Neal Halfon
• Milt Kotelchuck
• Cheri Pies

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• Why Reinvent MCH?

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Maternal Mortality
Source OECD Health Data 2008
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Infant Mortality
Source United Nations. Table 4. In United
Nations Demographic Yearbook, 2004. New York, NY
United Nations 20077393.
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U.S. Rank in OECD

• Maternal mortality
• All races 25th
• Whites only 19th
• Infant mortality
• All races 22nd
• Whites only 22nd

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Racial Ethnic DisparitiesPregnancy-Related
Mortality Ratio, 1991-1999
Deaths Per 1,000 Live Births
Chang et al MMWR 2003
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Racial Ethnic DisparitiesInfant Mortality, 2005
Deaths Per 1,000 Live Births
NCHS 2008
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Healthy People 2010Infant Mortality
Per 1,000 Live Births
Year 2010 Goal
NCHS 2008
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Healthy People 2010Low Birthweight
Per 1,000 Live Births
Year 2010 Goal
NCHS 2008
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Healthy People 2010Very Low Birthweight
Per 1,000 Live Births
Year 2010 Goal
NCHS 2008
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Healthy People 2010Preterm Birth
Per 1,000 Live Births
Year 2010 Goal
NCHS 2008
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• How Can This Be?

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How Can This Be?

• First, the pathways to better health do not
  generally depend on better health care, and
  second, even in those instances in which health
  care is important, too many Americans do not
  receive it, receive it too late, or receive
  poor-quality care.

Schroeder SA. NEJM 20073571221-8
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How Can We Do Better?

• Transform maternal and child healthcare in
  America
• Assure the conditions in which all mothers and
  children can be healthy

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• 1. Transforming Maternal
• Child Healthcare
• in America

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Pediatric Office 2.0
Preventive Care
Acute Care
Pediatric Office
Chronic Care
Developmental Services
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Pediatric Office 3.0
Evaluation (IDEA Sector
Screening Pediatric Services Sector
Surveillance Community Services and Resource
Sector
Assessment Peds/HPlan/PHSector
IDEA Regional Center for Developmental Disabilitie
s
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
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Health Development

• Preconception care 3.0
• Prenatal care 3.0
• Postpartum care interconception care 3.0
• Pediatric care 3.0
• School health 3.0
• Adolescent health 3.0
• Family planning/reproductive health 3.0
• Children with special healthcare needs 3.0
• Vertical, horizontal longitudinal integration
• Universal healthcare

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• 2. Assure Conditions
• in Which All Mothers Children Can Be Healthy

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Developmental Strategies

• Health development (health capital)
• Educational development (human capital)
• Economic development (material capital)
• Family development (relational capital)
• Community development (social capital)
• Sustainable development (natural capital)

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Educational Development

• Preconception and prenatal care
• Parenting education
• Child care
• Universal Preschool
• Early Head Start and Head Start
• K-12 small class size, teacher quality,
  standards
• After school and summer programs
• Youth development
• Health education/physical education
• Comprehensive school health clinics

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Educational Development

• Early Childhood programs
• After-school programs
• Summer Programs
• Comprehensive school health clinics
• 156 billion

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Economic Development

• Raise minimum wage
• Expand Earned Income Tax Credits
• Strengthen collective bargaining
• Providing safety net unemployment, housing,
  food stamps
• Providing job training and retraining
• Assuring universal healthcare
• Expanding access to family and medical leave,
  quality childcare, universal preschool
• Teach financial literacy
• Extend microloan programs
• Macroeconomic policies

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Family Development

• Human development (education, employment,
  legal/social services)
• Life skills training
• Reproductive health
• Violence prevention
• Marriage counseling/family therapy
• Economic development
• Criminal justice system reforms
• Tax reform
• Welfare reform
• Child support reform

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• Relationality is primary,
• All else is derivative.
• - Ronald David

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• Black babies are dying because their mothers are
  dying in dead relationships.
• - Sister Byllye Avery

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• Efforts to reduce maternal and infant mortality
  and morbidity must focus on the repair and
  support of interpersonal relationships at all
  levels.
• - National Commission on Infant Mortality

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Community Development

• Economic development
• Affordable decent housing
• Delink schools and property tax
• Community policing
• Municipal services
• Infrastructure development
• Clean air and water
• Create social capital
• Create cultural capital
• Residential desegregation

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Reproductive Social Capital

• Features of social organization that facilitate
  coordination and cooperation to promote
  reproductive health within a community
• community networks
• civic engagement
• local identity and a sense of solidarity and
  equity with other community members
• trust and reciprocal help and support.

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Sustainable Development

• Teach individual responsibility
• Protect air quality
• Protect water quality
• Protect food safety
• Provide consumer education
• Mobilize consumer actions
• Require higher standards and more testing of
  consumer products
• Promote smart growth
• Stop global warming
• Support research on environmental influences

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Now that youre here, the word of the Lorax
seems perfectly clear. UNLESS someone like
you Cares a whole awful lot, Nothing is going to
get better. Its not. SO Catch! calls the
Once-ler. He lets something fall. Its a
Truffula Seed. Its the last one of all! Youre
in charge of the last of the Truffula Seeds. And
Truffula Trees are what everyone needs. Plant a
new Truffula. Treat it with care. Give it clean
water. And feed it fresh air. Grow a forest.
Protect it from axes that hack. Then the
Lorax And all of his friends May come
back. - Dr. Seuss, the Lorax
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• Reinventing MCH

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Reinventing MCH

• Create a new roadmap for MCH
• Transform maternal child healthcare
• Assure conditions for optimal MCH development
• Revise MCH core functions
• Retool MCH workforce
• Reorganize MCH programs
• Establish MCH Trust Fund
• Engineer MCH innovations

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• 1. Create a New Roadmap to MCH

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• Map to Nowhere?

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• If you don't know where you are going, any road
  will take you there.
• Lewis Carroll, Alice in Wonderland

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• What should our national goals for MCH be for
  the Year 2020? 2030? 2040? What should be our
  Healthy People 2020 objectives for MCH?

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• 2. Transform Maternal
• Child Healthcare

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• Integration

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• Not just providing stop-gap services, but
  building integrated systems and assuring access,
  quality, coordination integration

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• Universal Coverage

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• 3. Assure Conditions
• for Optimal MCH Development

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Community Development
Environment
MCH
Healthcare
Education
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MCH Life- Course Organization
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• We must become the change we want to see.
• - MAHATMA GANDHI

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• 4. Redefine MCH Core Functions

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Ten Essential Public Health Services to Promote
Maternal and Child Health in America

• Assess and monitor maternal and child health
  status to identify and address problems.
• Diagnose and investigate health problems and
  health hazards affecting women, children, and
  youth.
• Inform and educate the public and families about
  maternal and child health issues.
• Mobilize community partnerships between
  policymakers, health care providers, families,
  the general public, and others to identify and
  solve maternal and child health problems.
• Provide leadership for priority-setting, planning
  and policy development to support community
  efforts to assure the health of women, children,
  youth and their families.
• Promote and enforce legal requirements that
  protect the health and safety of women, children,
  and youth, and ensure public accountability for
  their well-being.
• Link women, children, and youth to health and
  other community and family services, and assure
  access to comprehensive, quality systems of care.
• Assure the capacity and competency of the public
  health and personal health work force to
  effectively address maternal and child health
  needs.
• Evaluate the effectiveness, accessibility, and
  quality of personal health and population-based
  maternal and child health needs.
• Support research and demonstrations to gain new
  insights and innovative solutions to maternal and
  child health-related problems.

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• How will we redefine the 10 essential public
  health services to promote MCH in America?

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• 5. Retool MCH Workforce

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Retool MCH Workforce

• Assessment
• Longitudinal surveillance
• Multilevel surveillance
• Community-based participatory research

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Retool MCH Workforce

• Assurance
• Leadership
• Collaboration
• Advocacy

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Retool MCH Workforce

• Policy Development
• Health change theories
• Developmental strategies
• Political will

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• How would we revise the ATMCH core competencies
  to guide the transformation of the MCH workforce?

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• 6. Reorganize MCH Programs

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Reorganize MCH Programs

• Realign federal programs to support a transformed
  system, including establishing within DHHS the
  position of deputy secretary for MCH
• Establish a National MCH Investment Advisory
  Committee
• Establish systems to assure accountability and
  coordination of services at all levels

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• 7. Establish MCH
• Trust Fund

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Establish MCH Trust Fund

• Managed by Deputy Secretary for MCH
• Support systems building integration at state
  local levels
• Provide incentive grants to encourage innovations
  in MCH

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• 8. Engineer MCH Innovations

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• The definition of insanity is doing the same
  thing over and over and expecting different
  results
• - Benjamin
  Franklin

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Innovation is not an Option

• It is a necessity if we are going to improve MCH

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Figure 1 Collaborative Innovation Network
COIN Child Health
CoIN Financing
CLN
CoIN Measurement
CIN
CLN
CIN
CoIN Information Systems
CLN
State/Regional Policy CoIN
CIN
CLN
CIN
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Reinventing MCH

• Create a new roadmap for MCH
• Transform maternal child healthcare
• Assure conditions for optimal MCH development
• Revise MCH core functions
• Retool MCH workforce
• Reorganize MCH programs
• Establish MCH Trust Fund
• Engineer MCH innovations

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• All this will not be finished in the first 100
  days. Nor will it be finished in the first 1,000
  days, nor in the life of this Administration, nor
  even perhaps in our lifetime on this planet. But
  let us begin.

John F Kennedy (1961)
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