Creating Equity in Birth Outcomes in Wisconsin: Recommendations for Action

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Creating Equity in Birth Outcomes in Wisconsin
Recommendations for Action

• Richard Allan Aronson, MD, MPH
• raronson_at_verizon.net 207 622 8822
• Wisconsin Infant Mortality Summit
• May 22, 2008

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Objectives

• Provide overview of paper, Elimination of Racial
  and Ethnic Disparities in Birth Outcomes in
  Wisconsin.
• Highlight research related to birth outcome
  disparities.
• Give examples of promising practices.
• Provide basic set of assumptions that underlie
  the recommendations.
• Describe recommendations.

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The Root of Health Disparities

• Injustice anywhere is a threat to justice
  everywhere. We are caught in an inescapable
  network of mutuality, tied in a single garment of
  destiny. Whatever affects one directly, affects
  all indirectly.
• Rev. Martin Luther King, Jr.

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Overview of Paper

• July 2007 January 2008 Collected information
  from wide array of people in Wisconsin, not
  inclusive.
• Reviewed literature, data, and research.
• Interviewed selected researchers and people in
  programs.
• 6 Appendices 1) Promising models 2) 12-Point
  Plan Lu et al 3) Wisconsin investments in
  improving birth outcomes 4) Academic resources 5)
  Research on disparities 6) Evidence based medical
  practice

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Time of Opportunity and Vulnerability

• Sustained and multi-faceted approach.
• Contributions from multiple sectors beyond health
  care and public health.
• Build upon what is working.
• Financial resources are essential, but not the
  answer.
• Catalyst for dialogue and action

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Key Points for Action

• Service, education, and research.
• Incorporate Life Course Perspective and other
  research.
• Honor and include families and communities.
• Tap into strengths and resilience.
• Courage to address racial and other
  discrimination.
• Put this issue front and center and keep it
  there.
• Challenge individuals and organizations to step
  up.
• Inform and inspire new generation to move this
  forward.

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Institute of Medicine Unequal Treatment

• People of color receive lower quality of health
  care, even when other factors controlled.
• Sources of disparities rooted in historical and
  current inequities, occur at multiple levels.
• Conditions under which clinical encounter takes
  place may result in care poorly matched to the
  needs and strengths of patients of color.

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Joint Center for Political and Economic Studies
(2007) and Unnatural Causes (2008)

• Race, Stress, and Social Support Addressing the
  Crisis in Black Infant Mortality
• Recommended policy and funding for culturally
  competent, race and gender specific research and
  interventions.
• Unnatural Causes Is Inequality Making Us Sick
  Social, economic, racial inequities profoundly
  affect our health and longevity.

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Research Starting to Form a Foundation for
Effective Action

• Life Course Perspective
• Stress and Biology
• Early brain development
• Adverse Childhood Experiences Study
• Racism and Race as an Independent Stressor
• Resilience
• Social Connectedness
• Conditions for productive dialogue and action

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Life Course Perspective Allostasis

• The term came into being in the 1980s as a newer
  more appreciative way to view the bodys rapid
  and efficient methods of dealing with danger.
• Allostasis refers to the bodys ability to
  maintain stability amidst change.
• M Lu,
  N Halfon

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Allostasis

• Produced by a swift and intricately organized
  system of communication
• Links brain ?endocrine system?
• the immune system for internal defense
• Fight or Flight response

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Allostasis Maintain Stability through Change
McEwen BS. Protective and damaging effects of
stress mediators. N Eng J Med. 1998338171-9.
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Allostasis Wear and Tear

• There are, however, situations that ignite stress
  response in which neither fight nor flight is an
  option.the response cannot help us toward
  resolution. Then, deprived of its natural result,
  the system designed to protect us begins to cause
  wear and tear ? illness and vulnerability

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Allostastic Load
McEwen BS. Protective and damaging effects of
stress mediators. N Eng J Med. 1998338171-9.
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Stress and Biology Allostatic loading

• Unremitting chronic stress, including that of
  racial discrimination.
• Inability to adjust.
• Not hearing the all-clear signal
• Feedback loops impaired.

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HPA Axis Hypothalamic-pituitary-adrenal axis

• Initiated in the hypothalamus gland, it is the
  cornerstone of allostasis.
• Impaired HPA axis function from chronic stress
  leads to chronic high levels of cortisol in
  woman.
• High levels suppress immune function, lead to LBW
  and preterm birth.
• Maternal stresses may program fetus.

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Stressed vs. Stressed Out

• Stressed
• Increased cardiac output
• Increased available glucose
• Enhanced immune functions
• Growth of neurons in hippocampus prefrontal
  cortex

• Stressed Out
• Hypertension cardiovascular diseases
• Glucose intolerance insulin resistance
• Infection inflammation
• Atrophy death of neurons in hippocampus
  prefrontal cortex

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Healthy Brain Development is Key to Maximizing
our Childrens Potential

• The human brain profoundly influences our
  behavior.
• 85 of brain development occurs by age three.
• During this time, neurological connections are
  laying the foundation for intellectual,
  emotional, social, moral and physical
  development.

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Healthy brain development results from

• Nurturing, stable, and consistent relationships
  with supportive and responsive adults.
• Positive stimulation (visual, auditory,
  emotional) .
• Sense of safety and security.
• Reduced stress (i.e. family violence or substance
  abuse).
• Increased resilience.

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The Relationship of Adverse Childhood
Experiences to Adult Health Status
A collaborative effort of Kaiser Permanente and
The Centers for Disease Control
Vincent J. Felitti, M.D. Robert F. Anda, M.D.
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• The Adverse Childhood Experiences (ACE) Study
• The largest study of its kind ever done to
  examine the lifetime health and social effects of
  adverse childhood experiences (17,000
  participants)

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Categories of Adverse Childhood Experiences for
ACE Study
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Childhood Experiences Underlie Chronic Depression
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Childhood Experiences vs. Adult Alcoholism
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ACE Study Findings1. Adverse Childhood
Experiences appear to increase significantly the
likelihood of many health and mental health
illnesses and traumatic events in youth and
adults Depression, Suicide, Alcoholism, Drug
Abuse, Domestic Violence, Rape, and Psychosis.
2. ACEs also contribute to smoking, obesity, IV
drug use, multiple sexual partners, and hence the
chronic adult illnesses associated with them.
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What is conventionally viewed by providers and
policy makers as an individual behavioral
problem may be viewed by the individual as a way
to deal with the pain associated with these
experiences.
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Race An Array of Different Beliefs

• Genetic code Humans are more than 99 identical.
  
• Race is a social construct used to separate the
  worlds people.
• Does not take into account diversity and
  heterogeneity within groups of people.
• Required for reporting purposes as a way to
  address deeply rooted inequalities and
  disparities.
• Historical misuse of biology and genetics has
  pathologized communities of color , blocking
  recognition of strengths and capacity to survive,
  heal, and thrive.

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Levels of Racism Defined

• Institutionalized racism differential access to
  goods, services, and opportunities.
• Personally mediated racism prejudice and
  discrimination.
• Internalized racism acceptance...of negative
  messages about ones own abilities and
  intrinsic worth.

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Birth Outcome Racial Disparities Race as
Independent Factor

• Collins et al. 1997
• Women with 16 years or more Education
• Small-for-Dates Rate
• African-Americans 2.8
• Whites 1.2
• Odds Ratio 2.9 (CI 1.4-4.5)

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1st Generation African-Born Americans Compared to
African Americans

• Collins and David NEJM 1997
• Examined LBW of African-born blacks living in
  USA, U.S. born African Americans, and U.S. born
  whites.
• LBW among African-born blacks closer to U.S. born
  whites, but by 2nd generation black to white gap
  started to emerge.

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Race Impact on Birth Outcomes

• Established risk factors do not account for the
  African American IM gap, especially that of Very
  Low Birth Weight.
• There is something inherent in being an
  African-American woman in our society that puts
  babies at a much higher risk of dying in their
  first of life.
• Perception of discrimination matters.

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Role of Caring Relationships in Health

• How we live together - the quality of our
  relationships - deeply influences our health.
• Human beings, at their best, seek non-violent
  connections that enrich the fabric of life.
• Human relationships are to health what location
  is to real estate.

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Defining Social Capital

• Resources that individuals or groups can draw
  upon through their connections to others.
• Can take a wide array of forms mutual help,
  levels of trust, collective action, civic
  engagement.

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Resilience

• Capacity of women, children, families,
  neighborhoods, communities to bounce back
• Power of people to recover, heal, grow, and
  succeed in the midst of change and adversity
• As human beings, our greatness is not so much in
  remaking the worldas remaking ourselves Ghandi
  

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Resilience at Multiple Levels

• Individual
• Family
• School
• Community
• Systems and Policies

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Strategies that Strengthen Resilience

• Facilitate social and community support
• Affirm and support resilience in families
• Link families to services and opportunities to
  promote healthy healing child development

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Resiliency in African American Families

• Patricia McManus, Ph.D., RN, and Ronald Edari,
  Ph.D.
• Debra Davis McKissic, MS

A Protective Factor Against Interpersonal Violence
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Resiliency In African American Families

• Male spouses/partners add a positive dimension to
  the familys ability to cope with adversity.
  However, lack of a male in the home did not
  automatically produce a negative dimension

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Resiliency in African American Families

• In terms of residential mobility, the resilient
  families had much greater frequencies of mobility
  than the nonresilient families

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Resiliency in African American Families

• An overwhelming number of the resilient families
  owned a automobile, and this would seem to have
  enhanced the well-being of their family members

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Resiliency in African American Families

• A Continuum of Resiliency - If family resiliency
  is defined in terms of the ability to cope
  positively with adversity or to resist the
  pressures of negative forces in the neighborhood,
  it is evident that it is not an all-or-none
  attribute.

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Resiliency in African American Families

• A great deal of time, energy, and resources have
  been spent in looking at distressed families and
  neighborhoods, usually from a deficit
  perspective.
• Recommendations have hinged on the belief that
  these families required external intervention in
  order to mitigate the impact of adverse factors
  in their neighborhoods or households.

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Conditions for Effective Dialogue and Action

• Get the whole system in the room.
• Explore the whole before taking action on any
  part.
• Put common ground and future action front and
  center.
• Set up meetings so people can do the work
  themselves. Weisbord and Janoff

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International IMR and Military Spending

• Lancet 1985 Woolhandler Himmelstein
• 141countries
• ?GNP devoted to Military
• Increased IMR
• IMR went down with
• Economic development
• Better Health resources
• Social spending

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A Societys Priorities

• "A nation that continues year after year to spend
  more money on military defense than on programs
  of social uplift is approaching spiritual death."
  
• Martin Luther King,Jr.

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Underlying Assumptions for Action

• Honor and respect dignity of all people,
  cultures.
• Consider everyone as an expert.
• All stakeholders are equal partners.
• Simple, clear, non-jargon language.
• Draw on strengths and resilience.
• Useful, accurate, shared data.

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Underlying Assumptions for Action

• Mobilize public and political will.
• Move from paradigm focused just on eliminating
  disparities to one of also creating equity for
  all, regardless of race, ethnicity, income,
  gender, etc.
• Be non-judgmental.
• Stay relationship-centered.

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Closing the Black-White Gap in Birth OutcomesA
12-Point Plan

• 1. Provide interconception care to women with
  prior adverse pregnancy outcomes
• 2. Increase access to preconception care for
  African American women
• 3. Improve the quality of prenatal care
• 4. Expand healthcare access over the life course
• 5. Strengthen father involvement in African
  American families
• 6. Enhance service coordination and systems
  integration
• 7. Create reproductive social capital in African
  American communities
• 8. Invest in community building and urban
  renewal
• 9. Close the education gap
• 10. Reduce poverty among Black families
• 11. Support working mothers and families
• 12. Undo racism

Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C,
Halfon N. Closing the Black-White gap in birth
outcomes A life-course approach. Ethnicity and
Disease Forthcoming in 2008.
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Bold Leadership Risk

• He who risks and fails can be forgiven. He who
  never risks and never fails is a failure in his
  whole being.
• Paul Tillich

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Wisconsin Recommendations

• Improve the health of African American women and
  their families over their life span
• Promote cultural and linguistic competence in
  health care provision
• Maximize cooperation, collaboration, and trust.
• Strengthen and sustain infrastructure .
• Advance research and education.

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Rec. 1 Health of Black Women

• Provide model system of interconception care for
  African American women with prior adverse
  pregnancy outcome.
• Risk and resilience assessment
• Relationship-based (Home visitation, etc.)
• Stress reduction (Culture-specific)
• Mental health, especially depression
• Screen and treat hypertension, diabetes, etc.

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Maternal Depression Is Widespread

• Across race, ethnicity, and class.
• Disproportionately affects parents who experience
  economic hardship, discrimination, lack of social
  support, interpersonal violence, substance abuse,
  child abuse, and cumulative stress, both acute
  and chronic.

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Cumulative Impact of Depression in Combination
With Other Risks

• Depression often occurs in the presence of other
  psychosocial and environmental risks, stressors,
  and traumatic experiences.
• Cumulative effect An increased number of risks
  associated with increased behavioral problems
  (Whitaker, 2006).
• Adverse Childhood Experiences (ACE) Study

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Rec. 1 Health of Black Women

• Provide model system of preconception care for
  African American women and their families
• Early childhood Social-emotional development
• Medical home
• Fetal and infant mortality review (FIMR)
• Community mobilization
• Homeless and incarcerated population.
• Male involvement

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Depression affects how a woman is able to relate
to others, including her baby.