New Approaches for Improving the Health of Mothers and Infants

1
New Approaches for Improving the Health of
Mothers and Infants

• Arden Handler, DrPH
• University of Illinois School of Public Health
• Maternal and Infant Mortality Summit
• October 24, 2007

2
Infant/Fetal/MaternalMortality Why do We Care?

• Why in the first decade of the 21st century is
  infant mortality still a major focus of our
  efforts to improve perinatal outcomes in the US?
• What is the meaning of infant mortality as a
  measure of health?
• Why are fetal and maternal health just as
  important?

3
Infant Mortality

• Infant mortality is an internationally recognized
  measure of a societys ability to provide food,
  housing, income, education, employment and health
  care to its citizens

4
Infant Mortality and its Precursors Low
Birthweight and Prematurity

• Preterm birth is the most frequent cause of
  infant death in the US, accounting for
  approximately 1/3 of all infant deaths
• Declines in infant mortality in the U.S. have
  been increasingly due to improved survival of
  small or premature infants, rather than due to
  decreases in the rates of low birthweight and
  prematurity
• Low birthweight and prematurity are associated
  with multiple negative infant and child health
  outcomes

5
Infant Mortality US versus other Developed
Nations

• As such, current differences in Infant Mortality
  rates in the U.S. and other developed countries
  are due to
• Differences in birthweight distribution (how many
  low birthweight infants there are)
• Rather than differences in birthweight specific
  mortality (death rates at each weight) among low
  birth weight infants

6
Low Birthweight and Prematurity the New Infant
Mortality?

• Because of the increasing ability to keep very
  small infants alive in the US, low birthweight
  and prematurity have replaced infant mortality as
  measures of our societys ability to take care of
  its most vulnerable populations
• This is why so much of our focus on infant
  mortality solutions is on solutions for the
  problems of low birthweight and prematurity

7
Infant Mortality Racial and Ethnic Disparities

• Likewise, because the disparities in infant
  mortality, prematurity and low birthweight are so
  pervasive and persistent, particularly between
  African-Americans and European Americans, focus
  on infant mortality solutions tend to focus on
  solutions to reduce these disparities

8
Infant Mortality Racial and Ethnic Disparities

• Latinos as a whole typically have similar
  perinatal outcomes to European Americans despite
  often having socio-economic circumstances that
  are not favorable
• However, some Latinos (e.g., Puerto Ricans) have
  rates of adverse pregnancy outcomes very similar
  to African-Americans

9
Prematurity and LBW are not the only Issues in
the AA EA IM GAP

• In general, higher Black infant mortality rates
  are not only due to the larger number of black
  infants born at low birthweight, but to the
  higher rates of death among Black term normal
  birthweight infants
• In other words, solving the prematurity/low
  birthweight problem will not completely solve the
  AA-EA Gap in Infant Mortality

10
Prematurity and LBW Increasingly Become Issues
for the Latino Community

• While prematurity and infant mortality rates may
  be lower for some Latino groups, particularly
  Mexicans, when compared to EA, immigrant women
  born in Mexico have consistently better pregnancy
  outcomes than Mexican-American women born in the
  US
• US born Mex-Am. are more likely to deliver a low
  birthweight baby or to experience preterm
  delivery than women born in Mexico
• Issue of acculturation (diet, family support and
  other protective factors)

11
Prematurity and LBW Increasingly become Issues
for the Latino Community although Other Health
Concerns Important

• As such, over time low birthweight and
  prematurity are increasingly becoming concerns
  in the Latino community
• In addition, high birthweight and associated
  issues of maternal obesity and diabetes are major
  health concerns

12
Fetal Mortality Another Important Indicator

• Because the death of a fetus prior to birth is a
  more invisible event, fetal mortality gets
  little attention from policy-makers in comparison
  to infant mortality
• Many of the risk factors for fetal death are the
  same as those for infant death
• Measuring feto-infant mortality provides a much
  measure better of perinatal health than IM alone

13
Maternal Mortality Another Important Indicator

• Maternal mortality in the U.S., has become a
  sentinel event
• Given current medical knowledge and technology,
  all maternal deaths in the U.S. are markers for a
  system gone awry
• However, a maternal death does not carry the same
  political weight as an infant death

14
Maternal Mortality

• Maternal deaths are just the tip of the iceberg
• Many more women are unhealthy during pregnancy,
  only a few die
• Most factors contributing to maternal morbidity
  and mortality also affect the well-being and
  survival of fetuses/infants

15
Risk Factors for Fetal/Infant/Maternal
Mortality
16
Risk Factors for Fetal/Infant/Maternal Mortality
17
Risk Factors What Solutions?

• Given the multitude of risk factors for adverse
  maternal, fetal and infant outcomes and given
  that there are both proximal (e.g., maternal
  disease) and distal risk factors (e.g.,
  low-income), how do we intervene?
• What is a public health solution to this
  public health problem?

18
Strategies for Preventing Infant/Fetal/Maternal
Mortality

• Public Health/Clinical Strategies to prevent
  high-risk pregnancies
• Comprehensive Sexual Health Education
• Preconceptional care/interconceptional
  care/well-women care
• Family Planning
• Abortion access
• Genetic Counseling
• Prepregnancy nutrition
• Adolescent Pregnancy Prevention Programs

19
Strategies for Preventing Fetal/Infant/Maternal
Mortality

• Public Health/Clinical Strategies to prevent
  morbid events during pregnancy, maternal death,
  fetal death and LBW and preterm birth
• Prenatal care/risk assessment--
• associated expansions of Medicaid to increase
  access to PNC for higher income but still
  relatively low-income women

20
Strategies for Preventing Fetal/Infant/Maternal
Mortality

• Prenatal Care (contd)
• Psychosocial interventions including smoking
  cessation, substance abuse reduction, depression
  screening and treatment
• Health education and promotion
• Screening for variety of medical risks (e.g.,
  hypertension, diabetes, STDS, HIV) and management
  of high-risk pregnancies including tocolysis,
  progesterone
• Nutritional supplementation WIC

21
Strategies for Preventing Fetal/Infant/Maternal
Mortality

• Preterm birth prevention programs- (e.g.,
  awareness of signs and symptoms of preterm labor,
  uterine monitoring programs)
• Family case-management
• Prenatal home visiting (public health nurses, lay
  health workers, social workers)
• Provision of social support (use of doulas is one
  type but not widespread)
• Mass media/health education campaigns

22
Strategies for Preventing Infant Mortality

• Public Health/Clinical Strategies to improve
  birth weight-specific morbidity and mortality
• Regionalization of perinatal care/Neonatal
  Intensive Care Units
• Use of antenatal corticosteroids to accelerate
  fetal lung maturation for women at risk of
  preterm birth (reduce respiratory distress
  syndrome)
• Treatments for VLBW infants (e.g., surfactant to
  improve respiratory status of preterm infants)
• Kangaroo Care- skin to skin contact between
  mother and newborn

23
Strategies for Preventing Infant Mortality

• Public Health/Clinical Strategies to reduce
  postneonatal mortality
• SIDS Initiatives (Back to sleep campaign)
• Access to well-child care and immunizations
• Postnatal home visiting/Social support
• Breastfeeding

24
Strategies for Preventing Infant Mortality
(Postneonatal continued)

• Medicaid/SCHIP expansions to insure childrens
  health care access
• 0-3 Programs/Developmental Follow-up Programs
• Nutritional supplementation WIC program
• Safe and adequate housing (public health has some
  role but not much control)

25
What have MCH professionals in Illinois
emphasized?

• Expansion of financial access to PNC and child
  health care
• Support for Family Case Management
• Regionalized Perinatal Care
• WIC Program
• SIDS Initiatives
• 0-3 Programs/Developmental Follow-up

26
What have MCH professionals in Illinois not paid
sufficient attention to?

• Quality and content of prenatal care/new and
  innovative models of prenatal care
• Changing regionalized perinatal care environment
  and the growth of NICUs in non-Level III
  hospitals

27
What have MCH professionals in Illinois not paid
sufficient attention to?

• Within programs such as FCM and Healthy Start,
  little attention to differences in the type of
  support offered, the role of support versus
  referral versus health education
• Insufficient focus on determining what about FCM
  makes a difference, thus enabling us to support a
  best practice model of FCM

28
What have MCH professionals in Illinois not paid
sufficient attention to?

• Health of women independent of pregnancy
• Intersection of chronic illness and maternal
  health (e.g., diabetes, hypertension, bacterial
  vaginosis)
• Financial support for health care independent of
  pregnancy
• Womens ability to control their reproduction
  (access to family planning and abortion)

29
What have MCH professionals in Illinois not paid
sufficient attention to?

• The extent to which community infrastructure is
  available to provide the basic supports necessary
  for healthy lives (e.g., housing, safety, food
  security, employment)
• Environmental conditions residential
  segregation, inadequate housing, community
  violence, environmental contaminants, options for
  healthy food purchases

30
What have MCH professionals in Illinois not paid
sufficient attention to?

• The extent to which poverty and racism are
  pervasive and are the overriding issues affecting
  health and well-being in many communities

31
Times are a Changing in Illinois

• Closing the GAP Quality of PNC Project
• Illinois Family Planning Expansion Waiver
• Healthy Births for Healthy Communities
  Interconceptional Care Demonstration Project
• March of Dimes Centering Pregnancy Initiative
• Earmark for community-based Doula initiative in
  Senate Bill in S. 1710

32
We are Moving Forward but what Have we Missed?

• Emile Papiernik (Dept. of OB and Gyne, Universite
  Paris) argues that the expectation that programs
  targeted only at high-risk women will improve
  birth outcomes among these women is unfounded
• According to Papiernik, universal approaches
  reduce the occurrence of high-risk factors in
  the (overall) population, thereby reducing the
  proportion of women with a previous preterm birth
  women with an episode of bleeding..

33
Universal MCH Supports

• The .model of protection of (all) pregnant
  women and their children.. is the best hypothesis
  to explain why the rate of preterm births in all
  European countries is lower than the rate of
  preterm births for white American births in the
  U.S.
• Of note, the rate of preterm birth for women of
  African ancestry in France (9) is almost half
  the rate for AA women in US
• Papiernik, MCHJ, 2007

34
Universal MCH Supports

• How France supports the health of Women, Infants
  and Children
• Unimpeded access for young women and men to
  contraception
• Sexuality education integrated across the
  curricula of students at all levels
• Widespread education campaigns focused on sexual
  health
• Easier access to medical and surgical abortion

35
Universal MCH Supports in France

• Three year paid parental leave with guaranteed
  job protection upon returning to the workforce
• Universal full-time preschool starting at 3
• Subsidized day care before age 3
• Stipends for in-home nannies
• Monthly child care allowances that increase with
  the number of children per family
• (contrast this with US family cap)

36
What is Possible in Illinois? the U.S.?

• European experience suggests that the following
  may make a difference in Illinois/US as well
• Increase access to comprehensive sexuality
  education (in all communities)
• Ensure financial access of all women to
• Well-woman health care across the life-course
• Family planning and abortion services (beyond
  medically necessary)

37
What is Possible in Illinois? the U.S.?

• Provide reimbursement for high quality prenatal
  care - - support development and testing of new
  models of prenatal care that meet the needs of
  diverse groups of women (e.g., Centering
  Pregnancy)
• Expand/modify (e.g., state supplement) WIC
  program to ensure access to healthy food beyond
  pregnancy/postpartum period increase access to
  healthy food in communities historically without
  such access
• Provide paid Maternity leaves/paternity leaves-
  antenatal and postnatal

38
What is Possible in Illinois? the U.S.?

• Expand/enhance supports available to pregnant and
  parenting women
• Ensure use(testing) of best approaches (based
  on the evidence) to providing emotional and
  instrumental support
• Ensure sufficient resources to support (test)
  components in programs such as Family Case
  Management and Healthy Start that make a
  difference (we have never had a sufficient test
  of FCM in IL. given insufficient funding and
  diversity of models)
• Ensure the availability of sufficient resources
  to address psychosocial factors (e.g., smoking
  cessation, substance abuse, mental health)

39
What is Possible in Illinois? the U.S.?

• Develop policies to promote breastfeeding both at
  home and in public including the workplace
• Increase emphasis on the postneonatal period
  beyond a focus on SIDS
• Promote well-womans health care policies and
  clinical guidelines through the life-course with
  a consideration of the appropriate use of
  technology and pharmaceuticals in womens health
  (e.g., c-sections, ART, HPV vaccine)

40
Fundamental Changes in Income Support Essential
Possible in Illinois? In U.S.?

• Provide universal income-based supports
• childrens allowances (different than childrens
  savings accounts) --high-income individuals can
  be taxed
• guarantee of a living wage
• promotion of family friendly tax policies
• Focus on poverty and racism and their
  intersection

41

Reducing Fetal/Infant/Maternal Mortality What is
the Answer?

• Bold new initiatives
• adequate funding to fully implement (test)
  basic services a rethinking of targeted versus
  universal approaches
• an opportunity to improve the
  reproductive/perinatal outcomes of women, infants
  and children

42
National Childrens Study Greater Chicago Study
Center

• Northwestern University
• University of Chicago
• University of Illinois-Chicago
• National Opinion Research Center (NORC)

43
Introduction

• Largest study of childrens health ever
  undertaken in the United States
• Funded by the National Institute of Child Health
  and Human Development (NICHD)
• Sample is representative of all US children

44
Goals

• Enroll 100,000 children across the United States,
  following them from before birth until age 21
• Examine the effects of environmental influences
  on their health and development
• Environment is broadly defined and includes
• Natural and man-made environment factors
• Biological and chemical factors
• Physical surroundings
• Social and neighborhood factors
• Behavioral influences
• Genetics and gene-environment interactions
• Cultural and family influences
• Geographic location

45
National Childrens Study Greater Chicago Study
Center

• Coordinates data collection for 4,000 children in
  Cook County
• Contributes this information to the national
  study
• Provides results about Cook County sample to the
  community
• Develops and conducts ancillary studies

46
Methods

• Sample
• Community-based
• 25 enrolled pre-conception
• 75 enrolled during 1st trimester of pregnancy
• Data collection methods
• In-home visits
• Clinic visits
• Telephone follow-up

47
Methods

• Samples collected
• Biological vaginal, blood, urine, saliva, hair,
  nail clippings
• Environmental air, dust, water
• Physical/developmental exams anthropometric,
  blood pressure, ultrasound (each trimester),
  physical exam, observations, cognitive/development
  al exams
• Other community environmental sampling, medical
  chart abstractions, child care/school sampling,
  community/neighborhood assessment

48
Time Line

• Planning Phase 09/27/07-07/01/09
• Sample development
• Community engagement
• Provider engagement (Birthing hospitals)
• Staff recruitment and training
• Data Collection Phase 07/01/09-09/27/12
• Pre-conception visits
• Birth visits
• 6-month and 12 month visits
• 18,24,30 month calls

49
Questions?

• For questions about the NCS, please visit
  www.nationalchildrensstudy.gov/
• If you have questions about the Greater Chicago
  Study Center, contact
• Laura B. Amsden at 312.695.6950
• Arden Handler at handler_at_uic.edu