National
Healthy Start Association Newsletter
Fall 2007
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News from the Projects
Central Hillsborough Healthy Start, Tampa, Florida
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| Florida Governor Crist signs Black Infant Mortality Bill. National Healthy Start Association’s Vice President of Program, Lo Berry, is third from right. |
Florida Governor Charlie Crist signed HB 1269, the Black Infant Mortality Bill, in Tampa, on July 2, 2007. The process by which this Bill was developed is a wonderful example of community collaboration. On December 19, 2006, the Central Hillsborough County Federal Healthy Start (CHHS) Project organized an emergency Call to Action meeting to present disturbing Hillsborough County trends / data in infant mortality and morbidity to key maternal and child health African American community stakeholders. Preliminary data showed, among other trends, that the number of Black babies dying in the first year of life increased from 17.6 deaths per live births in 2001 to 22.7 deaths per 1,000 live births in 2005 in the area.
With assistance from REACH UP, Inc. (Respond, Educate, Advocate, Collaborate for Health in Underserved Populations), the Healthy Start Coalition of Hillsborough County, CHHS and The Lawton and Rhea Chiles Center, State Senator Arthenia Joyner (D-18) drafted SB 2120 to create a Black Infant Health Practice Initiative designed to identify factors in the health and social services systems contributing to higher mortality rates among African American infants. Representative Betty Reed (D-59) introduced the companion bill, HB 1269, in the Florida House of Representatives. The bill passed the House and Senate, appropriating $1million to the Department of Health to implement the program.
This is a very exciting and groundbreaking piece of legislation. The Black infant mortality rate is rising all across the country, especially in the southeastern United States. This piece of legislation puts Florida “front and center” among those states acting and not just lamenting.
Catholic Charities Healthy Start, Fort Worth, Texas
In June, Texas Governor Rick Perry signed Senate Bill 143 (approved by both the House and Senate), which gives cities and counties legal authority to create fetal infant mortality review (FIMR) teams. These teams of physicians, nurses, social service providers and others will examine medical records and interview families to find out why these high rates exist in our community. The bill became effective September 1st.
The Tarrant County Infant Mortality Network, of which Catholic Charities Healthy Start is a member, was very active in advocating, seeking legislation and helping to draft the FIMR bill. This network has worked closely with many legislators from all levels of government to increase awareness of and a strong response to the high rates in Tarrant County. For years, Tarrant County has recorded the highest infant mortality rates of any urban county in Texas. Pockets of Tarrant County have higher infant mortality rates than some third world countries. The magnitude of these high rates poses significant threats to our community and public health.
The last year has been particularly significant in the Task Force’s efforts to combat infant mortality. In 2006, U.S. Congressman Burgess (R-26) championed the legislation observing September as National Infant Mortality Awareness Month. (See article.)
Illinois Healthy Start Partnership’s Annual Consumer Conference, Chicago, Illinois
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National Healthy Start Association Board Member Tamela Milan looks on as Jerry Wynn, Chicago Healthy Start, presents award to actor Malik Yoba. |
Malik Yoba, actor and motivational speaker, was the highlight of a day-long conference sponsored by the six Healthy Start projects in Illinois on August 23rd. The conference goes beyond infant mortality reduction information, adding speakers from the financial and legal arenas offering information on self-sufficiency and disparities in the criminal justice system. Yoba, himself a father, interacted with the participants, bringing dads up on stage to talk about their experiences as a father.
Also from Chicago: National Healthy Start Association Board Member Tamela Milan – one of the first consumers elected to the national board – was recently given an appreciation award from the Illinois Maternal and Child Health coalition for her work as a peer educator with the Closing The Gap initiative. The award was for her untiring efforts and dedication in making Closing The Gap a success. Tamela is Consortium Coordinator of Westside Healthy Start, where she works as a Child Development Specialist.
Cleveland MomsFirst, Cleveland, OH
The MomsFirst Perinatal Depression Project won the Most Innovative Promising Practice Award at the 17th Annual CityMatCH Urban Leadership Conference "for presenting an innovative response to specific problems, issues, or barriers." Chosen by the CityMatCH Board over 26 other projects, MomsFirst received a trophy and certificate. Said Project Director Lisa Matthews, “I am sure it was due to the multi-agency collaboration / funding / support and the multifaceted approach that the collaboration has been able to achieve. We feel like we are making baby steps, but the problems are universal and people were very excited to see how we approached them.” |
Research News: Maternal Health Research and Michael C. Lu, MD, MS MPH
In August 2007, the inaugural class of National Healthy Start Association’s Healthy Start Leadership Institute was treated to Dr. Michael C. Lu, one of this nation’s major voices for a life course, intergenerational perspective in maternal health. Dr. Lu is Assistant Professor of Obstetrics and Gynecology at the UCLA School of Medicine and School of Public Health. He is a member of the research workgroup that drafted the CDC’s Recommendations to Improve Preconception Health.(1) In this issue, the National Healthy Start Association highlights some of the research Dr. Lu and his colleagues have done that may be of help to Healthy Start communities.
Prenatal care, as currently provided, has important health benefits, but is not effective at reducing low birthweight (LBW). In 1985, an Institute of Medicine Study(2) defined prenatal care as the model to reduce LBW in the U.S. Lu and colleagues reviewed research and concluded that few or no LBW reductions were found for psychosocial support, home visitation, low dose aspirin, bed rest and hydration.(3) Prenatal care is, however, established as critical for maternal health and the future overall health of a child, including reproductive potential.
In “Racial and Ethnic Disparities in Birth Outcomes: A life Course Perspective,”(4) Lu and Haflon reviewed research and reframed the model for reducing poor birth outcomes and disparities. Studies document poorer access to health care for minority populations. Yet disparities occur even when similar economic conditions and prenatal care exists. A woman’s risk for preterm birth is a result of complex interactive social, economic and biological factors, some of which cross generations. Greater risk may be the result of “allostatic load” – a wearing down of immune and adaptive systems from biological and environmental stress over time and across generations.(5) The life course model argues that disparities can be overcome with a life span and generational perspective that closes “the gap for one generation to give the next an equal start.” Prenatal care is just one of the critical investments for a future generation’s birth outcomes. Risk reduction and protective strategies should target all sensitive developmental periods for reproductive health.
Prenatal care for undocumented immigrants is cost beneficial.(6) Eliminating public funding for prenatal care would save California taxpayers $58 million in prenatal care but add an additional $194 million in postnatal maternal care and $211 million in long term costs from increased LBW, prematurity and poor maternal health outcomes.
Birth outcome risks greater for homeless women of color.(7-10) Greater cultural sensitivity and increased health outreach and educational efforts on birth control for homeless populations are needed. Women often become pregnant while homeless and have conditions related to poor birth outcomes such as stress, drug use, poor mental health and nutrition, poor hygiene, STDs, dental infections and abuse. Two studies by Lu and colleagues found that birth outcomes were significantly worse for African American, Hispanic and American Indian homeless women, but not significantly different for homeless White women.
Breastfeeding initiation increases associated with provider encouragement, childbirth education and for those who experienced sexual abuse, but not with postpartum visits or physical and emotional abuse. Forty percent of U.S. women never initiate breastfeeding; only 22% breast-feed for six months or more as recommended.(11) Initiation is lower among African American women and for low-income women and women with less than a high school education.(12) Lu and colleagues found that among families with children less than age three, nurse or physician encouragement of breastfeeding significantly improves breastfeeding initiation for all racial / ethnic and age groups.(13)
Childbirth education attendance is associated with a 75% increase in likelihood of breastfeeding initiation, but attendance by African American populations is significantly lower than that of White and Hispanic.(14) A postpartum visit was not associated with breastfeeding duration of six months or more, though it is associated with first trimester prenatal care.(15) Those who reported child sexual abuse were twice as likely to initiate breastfeeding as those who did not(16) and “…were significantly more likely to have attended a class or discussion about parenting and more likely to comfort their child immediately when he or she starts crying.”
Prenatal care is a critical time to assist in the prevention of childhood obesity.(17) A higher likelihood of obesity was found in children ages five to 21 when exposed prenatally to maternal conditions of diabetes, smoking and malnutrition during the first and second trimesters. More research is needed to determine effective interventions and other prenatal conditions related to later obesity (e.g., stress, genetics).
Quality of Care Standards.(18-20) Very important to the future of maternal health and Healthy Start programs is the development of standards for monitoring / assessing the quality of maternal health care. Lu and many colleagues are developing such standards in California. They recently established 24 indicators within five categories: health status and access, preconception and interconception care, antenatal care, labor and delivery care and postpartum care.
Dr. Lu’s work and that of his colleagues helps us connect some very complex dots that we need to understand as Healthy Start works to improve maternal health, reduce infant mortality and low birthweight and remove disparities in perinatal health care.
Endnotes
1. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, et al. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 2006;55(RR-6):1-23.
2. Institute of Medicine. Preventing low birthweight. Washington, DC: National Academy Press; 1985.
3. Lu MC, Tache V, Alexander GR, Kotelchuck M, Halfon N. Preventing low birth weight: is prenatal care the answer? J Matern Fetal Neonatal Med 2003;13(6):362-80.
4. Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J 2003;7(1):13-30.
5. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998;338(3):171-9.
6. Lu MC, Lin YG, Prietto NM, Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis. Am J Obstet Gynecol 2000;182(1 Pt 1):233-9.
7. Stein JA, Lu MC, Gelberg L. Severity of homelessness and adverse birth outcomes. Health Psychol 2000;19(6):524-34.
8. Gelberg L, Leake BD, Lu MC, Andersen RM, Wenzel SL, Morgenstern H, et al. Use of contraceptive methods among homeless women for protection against unwanted pregnancies and sexually transmitted diseases: prior use and willingness to use in the future. Contraception 2001;63(5):277-81.
9. Gelberg L, Leake B, Lu MC, Andersen R, Nyamathi AM, Morgenstern H, et al. Chronically homeless women's perceived deterrents to contraception. Perspect Sex Reprod Health 2002;34(6):278-85.
10. Gelberg L, Linn LS. Assessing the physical health of homeless adults. Jama 1989;262(14):1973-9.
11. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. Pediatrics 1997;100(6):1035-9.
12. Ryan AS. The resurgence of breastfeeding in the United States. Pediatrics 1997;99(4):E12.
13. Lu MC, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of breast-feeding: evidence from a national survey. Obstet Gynecol 2001;97(2):290-5.
14. Lu MC, Prentice J, Yu SM, Inkelas M, Lange LO, Halfon N. Childbirth education classes: sociodemographic disparities in attendance and the association of attendance with breastfeeding initiation. Matern Child Health J 2003;7(2):87-93.
15. Lu MC, Prentice J. The postpartum visit: risk factors for nonuse and association with breast-feeding. Am J Obstet Gynecol 2002;187(5):1329-36.
16. Prentice JC, Lu MC, Lange L, Halfon N. The association between reported childhood sexual abuse and breastfeeding initiation. J Hum Lact 2002;18(3):219-26.
17. Huang JS, Lee TA, Lu MC. Prenatal programming of childhood overweight and obesity. Matern Child Health J 2007;11(5):461-73.
18. Korst LM, Gregory KD, Lu MC, Reyes C, Hobel CJ, Chavez GF. A Framework for the Development of maternal quality of care indicators. Matern Child Health J 2005;9(3):317-41.
19. Korst LM, Reyes C, Fridman M, Lu MC, Hobel CJ, Gregory KD. Gestational Pyelonephritis as an Indicator of the Quality of Ambulatory Maternal Health Care Services. Obstet Gynecol 2006;107(3):632-640.
20. Lu MC, Fridman M, Korst LM, Gregory KD, Reyes C, Hobel CJ, et al. Variations in the incidence of postpartum hemorrhage across hospitals in California. Matern Child Health J 2005;9(3):297-306.
A recent article which may be of interest:
- Lu MC. Recommendations for preconception care. Am Fam Physician 2007;76(3):397-400.
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