Transcript Slide 1
We Can Do Better: Reinventing Maternal & Child Health in America Michael C. Lu, MD, MPH Associate Professor Department of Obstetrics & Gynecology David Geffen School of Medicine at UCLA Department of Community Health Sciences UCLA School of Public Health 2008 CityMatCH Conference Albuquerque, NM September 23, 2008
Acknowledgment
Mario Drummond Neal Halfon Milt Kotelchuck Cheri Pies
Why Reinvent MCH?
Maternal Mortality
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Icleand, 0
Norway, 0 1 Sweden, 1 Ireland, 1.6
Belium, 2.5
Greece, 2.8
Austria, 3.8
Australia, 3.9
Hungary, 4.2
Japan, 4.4
Spain, 4.6
Poland, 4.8
Germany, 5.2
Netherlands, 5.2
Switzerland, 5.5
Slovak Republic, 5.6
Canada, 5.9
New Zealand, 6.8
France, 7 United Kingdom, 7.7
Czech Republic, 8 Portugal, 8.2
Denmark, 9.2
Source: OECD Health Data 2008 2 3 4 5 6 7 8 9 10 11 12 Finland, 12.2
USA, 13.1
13 14
Infant Mortality
Japan, 2.8
Sweden, 3.1
Norway, 3.2
Finland, 3.3
Spain, 3.5
Czech Republic, 3.7
Portugal, 3.8
Greece, 4 France, 4 Germany, 4.1
Italy, 4.1
Switzerland, 4.2
Denmark, 4.4
Australia, 4.4
Netherlands, 4.4
Austria, 4.5
Belgium, 4.7
Ireland, 4.9
United Kingdom, 5.3
Canada, 5.3
New Zealand, 5.6
USA, 6.8
0 1 2 3 4 5 6 7 8 Source: United Nations. Table 4. In:
United Nations Demographic Yearbook, 2004
. New York, NY: United Nations; 2007:73 –93 .
U.S. Rank in OECD
Maternal mortality
All races – 25 th
Whites only – 19 th
Infant mortality
All races – 22 nd Whites only – 22 nd
Racial & Ethnic Disparities
Pregnancy-Related Mortality Ratio, 1991-1999
30 25 20 15 10 5 0 30 Deaths Per 1,000 Live Births 8.1
African American White
Chang et al MMWR 2003
2 0 6 4 14 12 10 8
Racial & Ethnic Disparities
Infant Mortality, 2005
Deaths Per 1,000 Live Births 13.7
5.7
African American White NCHS 2008
14 12 10 8 6 4 2 0
Healthy People 2010 Infant Mortality
Per 1,000 Live Births Year 2010 Goal
NCHS 2008
16 14 12 10 8 6 4 2 0
Healthy People 2010 Low Birthweight
Per 1,000 Live Births Year 2010 Goal
NCHS 2008
3.5
3 2.5
2 1.5
1 0.5
0
Healthy People 2010 Very Low Birthweight
Per 1,000 Live Births Year 2010 Goal
NCHS 2008
8 6 4 2 20 18 16 14 12 10 0
Healthy People 2010 Preterm Birth
Per 1,000 Live Births Year 2010 Goal
NCHS 2008
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 in America 2. Assure the conditions in which all mothers and children can be healthy
1. Transforming Maternal & Child Healthcare in America
Definition of Health Goals of Health System Client Model Health Production / Disease Causation Intervention Approach Old Operating Logic (2.0)
Absence of disease and disability Health maintenance and prolonging life of individual Individual
New Operating Logic (3.0) Health is a positive concept emphasizing the development of social and personal resources, as well as physical capacities (Ottawa, 1986 & IOM 2004) Optimizing individual and population health Individual, community, and population
Biomedical Diagnosis and treatment
Biopsychosocial, Life Course Health Development Emphasize disease prevention, health promotion and optimization Time Frame
Episodic Care
Lifespan: Sensitive, Critical Periods to optimize health trajectories
Pediatric Office 2.0
Parenting Support Early Intervention Home-visiting network Preventive Care Acute Care Developmental Services Chronic Care Developmental Services Lactation Support Early Child Mental Health Services Early HeadStart & HeadStart Child Care Resource & Referral Agency
Surveillance Community Services and Resource Sector
Pediatric Office 3.0
Screening Pediatric Services Sector
Preventive Care Acute Care
Assessment Peds/HPlan/ PHSector Mid-Level Assessment Center Evaluation (IDEA Sector IDEA Regional Center for Developmental Disabilities Other Specialized Services
Developmental Services Chronic Care
Child Care/Family Resource Center
Program COORDINATION CENTER Program
Health Development
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Preconception care 3.0
Prenatal care 3.0
Postpartum care & interconception care 3.0
Pediatric care 3.0
School health 3.0
Adolescent health 3.0
Family planning/reproductive health 3.0
Children with special healthcare needs 3.0
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Vertical, horizontal & longitudinal integration 10. Universal healthcare
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) Sustainable development (natural capital)
Educational Development
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Preconception and prenatal care Parenting education Child care Universal Preschool Early Head Start and Head Start K-12 – small class size, teacher quality, standards After school and summer programs 8.
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Youth development Health education/physical education 10. Comprehensive school health clinics
Educational Development
+ Early Childhood programs After-school programs Summer Programs Comprehensive school health clinics $ 156 billion
Economic Development
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Raise minimum wage Expand Earned Income Tax Credits 3.
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Strengthen collective bargaining Providing safety net – unemployment, housing, food stamps Providing job training and retraining Assuring universal healthcare 8.
Expanding access to family and medical leave, quality childcare, universal preschool Teach financial literacy 9.
Extend microloan programs 10. Macroeconomic policies
Family Development
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Human development (education, employment, legal/social services) Life skills training Reproductive health Violence prevention Marriage counseling/family therapy Economic development Criminal justice system reforms Tax reform 9.
Welfare reform 10. Child support reform
Relationality is primary, All else is derivative.
- Ronald David
Black babies are dying because their mothers are dying in dead relationships.
- Sister Byllye Avery
Efforts to reduce maternal and infant mortality and morbidity must focus on the repair and support of interpersonal relationships at all levels .
- National Commission on Infant Mortality
Community Development
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Economic development Affordable decent housing Delink schools and property tax Community policing Municipal services Infrastructure development Clean air and water Create social capital 9.
Create cultural capital 10. Residential desegregation
Reproductive Social Capital
Features of social organization that facilitate coordination and cooperation to promote reproductive health within a community
community networks civic engagement local identity and a sense of solidarity and equity with other community members; trust and reciprocal help and support.
Sustainable Development
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Teach individual responsibility Protect air quality 3.
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Protect water quality Protect food safety Provide consumer education Mobilize consumer actions 8.
Require higher standards and more testing of consumer products Promote smart growth 9.
Stop global warming 10. Support research on environmental influences
“Now that you’re here, the word of the Lorax seems perfectly clear. UNLESS someone like you Cares a whole awful lot, Nothing is going to get better.
It’s not. “SO… Catch!” calls the Once-ler.
He lets something fall.
“It’s a Truffula Seed.
It’s the last one of all!
You’re in charge of the last of the Truffula Seeds.
And Truffula Trees are what everyone needs.
Plant a new Truffula. Treat it with care.
Give it clean water. And feed it fresh air.
Grow a forest. Protect it from axes that hack.
Then the Lorax And all of his friends May come back.” - Dr. Seuss, the Lorax
Reinventing MCH
Reinventing MCH 1.
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Create a new roadmap for MCH Transform maternal & child healthcare Assure conditions for optimal MCH development Revise MCH core functions Retool MCH workforce Reorganize MCH programs Establish MCH Trust Fund Engineer MCH innovations
1. Create a New Roadmap to MCH
Map to Nowhere?
“If you don't know where you are going, any road will take you there.” Lewis Carroll, Alice in Wonderland
What should our national goals for MCH be for the Year 2020? 2030? 2040? What should be our Healthy People 2020 objectives for MCH?
2. Transform Maternal & Child Healthcare
Integration
Not just providing stop-gap services , but building integrated systems and assuring access, quality, coordination & integration
Universal Coverage
3. Assure Conditions for Optimal MCH Development
Community Development Environment Education MCH Healthcare
MCH Life Course Organization
We must become the change we want to see.
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MAHATMA GANDHI
4. Redefine MCH Core Functions
Ten Essential Public Health Services to Promote Maternal and Child Health in America
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Assess and monitor maternal and child health status to identify and address problems.
Diagnose and investigate health problems and health hazards affecting women, children, and youth.
Inform and educate the public and families about maternal and child health issues.
Mobilize community partnerships between policymakers, health care providers, families, the general public, and others to identify and solve maternal and child health problems.
Provide leadership for priority-setting, planning and policy development to support community efforts to assure the health of women, children, youth and their families.
Promote and enforce legal requirements that protect the health and safety of women, children, and youth, and ensure public accountability for their well-being.
Link women, children, and youth to health and other community and family services, and assure access to comprehensive, quality systems of care.
Assure the capacity and competency of the public health and personal health work force to effectively address maternal and child health needs.
Evaluate the effectiveness, accessibility, and quality of personal health and population-based maternal and child health needs.
Support research and demonstrations to gain new insights and innovative solutions to maternal and child health-related problems.
How will we redefine the 10 essential public health services to promote MCH in America?
5. Retool MCH Workforce
Retool MCH Workforce
Assessment
Longitudinal surveillance Multilevel surveillance Community-based participatory research
Retool MCH Workforce
Assurance
Leadership Collaboration Advocacy
Retool MCH Workforce
Policy Development
Health & change theories Developmental strategies Political will
How would we revise the ATMCH core competencies to guide the transformation of the MCH workforce?
6. Reorganize MCH Programs
Reorganize MCH Programs
Realign federal programs to support a transformed system, including establishing within DHHS the position of “deputy secretary for MCH” Establish a National MCH Investment Advisory Committee Establish systems to assure accountability and coordination of services at all levels
7. Establish MCH Trust Fund
Establish MCH Trust Fund
Managed by Deputy Secretary for MCH Support systems building & integration at state & local levels Provide incentive grants to encourage innovations in MCH
8. Engineer MCH Innovations
The definition of insanity is doing the same thing over and over and expecting different results
- Benjamin Franklin
Innovation is not an Option
It is a necessity if we are going to improve MCH
Figure 1: Collaborative Innovation Network CIN CoIN – Measurement COIN – Child Health CoIN – Financing
CLN CIN
CLN CoIN – Information Systems
CLN CIN
CIN State/Regional Policy CoIN CLN
Reinventing MCH 1.
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Create a new roadmap for MCH Transform maternal & child healthcare Assure conditions for optimal MCH development Revise MCH core functions Retool MCH workforce Reorganize MCH programs Establish MCH Trust Fund Engineer MCH innovations
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)