Title: The Maternal and Child Health Life Course Model: Introduction and Opportunities for Public Health Nutrition
1The Maternal and Child Health Life Course
ModelIntroduction and Opportunities for Public
Health Nutrition
- Milton Kotelchuck, PhD, MPH
- Harvard Medical School
- Massachusetts General Hospital
- Center for Child and Adolescent Health Policy
- October 12, 2010
2Goal of Presentation
- Provide an understanding for the current new
emphasis on life course and social determinant
models - Introduce the MCH Life Course paradigm and
briefly note its scientific underpinnings - Review its theoretical principles
- Present an MCH Life Course strategic framework
for the Title V MCH Bureau - Provide examples of MCH Life Course related
public health research, program and policy,
partnership initiatives - And explore barriers and opportunities for MCH
life course use by public health nutritionists
3- Ideas and Slides Freely Adapted
- From my Colleagues
- Amy Fine
- Michael Lu
- Cheri Pies
- Deborah Allen
- Neal Halfon
4Richmond Kotelchuck, 1983
575th Anniversary of Title V of the Social
Security Act
- MCHB will initiate a new strategic planning
effort using MCH Life Course and Social
Determinants as its guiding framework - October 20, 2010
6Life Course is not new to MCH
- MCH does not raise children, it raises adults.
All of tomorrow's productive, mature citizens are
located someplace along the MCH continuum. They
are at some point in their creation either being
conceived or born or nurtured for the years to
come. There is very little genuine perception
that mature people come from small beginnings,
that they've had a perilous passage every moment
of the way. All the population, everybody of
every age were all at one time children. And
they bring to their maturity and old age the
strength and scars of an entire lifetime.
Pauline Stitt, MCHB 1960
7Why a new strategic approach?
- MCH health status is not improving -- existing
MCH programmatic approaches are not sufficiently
effective - The current balance of clinical public health
practices relative to social environmental
practices and policies seems out of kilter - There is substantial new life course research to
guide new initiatives - Reasserts the Childrens Bureau/Title V MCH
leadership mandates - New political and programmatic opportunities
- Prior 5 year strategic plan expired and on life
supports
8MCH Populations Health Status Not Improving
- Perinatal health is not improving
- IM stagnant LBW rising PTB raising C-sections
increasing - Child Health Status is not improving
- Obesity rates sky rocketing
- Maternal Health Status is unknown
- Too much post-partum weight gain, rising rates of
diabetes - High rates of parental depression
- Family Health is straining
- Less family stability
- MCH racial/ethnic disparities remain and may be
rising - US International health status rankings declining
- We have to do something different
9Low birth weight
US, 1996-2006
Low birth weight is less than 2500 grams (5 1/2
pounds). Source National Center for Health
Statistics, final natality data. Retrieved
February 22, 2010, from www.marchofdimes.com/peris
tats.
10Adequate/adeq prenatal care
US, 1992-2002
Footnotes available in notes section. Source
National Center for Health Statistics, final
natality data. Kotelchuck M. An evaluation of the
Kessner Adequacy of Prenatal Care Index and a
proposed Adequacy of Prenatal Care Utilization
Index. Am J Public Health 1994 84 1414-1420.
Retrieved February 21, 2010, from
www.marchofdimes.com/peristats.
11Failure of Enhanced Prenatal Care to Reduce
Racial Disparities or Improve Birth Outcomes
- You cant cure a life time of ills in nine
months of a pregnancy - Failure of late 20th Century movement to reduce
Infant Mortality through increased access to
comprehensive prenatal care (WIC) - Renewed search for understanding of disparities
- New scientific knowledge
- Paradigm shift in MCH to MCH Life Course
12Current programmatic approaches
- Pay insufficient attention to social and
environmental/root causes of illnesses - Focus on increasing access to medical care,
quality of health care services (while reducing
costs), changing individuals behavior, building
service systems for treatment of specific chronic
conditions - Utilize life stage not life course approaches,
with limited child to adult to aging adult
continuities
13Need for Change
- The old MCH/PH practices are not working
sufficiently - New 21st Century Science emerging
- New or renewed scientific/causal theory emerging
14MCH Life Course Scientific Basis
- The challenge is to understand how the social
environment gets built into or embodied into our
physical bodies which manifests itself in our
health and disease status. - To bridge the world of our intuitive social
understanding of the causes of ill health
(poverty, malnutrition) with our understanding of
its clinical manifestations and treatment - To better link downstream with upstream health
(or to move downstream further downstream (root
causes))
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16LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
17LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
18Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in
birth outcomes a life-course perspective.Matern
Child Health J. 2003713-30.
19The MCH Life Course Perspective Moving from
Research and Theory to Practice
- There is a convergence of similar life course
frameworks in related health fields - Reproductive life course models
- Child development models
- Chronic Illness models
- The knowledge base for the MCH Life Course
Perspective is strong and getting stronger
20Underlying Scientific Basis for Life Course Models
- Reproductive Health
- Cumulative Stress Impact / Weathering
- Early Programming (Epigenetics / Set Points)
- Intergenerational Reproductive Health Effects
- Child Health and Development
- Brain Development / Developmental Sciences
- Early Childhood Interventions
- Chronic Illness / Obesity Onset
- Teratogens
- Chronic Disease Models
- Fetal Origins of Adult Diseases
21New Science Underlying MCH Life Course
Reproductive Health
- Cumulative Impact
- Cumulative multiple stresses over time can have a
profound direct impact on health and development,
and an indirect impact through associated
behavioral or health service seeking change
(Weathering) - Early Programming
- Early experiences can program an individuals
future health and development, either directly in
a disease or condition or in a vulnerability to a
disease in the future
22Epigenetics
Gibbs WW. The Unseen Genome Beyond DNA.
Scientific American 2003
23Prenatal Programming of Childhood Obesity
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25Neurons to NeighborhoodsEarly Environments
Matter and Nurturing Relationships are Essential
- Parents and other regular caregivers in
childrens lives are active ingredients of
environmental influence during early childhood - Childrens early development depends on health
and well being of parents - Early experiences affect the brain (the focus on
the 0-3 period begins too late and ends too
soon) - A wide range of environmental hazards threaten
the developing central nervous system - The capacity exists to increase the odds of
favorable development outcomes through planned
interventions
26Drawing by Tom Prentiss In Cowan MW 1979. The
development of the brain. Scientific American
113 113-133
Als, H. 1986
27Human Brain Development - Synapse Formation
Language
Sensing Pathways (vision, hearing)
Higher Cognitive Function
Conception
-6
-3
0
3
6
9
1
4
8
12
16
Months
Years
AGE
C. Nelson, in From Neurons to Neighborhoods, 2000.
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292004 National Research Council and Institute of
Medicine Report
30IOM/NRC Definition of Childrens Health (2004)
- Childrens health is the extent to which
individual children or groups of children are
able or enabled to (a) develop and realize their
potential, (b) satisfy their needs, and (c)
develop the capacities that allow them to
interact successfully with their biological,
physical, and social environments. - From Childrens Health, the Nations Wealth,
National Academies Press, 2004.
31WHO Definition of Community Health
- A healthy city or community isone that is
continually creating and improving those physical
and social environments and expanding those
community resources that enable people to
mutually support each other in performing all the
functions of life and in developing their maximum
potential
Hancock and Duhl, WHO Healthy Cities Papers No.1,
1988
32Life Course Chronic Disease Epidemiology
- Adolescent Origins of Adult Diseases
- Childhood Origins of Adult Diseases
- Fetal Origins of Adult Diseases
- High blood pressure
- Diabetes Mellitus
- Coronary Heart Disease
- Cancer
- Obesity
- The Barker Hypothesis Historical Cohort Analysis
33Barker HypothesisBirth Weight and Insulin
Resistance Syndrome
Odds ratio adjusted for BMI
Barker 1993
34Barker HypothesisBirth Weight and Hypertension
Law 1993
35Barker HypothesisBirth Weight and Coronary Heart
Disease
Age Adjusted Relative Risk
Rich-Edwards 1997
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38MCH Life Course Model
- Posits a new scientific paradigm for the MCH
field - Addresses enduring health issues with new
perspectives (e.g.,disparities) - Requires new longitudinal and holistic approaches
to MCH programs, policy and research - Provides an integrated framework for facilitating
the MCH policy agenda - Links the MCH community to adult and elderly
health and social service policy development
39Social Determinants
- The social determinants of health are those
factors which are outside of the individual they
are beyond genetic endowment and beyond
individual behaviors. They are the context in
which individual behaviors arise and in which
individual behaviors convey risk. The social
determinants of health include individual
resources, neighborhood (place-based) or
community (group-based) resources, hazards and
toxic exposures, and opportunity structures.
Camara Jones, 2010
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41 Health Equity
- Where systematic differences in health are
judged to be avoidable by reasonable action they
are, quite simply, unfair. It is this that we
label health inequity. - Putting right these inequities the huge and
remediable differences in health between and
within countries is a matter of social justice.
- World Health Organization
- Commission on Social Determinants of Health
42Human Rights
- .these commitments (human rights) provide a
useful framework for shaping national laws and
policies, provide a useful tool for ensuring
accountability and point to approaches useful for
promoting public health. - Gruskin and Dickens, 2006,
- American Journal of Public Health 961903-1905
43Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in
birth outcomes a life-course perspective.Matern
Child Health J. 2003713-30.
44MCH Life Course
- Could it be true?
- Could we really transform disparities into
equity? - The WHO Nutrition Standards
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46WHO Multicentre Growth Reference StudyBackground
/ Context
- Current growth curves developed from 1930s Fels
longitudinal studies (White middle class sample) - Should there be separate norms for each cultural
/ racial group? - Fierce debate among MCH Epidemiologists,
especially given major LBW racial disparities in
U.S. - Issue arose in Guatemalan INCAP study of the
effects of malnutrition on mental development
(since Guatemalans were shorter, why use U.S.
norms?)
47WHO Multicentre Growth Reference Study Purpose
of Study
- Goal to assess optimal child growth (and motor
development) and create standards usable
throughout the world - Distinction between standards and norms
- Ideal vs.. actual growth curves
48WHO Multicentre Growth Reference Study Methods I
- Sample selected for optimal growth
- All upper middle class families
- All infants exclusively breastfed for four
months - All full-term births, with no birth defects
- Longitudinal (0 24 months) and cross-sectional
samples (18 71 months) - N1743 longitudinal, N6697 cross-sectional
(N8440) - Six sites chosen around the world
- U.S. (Palo Alto), Ghana (Accra), Oman (Muscat),
India (South New Delhi), Brazil (Pelatos), Norway
(Oslo), China dropped out
49WHO Multicentre Growth Reference Study Methods
II
- Standardized measurement protocols, very well
trained and supervised staff - Physical measurement recorded
- Length / height, weight, weight for height, BMI
- Monthly thru12 months, bi-monthly thru 24 months,
then 4 times thru age 5 - Motor development milestones
- Sitting with support hands and knees crawling
standing with assistance standing alone walking
with assistance walking alone - Measured at same age as above thru 24 months,
plus utilized mothers reports - All measurements were home-based
50WHO Multicentre Growth Reference Study Detailed
Results
- Physical Growth (standards)
- Essential similar everywhere (data combined)
- Only 3.4 inter-site variations 70 intra-site
variability 26 error - Motor Development
- No sex differences
- 5/6 of motor developments sequential
- No relationship between infant size and motor
development - Birth Characteristics
- Modest variations 3,300 mean birth weight
(3.1-3.6 Kg range) - 3.2 LBW (vs.. national estimates (up to 30 in
India)), shows powerful impact on SES on birth
outcomes
51WHO Multicentre Growth Reference Study Major
Conclusions
- Inter-cultural variability only 4 of variance
- All growth retardation reflects environmental
insults - Overall (genetic / cultural) longitudinal
continuity for human growth and motor development
under optimal conditions - Breastfeeding established as norm for growth
standards - Supports social justice orientation
52MCH Life Course Paradigm ShiftMCH Life Course
Conference June 2008, Oakland CA MCH Life
Course Model Topics to be Addressed
- Theory
- Research
- Practice
- Policy
- Education and Training
Kotelchuck, Lu, Pies, 2008
53MCH Life Course Theory
- There is no formal or official MCH Life Course
theory - Indeed, it is unclear if the correct word is even
theory or perspective or model or paradigm - But without theory there is no guide practice and
policy - Life Course theory must be surmised from existing
literature
54HRSA/MCHB Concept Paper
- Rethinking MCH The Life Course Model as an
Organizing Framework - Amy Fine
- Milton Kotelchuck
- October 2010
55Life Course Perspective
-
-
- A way of looking at life not as disconnected
stages, but as an integrated continuum -
-
M. Lu, 2010
56Life Course Development
- Life course development provides a framework to
understand how multiple determinants of health
interact across the life span and across
generations to produce health outcomes
Halfon, 2007
57MCH Life Course Goals
- To optimize health across the lifespan for all
people and - To eliminate health disparities across
populations and communities
Draft, Fine and Kotelchuck 2010
58Key concepts of the MCH Life- course Model
- Todays experiences and exposures determine
tomorrows health - Health trajectories are particularly affected
during critical or sensitive periods - The broader environment biologic, physical, and
social strongly affects the capacity to be
healthy - Inequality in health reflects more than genetics
and personal choice.
Amy Fine, Milt Kotelchuck, 2009
59Key concepts of the MCH Life- course Model
- Timeline conveys movement along a continuum and
cumulative impacts over time. - Timing reflects the importance of the earliest
experiences and exposures and of critical periods
throughout life. - Environment recognizes the importance of family
and community in shaping health, including the
physical, social, and economic environment in
which people live, grow and develop. - Equity refers to the importance of addressing
disparities in health and development across
populations.
60MCH Life Course core concepts
- MCH life course, social determinants, and social
justice models are complementary and synergistic - Move beyond, but include, medical/clinical care
they are not safety net programs - Life course not as disconnected stages, but as an
integrated continuum we are one - Not deterministic but transformational and
interactive trajectories - Equitable valuation of life at every age
61MCH Life Course
- Our challenge is to transform this new MCH Life
Course theory and research into new MCH practice
and policies - MCHB Strategic Planning Initiative
62MCH Bureau Life Course Initiatives
- Commitment of Dr. Peter Van Dyck to use MCH life
course theory as a strategic planning framework
for the Bureau - Multiple MCH Bureau-wide and Senior Leadership
meetings and presentations - State Needs Assessment Conference, and a State
Title V Directors workgroup - Several new MCHB Life Course initiatives
- Amy Fine and Milt Kotelchuck engaged to develop a
Life Course concept paper to help kick off their
new Strategic Planning initiative
63Developing an MCHB strategic agenda for change
- Strengthening the life course knowledge base
- Developing new program and policy strategies
- Enhancing political will
Draft, Fine and Kotelchuck, 2010
64MCH Life Course Research
- Research growing, but more is needed
- Barriers to longitudinal life course research
- Limited longitudinal analytic capacity
- Scattered longitudinal data bases
- Disciplinary and institutional silos
- Virtually no measures of life-course
trajectories, cumulative risks, cumulative
experiences - Confidentiality legal infrastructure not in place
- Few longitudinal data/life course training
opportunities - New MCHB initiatives
65MCH ResearchMCH Life Course Research Network
66Public Health Nutrition Research Needs and MCH
Life Course
- Basic obesity research
- Intergenerational transmission of obesity/GDM
- Early cellular/genetic transformations
- Micronutrients
- Childhood dietary history and intervention
impacts - Longitudinal and programmatic research
- Epidemiologic research
- Public Policy and Public Health root cause
analyses - ..
67MCH Life Course Practice and Policies
- The ultimate challenge transforming life course
to concrete programs and policies - The most difficult MCH Life Course task
- Requires more than renaming existing programs
- The science of MCH practice is the hardest
science - MCH learning community needed
68MCH Life Course Model Barbara Ferrars Overview
of its Meaning for Practice
- Multiple time points for intervention
- Expanded settings for intervention
- Policy is important at local, state and national
levels
69MCH Life Course Practice
- The MCH Life Course Theory suggests a greater
attention to four key continuities or
discontinuities in health and health care that
impact on achieving optimal health - Longitudinal continuity
- Vertical ( or programmatic) continuity
- Horizontal (or contextual) continuity
- Holistic continuity
70Public Health Nutrition Discontinuities
- Longitudinal
- Public Health nutrition more thoughtful than
other MCH areas (about upstream causes
longitudinality of impacts) - Limited downstream intervention effectiveness (TV
monitoring itself Adolescent diets) - Poor longitudinal nutrition records
- Vertical or programmatic
- WIC ends, where do the children or mothers go?
- Limited primary care to tertiary care handoffs
- Horizontal
- Limited ties between physicians and schools
- Difficulties of recruiting parents to community
nutrition resources - Holistic
- You are what you eat
- Too many intervention overloads
71Public Health NutritionLife Course Initiatives
- Within public health/clinical programs
- Across programs
- MCH Life Course organizations
- Policy level
72MCH Nutrition Life Course Interventions (examples)
- Pediatric practice quality care improvement
initiatives (NICHQ) - Birmingham Sunday Greens
- Numerous multi-pronged community-based Obesity
reduction campaigns - Michelle Obamas LetsMove.gov efforts
- Delaware Nemours Obesity Reduction Initiative
(5,2,1,Almost None)
73Housing
Childcare
Medical Care
Jobs
Healthy Food
Alameda County Building Blocks Collaborative
Clean Air
Parks and Activities
Policy Makers
Education
Economic Justice
Preschool
Safe Neighbor-hoods
Residents
Transportation
74MCH Life Course Policy
- Many needed public health nutrition life course
reforms require policy level initiatives - Creating a policy agenda
75Policy Implications for the Government Sector
- Avoid the allure of categorical solutions
- Focus on upstream population needs
- Assure that needed programmatic collaboration
happens - Partner with all sectors
- Install visionary leadership
- Invest in data for policy decisions
Debbie Allen, 2008
76Policies that seek to remedy deficits incurred
in early years are much more costly than early
investments wisely made, and do not restore lost
capacities even when large costs are incurred.
The later in life we attempt to repair early
deficits, the costlier the remediation
becomes.James J. Heckman, PhDNobel Laureate
in Economics, 2000
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78Policy concepts deriving from the MCH Life-course
Model
- Refocus the organization and delivery of MCH
clinical and population health services - Enhance linkages between health services and
other child and family services and supports
sectors (e.g., educational, social services) - Rebuild and redirect social, economic and
physical environments to support and promote the
health of the population (e.g. building community
capacity to support health)
Fine, Kotelchuck et al, 2009
79MCH Life Course Policy Initiative
- Realigning Health Services and Systems
- Integrating Health and Other Service Systems for
Women, Children and Families - Building Community Capacity to Support Health
- Creating National and Federal Agenda to Address
Social Determinants of Health
Draft, Kotelchuck and Fine 2010
80MCH Life CoursePartnerships
- Generate new political will to implement the MCH
life course models
81MCH Partners/Political Will
- MCH Bureau (and HRSA) Staff
- The broader MCH family
- Other health and non-health federal agencies
- Non-traditional stakeholders
- Local community and political stakeholders
Draft, Fine and Kotelchuck, 2010
82MCH Life Course Training and Education Tasks
- Integrate MCH life course models into MCH
training programs - Leadership training
- Retool the current MCH workforce
- Enhance MCHB leadership competencies/long term
training to prepare future MCH leadership
83New Needed MCH Life Course Skills/Capacities
- Coalition building and collaboration
- Advocacy
- Longitudinal data capacity
- Community-based participatory research
- Enhanced needs assessment capacities
- And many other skills
84Possible MCH Life Course Barriers for Public
Health Nutritionists
- Difficulty of balancing social determinant with
clinical nutrition models of care (RD vs. PH
Nutritionist) - Lack of capacity for addressing non-health
aspects of population nutrition - Limited success of primary prevention / upstream
involvement - Isolation from other health, welfare, education
and community development systems - Difficulty of balancing new life course
opportunities versus existing programmatic
mandates
85MCH Life Course Strengths for Public Health
Nutritionists
- There is already strong motivation for social
justice - There is a strong longitudinal and social
determinant orientation for PHN - Long programmatic history of Public Health
Nutrition-MCH life course initiatives - There are strong links between basic/epidemiologic
sciences and public health practices - PHN is a multi-disciplinary field
- The new initiatives may help PHN gain new allies
(and vice versa), new political will to address
upstream health issues, be less isolated and part
of broader MCH/Public health agenda - The MCH Life Course is not new to you
86MCH Bureau Strategic Planning and Leadership
- MCHB has a critical leadership role in fostering
the MCH life course paradigm shift - The life course perspective, along with the
social determinants, and social justice models,
offers MCHB the opportunity to reinvigorate its
Childrens Bureau legacy and political mandate
to address all factors that impact on childrens
health and well-being - It provides a federal and national leadership
opportunity to broadly improve the health and
well being of mothers, children and families
8775th Anniversary of Title V of the Social
Security Act
- MCHB will initiate a new strategic planning
effort using MCH Life Course and Social
Determinants as its guiding framework - October 20, 2010
88MCH Life Course Resources
- CityMatCH http//www.citymatch.org/lifecoursetoolb
ox/ - MCHB
- http//mchb.hrsa.gov/lifecourseresources.htm
- Future MCHB Web site
89Richmond Kotelchuck, 1983