View
221
Download
4
Category
Tags:
Preview:
Citation preview
We Can Do Better:Reinventing Maternal & Child Health in America
Michael C. Lu, MD, MPHAssociate Professor
Department of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA
Department of Community Health SciencesUCLA School of Public Health
2008 CityMatCH ConferenceAlbuquerque, NM
September 23, 2008
Acknowledgment Mario Drummond Neal Halfon Milt Kotelchuck Cheri Pies
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.
U.S. Rank in OECD Maternal mortality
All races – 25th
Whites only – 19th
Infant mortality All races – 22nd
Whites only – 22nd
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
Healthy People 2010Infant Mortality
0
2
4
6
8
10
12
14A
fric
an
Am
eric
an
Na
tiv
eA
mer
ica
n
Pu
erto
Ric
an
Wh
ite
Mex
ica
n
Cu
ba
n
Asi
an
/PI
Per 1,000 Live Births
NCHS 2008
Year 2010 Goal
Healthy People 2010Low Birthweight
0
2
4
6
8
10
12
14
16A
fric
an
Am
eric
an
Na
tiv
eA
mer
ica
n
Pu
erto
Ric
an
Wh
ite
Mex
ica
n
Cu
ba
n
Asi
an
/PI
Per 1,000 Live Births
NCHS 2008
Year 2010 Goal
Healthy People 2010Very Low Birthweight
0
0.5
1
1.5
2
2.5
3
3.5A
fric
an
Am
eric
an
Na
tiv
eA
mer
ica
n
Pu
erto
Ric
an
Wh
ite
Mex
ica
n
Cu
ba
n
Asi
an
/PI
Per 1,000 Live Births
NCHS 2008
Year 2010 Goal
Healthy People 2010Preterm Birth
0
2
4
6
8
10
12
14
16
18
20A
fric
an
Am
eric
an
Na
tiv
eA
mer
ica
n
Pu
erto
Ric
an
Wh
ite
Mex
ica
n
Cu
ba
n
Asi
an
/PI
Per 1,000 Live Births
NCHS 2008
Year 2010 Goal
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
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
Pediatric Office 2.0
Developmental Services
Home-visitingnetwork
Early Intervention
Child CareResource &ReferralAgency
Early HeadStart& HeadStart
Early ChildMental Health Services
Preventive Care
Acute Care
Chronic Care
Developmental Services
Parenting Support
Lactation Support
Preventive Care
Acute Care
Chronic Care
Developmental Services
Pediatric Office 3.0
ScreeningPediatric Services
Sector
SurveillanceCommunity Services and Resource Sector
AssessmentPeds/HPlan/
PHSector
Evaluation (IDEA Sector
Child Care/FamilyResource Center
Mid-LevelAssessment
Center
Surveillance
Program
Program
IDEARegionalCenter for
DevelopmentalDisabilities
OtherSpecialized
Services
COORDINATIONCOORDINATIONCENTERCENTER
Health Development1. Preconception care 3.02. Prenatal care 3.03. Postpartum care & interconception care 3.04. Pediatric care 3.05. School health 3.06. Adolescent health 3.07. Family planning/reproductive health 3.08. Children with special healthcare needs 3.09. Vertical, horizontal & longitudinal integration10. 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 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
Educational Development
Early Childhood programs
After-school programs
Summer Programs
+ Comprehensive school health clinics
$ 156 billion
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
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
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 Development1. Economic development 2. Affordable decent housing 3. Delink schools and property tax 4. Community policing 5. Municipal services6. Infrastructure development 7. Clean air and water8. Create social capital9. Create cultural capital10. 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 Development1. Teach individual responsibility2. Protect air quality3. Protect water quality4. Protect food safety5. Provide consumer education6. Mobilize consumer actions7. Require higher standards and more testing of consumer
products8. Promote smart growth9. Stop global warming10. Support research on environmental influences
“Now that you’re here,the word of the Lorax seems perfectly clear.
UNLESS someone like youCares 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 LoraxAnd all of his friends
May come back.”
- Dr. Seuss, the Lorax
Reinventing MCH
Reinventing MCH
1. Create a new roadmap for MCH2. Transform maternal & child healthcare3. Assure conditions for optimal MCH development4. Revise MCH core functions5. Retool MCH workforce6. Reorganize MCH programs7. Establish MCH Trust Fund8. 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
HealthcareEducation
CommunityDevelopment
Environment
MCH
MCH Life-Course
Organization
We must become the change we want to see.
- MAHATMA GANDHI
4. Redefine MCH Core Functions
Ten Essential Public Health Services to Promote Maternal and Child Health in America
1. Assess and monitor maternal and child health status to identify and address problems.
2. Diagnose and investigate health problems and health hazards affecting women, children, and youth.
3. Inform and educate the public and families about maternal and child health issues.4. Mobilize community partnerships between policymakers, health care providers,
families, the general public, and others to identify and solve maternal and child health problems.
5. Provide leadership for priority-setting, planning and policy development to support community efforts to assure the health of women, children, youth and their families.
6. Promote and enforce legal requirements that protect the health and safety of women, children, and youth, and ensure public accountability for their well-being.
7. Link women, children, and youth to health and other community and family services, and assure access to comprehensive, quality systems of care.
8. Assure the capacity and competency of the public health and personal health work force to effectively address maternal and child health needs.
9. Evaluate the effectiveness, accessibility, and quality of personal health and population-based maternal and child health needs.
10. 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
COIN – Child HealthCOIN – Child Health
CoIN – Measurement
CLNCIN
CoIN – FinancingCLN
CLN
CLNCIN
CIN
CIN
CoIN – Information Systems
State/Regional Policy CoIN
Reinventing MCH
1. Create a new roadmap for MCH2. Transform maternal & child healthcare3. Assure conditions for optimal MCH development4. Revise MCH core functions5. Retool MCH workforce6. Reorganize MCH programs7. Establish MCH Trust Fund8. 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)
Recommended