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

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Per 1,000 Live Births

NCHS 2008

Year 2010 Goal

Healthy People 2010Low Birthweight

0

2

4

6

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10

12

14

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NCHS 2008

Year 2010 Goal

Healthy People 2010Very Low Birthweight

0

0.5

1

1.5

2

2.5

3

3.5A

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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

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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)