Transcript Slide 1

Improving Maternal & Child Health in America:
A Life-Course Perspective
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
UCLA OB-GYN Grand Rounds
December 4, 2009
Acknowledgment
 National Institute of Child Health and
Development
 Community Child Health Network
 National Children’s Study
Acknowledgment
Maternal Mortality
Icleand, 0
Source: OECD Health Data 2008
Norway, 0
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
Finland, 12.2
USA, 13.1
0
1
2
3
4
5
6
7
8
9
10
11
12
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 – 25th
 Whites only – 19th
 Infant mortality
 All races – 22nd
 Whites only – 22nd
Racial & Ethnic Disparities
Pregnancy-Related Mortality Ratio, 19911999
30
Deaths Per 1,000 Live Births
25
20
30
15
10
5
8.1
0
African American
White
Chang et al MMWR 2003
Racial & Ethnic Disparities
Infant Mortality, 2005
Deaths Per 1,000 Live Births
14
12
10
13.7
8
6
4
5.7
2
NCHS 2008
How Can This Be?
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
 Implications for research, practice, and
policy
Early Programming
Barker Hypothesis
Birth Weight and Coronary Heart Disease
1.5
Age Adjusted Relative Risk
1.25
1
0.75
0.5
0.25
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
8.6-10.0
>10.0
Birthweight (lbs)
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 Hypothesis
165
160
155
Systolic Pressure (mmHg)
170
Birth Weight and Hypertension
<=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 Hypothesis
Birth Weight and Insulin Resistance Syndrome
18
Odds ratio adjusted for BMI
16
14
12
10
8
6
4
2
0
<5.5
5.6-6.5
6.6-7.5
7.6-8.5
8.6-9.5
>9.5
Birthweight (lbs)
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
Epigenetics
Same 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
25
Children 6-18 Overweight
Percent
20
15
10
5
0
1976-1980
1988-1994
Black
Hispanic
1999-2002
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
Prenatal Programming of
Childhood Overweight & Obesity
Prenatal Programming of Childhood
Obesity
Maternal Diabetes &
Intrauterine Hyperglycemia
Intrauterine Hyperinsulinemia (Fetal
Pancreatic β Cells)
Preadipocyte
Differentiation
Adipocyte
Hyperplasia
Prenatal& Postnatal
Hyperleptinemia
Programmed
Insulin
Resistance
Postnatal
Hyperinsulinemia
Hypothalamic
Leptin Resistance
Pancreatic βCell Leptin
Resistance
Hyperphagia
Hyperinsulinism
Adipogenesis
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 System
Chikanza 2000
Stressed vs. Stressed Out
 Stressed
 Stressed Out

Increased cardiac output

Hypertension &
cardiovascular diseases

Increased available
glucose

Glucose intolerance &
insulin resistance

Enhanced immune
functions

Infection & inflammation

Growth of neurons in
hippocampus &
prefrontal cortex

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 Birth
75%
Perinatal
Mortality
12%
50%
Term Births
Preterm Birth
Neurologic
Disabilities
Racial & Ethnic Disparities
Infant Mortality
14
Deaths Per 1,000 Live Births
12
10
8
13.6
6
Year 2010 Goal
4
5.7
2
0
African American
White
NCHS 2007
Racial & Ethnic Disparities
Preterm Births < 37 Weeks
20
Percent of Live Births
18
16
14
12
18.4
10
Year 2010 Goal
8
11.7
6
4
2
0
African American
White
NCHS 2007
Racial & Ethnic Disparities
Very Preterm Births < 32 Weeks
4.5
Percent of Live Singleton Births
4
3.5
4.17
3
2.5
2
Year 2010 Goal
1.5
1.64
1
0.5
0
African American
White
NCHS 2007
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
Smith et al Lancet 2001;357:2002-06
Kaplan-Meier plots of cumulative probability of survival without admission or death
from ischemic heart disease after first pregnancy in relation to preterm birth
Improving MCH
in America
Research
Pre-disease Pathways
Early and long-term biological, behavioral,
psychological and social precursors to
disease.
Community Child Health Network
(CCHN)

Longitudinal study of the causes of disparities in birth and child
health outcomes

4,000 families at 5 locations (LA, Baltimore, DC, NC, Chicago)
recruited at birth of index child

One of the richest databases to study developmental origins of
child health disparities

Community Based Participatory Research (CBPR)

A collaborative process that equitably involves all partners in the research
process and recognizes the unique strengths that each brings. CBPR begins
with a research topic of importance to the community with the aim of
combining knowledge and action for social change to improve community
health and eliminate health disparities (Minkler & Wallerstein 2003)
National Children’s Study

Longitudinal study – from before birth to 21 years of age

Cohort of 100,000 children from 100 Study Locations

Study how children’s genes and their environments interact to
affect their health and development

In




Los Angeles,
4,000 children
56 neighborhoods
67 birth hospitals
Followed for 21+ years
Practice
Prenatal Care 1.0
Receptionist
Medical
Assistant
Nurse Manager
Ultrasound
Tech
Prenatal Care 2.0
High Risk
OB
Primary &
Specialty Care
Nutritional
Counseling
Medical
Assistant
Receptionist
Teratogen
Information
Services
Mental
Health
Ultrasound
Tech
Nurse Manager
Social
Services
Oral Health
Family Support
Optimal Health
Development
Prenatal Care 3.0
Primary
Care
Lower Health
Development
Trajectory
Reproductive
Potential
Prenatal Family
Care
Planning
Medical Home
for Women’s Health
Medical Home
for Adolescent Health
PED
Pediatric Medical Home
NHVFRC
0
10
20
30
40 Years
Community
Development
Environment
MCH
Education
Healthcare
NMPP
MCH LifeCourse
Organization
Policy
Closing the Black-White Gap in Birth Outcomes:
A 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 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)