Reinventing Maternal & Child Health: A Life-Course Perspective

Michael C. Lu, MD, MPHAssociate Professor of Obstetrics, Gynecology, and Public Health

UCLA Schools of Medicine and Public HealthUCLA Center for Healthier Children, Families and CommunitiesNational Center for Infancy & Early Childhood Health Policy

MCHB-AIM Child & Adolescent Policy Support Center

Alameda CountyBuilding Blocks for Healthy Babies, Healthy Families,

& Healthy CommunitiesSeptember 10, 2009

The definition of insanity is doing the same thing over and over and expecting different results

Benjamin Franklin

Acknowledgment

Mario Drummond Neal Halfon Milt Kotelchuck Cheri Pies

Acknowledgment

Life-Course Perspective

A way of looking at life not as disconnected stages, but as an integrated continuum

Life Course Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

Life Course Perspective

Early programming Cumulative pathways Reinventing MCH

Early Programming

Barker HypothesisBirth Weight and Coronary Heart Disease

0

0.25

0.5

0.75

1

1.25

1.5

<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0

Birthweight (lbs)

Age Adjusted Relative Risk

Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.

Barker HypothesisBirth Weight and Hypertension

155

160

165

170

Sys

toli

c P

ress

ure

(m

mH

g)

<=5.5 5.6-6.5 6.6-7.5 7.6-8.5 >8.5

Birthweight (lbs)

Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in utero and its amplification throughout life. Br Med J 1993;306:24-27.

Barker HypothesisBirth Weight and Insulin Resistance Syndrome

0

2

4

6

8

10

12

14

16

18

<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5

Birthweight (lbs)

Odds ratio adjusted for BMI

Barker DJP, Hales CN, Fall CHD, Osmond C, Phipps K, Clark PMS. Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (Syndrome X): Relation to reduced fetal growth. Diabetologia 1993;36:62-67.

Maternal Stress & Fetal Programming

Prenatal Stress & Programming of the Brain

Prenatal stress (animal model) Hippocampus

Site of learning & memory formation Stress down-regulates glucocorticoid receptors Loss of negative feedback; overactive HPA axis

Amygdala

Site of anxiety and fear Stress up-regulates glucocorticoid receptors Accentuated positive feedback; overactive HPA

axis

Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.

Prenatal Programming of the Hypothalamic-Pituitary-Adrenal Axis

Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.

Epigenetics

Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

EpigeneticsSame Genome, Different Epigenome

R.A. Waterland, R.A. Jirtle, "Transposable elements: targets for early nutritional effects on epigenetic gene regulation," Mol Cell Biol, 23:5293-300, 2003. Reprinted in the New Scientist 2004

Prenatal Programming of Childhood Obesity

Epidemic of Childhood Overweight & Obesity

0

5

10

15

20

25

1976-1980 1988-1994 1999-2002

Perc

en

t

Black Hispanic White

Source: National Center for Health Statistics, National Health and Nutrition Examination Survey

Note: Estimate not available for 1976-1980 for Hispanic; overweight defined as BMI at or above the 95th percentile ofr the CDC BMI-for-age growth charts

Children 6-18 Overweight

Prenatal Programming ofChildhood Overweight & Obesity

Maternal Diabetes & Intrauterine Hyperglycemia

Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells)

Prenatal& PostnatalHyperleptinemia

Preadipocyte Differentiation

Adipocyte Hyperplasia

HypothalamicLeptin Resistance

Pancreatic β- Cell Leptin Resistance

HyperphagiaHyperinsulinism

Programmed Insulin

Resistance

Postnatal Hyperinsulinemia

Adipogenesis

Prenatal Programming of Childhood Obesity

Cumulative Pathways

Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/

Allostasis: Maintain Stability through Change

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Allostastic Load:Wear and Tear from Chronic Stress

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

HPA Axis & Immune SystemChikanza 2000

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

Allostasis & Allostatic Load

McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002

Rethinking Preterm Birth

Sequelae of Preterm BirthSequelae of Preterm Birth

Term Births

Preterm Birth

75%Perinatal Perinatal MortalityMortality

NeurologicNeurologicDisabilitiesDisabilities

50%

12%

Racial & Ethnic DisparitiesInfant Mortality, 2005

13.7

5.7

0

2

4

6

8

10

12

14

African American White

Deaths Per 1,000 Live Births

NCHS 2008

NCHS 2008

Racial & Ethnic DisparitiesPreterm Births < 37 Weeks

18.4

11.7

0

2

4

6

8

10

12

14

16

18

20

African American White

Percent of Live Births

NCHS 2008

Year 2010 Goal

Racial & Ethnic DisparitiesVery Preterm Births < 32 Weeks

4.17

1.64

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

African American White

Percent of Live Singleton Births

Year 2010 Goal

NCHS 2008

Rethinking Preterm Birth

Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)

Preterm Birth &Maternal Ischemic Heart Disease

Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth

Smith et al Lancet 2001;357:2002-06

Reinventing MCH

Why Reinvent MCH?

Finland, 12.2

Denmark, 9.2

Portugal, 8.2

Czech Republic, 8

United Kingdom, 7.7

France, 7

New Zealand, 6.8

Canada, 5.9

Slovak Republic, 5.6

Switzerland, 5.5

Netherlands, 5.2

Germany, 5.2

Poland, 4.8

Spain, 4.6

Japan, 4.4

Hungary, 4.2

Australia, 3.9

Austria, 3.8

Greece, 2.8

Belium, 2.5

Ireland, 1.6

Sweden, 1

USA, 13.1

Norway, 0

Icleand, 0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Maternal MortalitySource: OECD Health Data 2008

New Zealand, 5.6

Canada, 5.3

United Kingdom, 5.3

Ireland, 4.9

Belgium, 4.7

Austria, 4.5

Netherlands, 4.4

Australia, 4.4

Denmark, 4.4

Switzerland, 4.2

Italy, 4.1

Germany, 4.1

France, 4

Portugal, 3.8

Czech Republic, 3.7

Spain, 3.5

Sweden, 3.1

Japan, 2.8

USA, 6.8

Greece, 4

Finland, 3.3

Norway, 3.2

0 1 2 3 4 5 6 7 8

Infant Mortality

Source: United Nations. Table 4. In: United Nations Demographic Yearbook, 2004. New York, NY: United Nations; 2007:73–93.

Racial & Ethnic DisparitiesPregnancy-Related Mortality Ratio, 1991-1999

30

8.1

0

5

10

15

20

25

30

African American White

Deaths Per 1,000 Live Births

Chang et al MMWR 2003

Racial & Ethnic DisparitiesInfant Mortality, 2005

13.7

5.7

0

2

4

6

8

10

12

14

African American White

Deaths Per 1,000 Live Births

NCHS 2008

Racial & Ethnic DisparitiesInfant Mortality, Alameda County, 2001-03

11.7

3.6

0

2

4

6

8

10

12

African American White

Deaths Per 1,000 Live Births

Alameda County Health Status Report, 2006: http://www.acgov.org/health/disparitiesStudy.pdf

Racial & Ethnic DisparitiesLow Birth Weight, Alameda County, 2001-03

12.4

5.9

0

2

4

6

8

10

12

14

African American White

Percentage of Live Births

Alameda County Health Status Report, 2006: http://www.acgov.org/health/disparitiesStudy.pdf

How Can This Be?

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 2007;357:1221-8

How Can We Do Better?

1. Transform maternal and child healthcare

2. Assure the conditions in which all mothers and children can be healthy

1. Transforming Maternal & Child Healthcare

Prenatal Care 1.0

ReceptionistMedical

Assistant

UltrasoundTechNurse Manager

Prenatal Care 2.0

Oral Health

TeratogenInformationServices

Primary &Specialty Care

SocialServices

Mental Health

NutritionalCounseling

ReceptionistMedical

Assistant

Ultrasound TechNurse Manager

High RiskOB

Family Support

0 10 20 30 40 Years

Prenatal Care 3.0

NHVFRCPED

Rep

rodu

ctiv

e P

oten

tial

Optimal Health Development

Lower Health Development

Trajectory

Medical Home for Women’s Health

Medical Home for Adolescent Health

Pediatric Medical Home

Old Operating Logic (2.0) New Operating Logic (3.0)

Definition of Health Absence of disease and disability

Health is a positive concept emphasizing the development of social and personal resources, as well as physical capacities (Ottawa, 1986 & IOM 2004)

Goals of Health System Health maintenance and prolonging life of individual

Optimizing individual and population health

Client Model Individual Individual, community, and population

Health Production / Disease Causation

Biomedical Biopsychosocial, Life Course Health Development

Intervention Approach Diagnosis and treatment Emphasize disease prevention, health promotion and optimization

Time Frame Episodic Care Lifespan: Sensitive, Critical Periods to optimize health trajectories

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

Developmental Strategies Health development (health capital) Educational development (human capital) Economic development (material capital) Family development (relational capital) Community development (social capital)

Educational Development1. Preconception and prenatal care2. Parenting education 3. Child care 4. Universal Preschool5. Early Head Start and Head Start6. K-12 – small class size, teacher quality, standards7. After school and summer programs8. Youth development9. Health education/physical education10. Comprehensive school health clinics

Racial and Ethnic DisparitiesBirths to Unmarried Mothers

69.1

40.9

25.8

01020

3040

5060

708090

100

African American Hispanic American White American

Percent of Live Births

Family Development

1. Human development (education, employment, legal/social services)

2. Life skills training3. Reproductive health4. Violence prevention5. Marriage counseling/family therapy6. Economic development7. Criminal justice system reforms8. Tax reform9. Welfare reform10. Child support reform

Economic Development1. Raise minimum wage2. Expand Earned Income Tax Credits3. Strengthen collective bargaining4. Providing safety net – unemployment, housing, food stamps5. Providing job training and retraining6. Assuring universal healthcare7. Expanding access to family and medical leave, quality childcare,

universal preschool8. Teach financial literacy9. Extend microloan programs10. Macroeconomic policies

Community Development1. Economic development 2. Affordable decent housing 3. Delink schools and property tax 4. Community policing 5. Municipal services & infrastructural development 6. Protect clean air and water7. Promote food quality and safety8. Mobilize community activism9. Create social capital10. Address racism at all levels

HealthcareEducation

CommunityDevelopment

Environment

MCH

"We must become the change we want to see.”

- MOHANDAS GANDHI

NMPPMCH Life-Course

Organization

Closing the Black-White Gap in Birth Outcomes:A 12-Point Plan

Racism

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT

(Collins et al, AJPH, 2004)

02468

101214161820

% exposed to racism

VLBW (n=104) non-LBW(n=208)

OR=2.7 (1.3-5.4)

Jones CP. Levels of racism: A theoretical framework and a gardener’s tale. AJPH 2000;90:1212-5

Closing the Black-White Gap in Birth Outcomes:A 12-Point Plan

1. Provide interconception care to women with prior adverse pregnancy outcomes2. Increase access to preconception care for African American women3. Improve the quality of prenatal care4. Expand healthcare access over the life course5. Strengthen father involvement in African American families6. Enhance service coordination and systems integration7. Create reproductive social capital in African American communities8. Invest in community building and urban renewal9. Close the education gap10. Reduce poverty among Black families11. Support working mothers and families12. 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 2009.

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)