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The Maternal and Child Health Life Course Model: Introduction and Opportunities for Public Health Nutrition

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Title: The Maternal and Child Health Life Course Model: Introduction and Opportunities for Public Health Nutrition


1
The 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

2
Goal 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

4
Richmond Kotelchuck, 1983
5
75th 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

6
Life 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
7
Why 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

8
MCH 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

9
Low 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.
10
Adequate/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.
11
Failure 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

12
Current 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

13
Need for Change
  • The old MCH/PH practices are not working
    sufficiently
  • New 21st Century Science emerging
  • New or renewed scientific/causal theory emerging

14
MCH 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))

15
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16
LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
17
LCHD and Birth Outcomes
White
Reproductive Potential
African American
Pregnancy
Age
18
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in
birth outcomes a life-course perspective.Matern
Child Health J. 2003713-30.
19
The 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

20
Underlying 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

21
New 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

22
Epigenetics
Gibbs WW. The Unseen Genome Beyond DNA.
Scientific American 2003
23
Prenatal Programming of Childhood Obesity
24
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25
Neurons 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

26
Drawing by Tom Prentiss In Cowan MW 1979. The
development of the brain. Scientific American
113 113-133
Als, H. 1986
27
Human 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.
28
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29
2004 National Research Council and Institute of
Medicine Report
30
IOM/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.

31
WHO 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
32
Life 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

33
Barker HypothesisBirth Weight and Insulin
Resistance Syndrome
Odds ratio adjusted for BMI
Barker 1993
34
Barker HypothesisBirth Weight and Hypertension
Law 1993
35
Barker HypothesisBirth Weight and Coronary Heart
Disease
Age Adjusted Relative Risk
Rich-Edwards 1997
36
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37
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38
MCH 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

39
Social 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
40
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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

42
Human 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

43
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in
birth outcomes a life-course perspective.Matern
Child Health J. 2003713-30.
44
MCH Life Course
  • Could it be true?
  • Could we really transform disparities into
    equity?
  • The WHO Nutrition Standards

45
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46
WHO 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?)

47
WHO 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

48
WHO 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

49
WHO 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

50
WHO 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

51
WHO Multicentre Growth Reference Study Major
Conclusions
  1. Inter-cultural variability only 4 of variance
  2. All growth retardation reflects environmental
    insults
  3. Overall (genetic / cultural) longitudinal
    continuity for human growth and motor development
    under optimal conditions
  4. Breastfeeding established as norm for growth
    standards
  5. Supports social justice orientation

52
MCH 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
53
MCH 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

54
HRSA/MCHB Concept Paper
  • Rethinking MCH The Life Course Model as an
    Organizing Framework
  • Amy Fine
  • Milton Kotelchuck
  • October 2010

55
Life Course Perspective
  • A way of looking at life not as disconnected
    stages, but as an integrated continuum

M. Lu, 2010
56
Life 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
57
MCH 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
58
Key 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
59
Key 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.

60
MCH 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

61
MCH 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

62
MCH 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

63
Developing 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
64
MCH 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

65
MCH ResearchMCH Life Course Research Network
66
Public 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
  • ..

67
MCH 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

68
MCH 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

69
MCH 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

70
Public 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

71
Public Health NutritionLife Course Initiatives
  • Within public health/clinical programs
  • Across programs
  • MCH Life Course organizations
  • Policy level

72
MCH 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)

73
Housing
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
74
MCH Life Course Policy
  • Many needed public health nutrition life course
    reforms require policy level initiatives
  • Creating a policy agenda

75
Policy 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
76
Policies 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
77
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78
Policy 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
79
MCH 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
80
MCH Life CoursePartnerships
  • Generate new political will to implement the MCH
    life course models

81
MCH 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
82
MCH 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

83
New 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

84
Possible 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

85
MCH 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

86
MCH 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

87
75th 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

88
MCH Life Course Resources
  • CityMatCH http//www.citymatch.org/lifecoursetoolb
    ox/
  • MCHB
  • http//mchb.hrsa.gov/lifecourseresources.htm
  • Future MCHB Web site

89
Richmond Kotelchuck, 1983
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