Are We Rising to the Challenge? "What Can MCH Do?"

Michael Liu: I’m going to talk about pre-term birth and especially racial and ethnic disparities in pre-term birth this morning. As you all know, pre-term birth is one of the most important problems in maternal and child health today. It’s related to about 70 percent of all perinatal mortality, about half of all neurological disabilities in children. It also contributes significantly to the racial and ethnic disparities in birth outcomes. An African-American baby born today still nearly twice as likely to be born pre-term and nearly three times as likely to be born very pre-term compared to a white baby, and this three-fold difference in early pre-term birth accounts for about two-thirds of the excess deaths amongst African-American infants. So if we can only do something about preventing pre-term birth, it will go a long way toward eliminating racial ethnic disparities in birth outcomes. But unfortunately, over the past 40 years, we really haven’t made much progress at all, as you can see. Although in recent years, this black white gap in pre-term birth has been decreasing, this decrease is largely due to an increase in white pre-term birth rather than a decrease in black pre-term birth. And although this morning I’m just going to address this black and white gap, I don’t want you to think this is a black and white issue. It isn’t because there are great disparities across all racial and ethnic groups in pre-term birth with Native Americans, Puerto Ricans, Native Hawaiians, and Philippino’s reporting some of the highest rates of pre-term birth in our nation. So what causes pre-term birth? I think one of the most important lessons that we’ve learned from the past 40 years of research is that pre-term birth is really a multi-factorial disease.

There are multiple causes of pre-term birth on multiple levels: at the individual level, at the interpersonal level, at the neighborhood and community level, and at the societal level. Many of you will recognize this as the adaptation of the social ecology model. So at the individual level, we know that there are three major pathways towards spontaneous pre-term birth: neuroendocrine, infectious immunologic, and behavioral. Here’s a simplified schematic of the neuroendocrine pathway. We know that stress plays a very important role in the pathogenesis of pre-term labor and that stress increases the release of a certain stress hormone corticotrophin-releasing hormone, or CRH, from the maternal brain as well as the placenta, which could then go onto precipitate a biological cascade leading to pre-term labor. Now here’s a perspective study showing that women who go on to deliver pre-term have significantly higher level of this stress hormone, the CRH, compared to women who deliver at term, and you can actually see this difference as early as the second trimester. Here’s another simplified schematic of the infectious pathway. Now some experts believe that up to 80 to 90 percent of pre-term birth under 30 weeks of gestation are caused by this pathway, and some of the infections that have been implicated include sexually transmitted infections, urinary tract infections, reproductive tract infections like bacterial vaginosis, VD, and more recently, periodontal infections have also been implicated.

Now in research we’re beginning to pay more attention not just to the infection, but also to inflammation at special (inaudible) inflammatory cytokines like TNF alpha, IL1, IL6 in the pathogenesis of pre-term birth. We’re also beginning to map out some of these interrelated relationships. So, for example, we know that there’s a great deal of interconnections between the (inaudible) pituitary adrenal axis and the immunoflammatory pathways, and we’re beginning to explore the neuroendocrine and the immunologic control the behavior, for example, the effects of (inaudible) inflammatory cytokines on behavior. Now at the interpersonal level, I’m going to put a big box here for the partner because we know that partner can play a major role, either positive or negative, in mediating some of these pathways. For example, partner can be a source of stress or they can help buffer against stress. In many places and cultures, the family also plays a very important role in a number of these pathways, especially if the partner is absent.

At the neighborhood and community level there are also a number of social factors that’s been linked to poor birth outcomes and Jennifer (inaudible) going to talk to you a lot more about these different factors, such as housing stability, neighborhood violence, residential segregation, lack of social services. They’ve all been linked to either pre-term birth or other adverse birth outcomes. Even the degree that social connectedness that you have with your neighbors, what social scientists call “Social Capital,” has also been linked to infant mortality. And then finally, at the society level we know that social norms, institutional practices, and public policy can have profound impact on birth outcomes. Just look at policies around welfare reform, child support, employment safeguards, and parental leaves. We also know that racism has also been linked to pre-term birth. Now we’ve known for a long time now that racism is bad for your health and health care. It’s surprising to me that it wasn’t until three years ago that the first study on racism and birth outcome was published. During a very small study, *Collins found that women who deliver a very low birth weight baby--most of whom are pre-term--women who deliver a very low birth weight baby were significantly more likely to experience racial discrimination during pregnancy, than women who deliver a normal birth weight baby.

In fact, through multi-regression analysis, found that the experience of racial discrimination during pregnancy increase your likelihood of having a very low birth weight baby by three-fold. So there you have it. So these are the multiple determinants of pre-term birth, and it follows that these require multiple interventions. So the question I would pose to you is that why do we keep looking for that quick fix? Because we all know this for a long time that pre-term birth is a multi-factorial disease, then why do we keep looking for that silver bullet? For about 40 years now we keep looking for that one single intervention that’s going to turn out to be the cure for pre-term birth the way we found the vaccine for polio. Again and again, we’ve been disappointed. There’s a partial list of the interventions that we’ve tried and based on their systematic review of the literature, *Goldenberg and colleagues found that most interventions designed to prevent pre-term birth do not work and the few that do are not universally effective and are applicable to only a small percentage of women at a risk for pre-term birth. So what we really need in this nation to do something about preventing pre-term birth are not these quick fixes or silver bullets. What we really need is a systematic, comprehensive, integrated approach addressing the multiple determinants of pre-term birth at multiple levels; again, at the individual level, at the inter-personal level, at the neighborhood and community level, again at societal level. This means that at the individual level we’ve got to start to intervene at all of these different pathways. This means that we’ve got to start to screen for infections, including periodontal infections that Jennifer (inaudible) going to talk to you about. I think timing is everything here. When you start to screen for infection of (inaudible) pregnancy, when the infection has been there since the beginning of pregnancy and even before pregnancy, you may be doing too little too late. In fact, even if you get the infections treated, you may still have a real tough time stopping all the inflammatory processes and all the (inaudible) inflammatory cytokines that’s been activated since the beginning of the pregnancy and that may be a partial explanation for the inconsistent and inconclusive results of many of the antibiotic trials in pregnancy. We’ve also got to start screening for maternal depression and intimate (inaudible) violence that can activate the neuroendocrine pathway.

We also need to screen for nutrition and maternal smoking and environmental smoking and substance abuse. And by nutrition I don’t mean just how much you eat or how much weight gain you have, but also how you eat and what you eat because we know that fasting and skipping meals, which a lot of pregnant women do, can activate the CRH release, leading to pre-term labor. We also know that eating a lot of fast food and fried foods, which a lot of pregnant women do, could also tip that balance between Omega 6 and Omega 3 to a more pro-inflammatory profile, which could then increase her vulnerability to pre-term labor. So we got to do a lot better in terms of our nutritional counseling and screening. There are actually best practice standards that have been developed. The problem, as you’re well aware of, are the providers are just not doing them. So how do we get providers to do what they’re supposed to do in prenatal care? And there are a number of healthcare quality improvement methodologies that have been identified, and I’m going to call your attention to just one of them, The Breakthrough Series, developed by the Institute for Health Care Quality Improvement.

But the Breakthrough Series is that it uses collaborative learning to implement best practice standards, and very recently a group has been started in Vermont by NICHQ, The National Institute for Child Health Quality, to start applying the breakthrough series to try to improve perinatal health services. While we’re talking about improving the quality of perinatal health services, we got to make sure that we do that for all women, for black women as well as for white women. Based on studies that Michael Cogan has done, we know that African-American women are significantly less likely to receive advice about smoking, alcohol, and breast-feeding during prenatal care, and they receive less advice that’s been associated with low birth weight. Now remember one of your core functions is assurance, so you have to assure that all women, regardless of the color of their skin, receive the same high quality of prenatal care. Now at the interpersonal level, we have the increased social support. Of course when I talk about social support you immediately think of what? Case management? Home visitation? And certainly they can be very important sources of support and some successful and effective models have been developed, such as the one in Colorado that *Erin Murray’s going to talk to you about. But for many women, and particularly for women of color that type of support is still not enough to buffer against the daily social stressors that women experience day in and day out. So I think men can actually play a very important role in providing psychosocial support except that most men are actually pretty clueless about providing support, and I can say that now because I have a nine month old daughter at home and I’m still struggling to learn how to provide support.

In maternal child health, men are often an afterthought in most of our programs. Now this becomes especially difficult in light of the fact that most African-American families are still headed by a single female parent. The absence of the father is still the norm rather than the exception in the African-American household. So we really need to understand the structural forces behind this and how do we start to strengthen male involvement in pregnancy and in parenting in the real life context of the African-American families. In the absence of the partner, the family, grandmothers, sisters, play an increasingly important role in providing psychosocial support. Again, we need to think about how do we strengthen their capacity to offer social support and I think a family resource center can be a promising strategy for that, and this should be expanded to include the extended family. Let me give you one more example of social support, and this time at the neighborhood and community level, and this is what an organization called Healthy African-American Families that I’ve been working with in South Central headed by Loretta Jones. And what this organization did was they actually started with these focus groups for pregnant women, and they asked them about the social stressors, their impact on their pregnancies, and then they asked two more questions:

What can your families and friends do for you that will help improve your pregnancy? And what can strangers do for you to help improve your pregnancy? And guess what kind of responses they were getting from the pregnant women? It’s things like “giving up the seat on the bus when I get on the bus,” or “let me go to the front of the line at the grocery store,” or “help me carry groceries to my car,” or “don’t touch my belly without asking me first.” It’s all of those simple things, and basically they compiled a list of these things that families, friends, and strangers can do for the pregnant woman, what they call “A Hundred Intentional Acts of Kindness Toward Pregnant Women.” And they’re going to publicize this list in churches, in barbershops, in nail salons, and I think this is just brilliant. What they in essence have done is to increase social capital. Remember, that’s the social connectedness between neighbors and even among strangers in a community to create that supportive community around the pregnant woman. I think we also need to start to address the lack of social services. Obviously, it doesn’t make sense to screen for maternal depression if mental health services are not available or accessible at the other end of the referral. And one of the biggest deterrents for the screening for domestic violence is the lack of shelter beds, an infrastructural support for battered pregnant women and their children. So we need to improve community infrastructure to provide support for pregnant women and their families. The problem is where in many states and cities and many communities color, we’re going in the wrong direction. These supported services are not being created; they’re being cut. So one of your most important jobs over these next few years is to ensure that these support services that impact so much on maternal child health aren’t cut. I’m going a step further than that. We need to start addressing a number of these social determinants that we talked about: housing stability, neighborhood violence, residential segregation, air pollution, and all the other social determinants of birth outcome. Now you might say, “Well these don’t really fall within the jurisdiction of maternal child health,” but just because they’re not in maternal child health, doesn’t mean that you’re exempt from addressing these social determinants that have a profound impact on maternal and child health.

It doesn’t mean that you have to solve all the social problems, but you need to start to corner what can solve these problems. You need to start partnering with housing authority and municipal transportation and the police and to start building these collaborative partnerships. And that’s what we’re beginning to do in Los Angeles County with the Healthy Birth Learning Collaboratives, and that’s funded by Proposition 10, the tobacco tax. What the Healthy Birth Learning Collaborative, or the HBLC, is it’s a network of providers, consumers, researchers, public health professionals like you, community leaders and advocates, and other stakeholders. It provides that infrastructure for them to come together on a monthly basis to talk about, “How do we improve birth outcomes in our community? How do we reduce disparities in our communities?” And we created an HBLC in all of the H Service planning areas in Los Angeles County, and we’re going to start inviting non-MCH people to the table so we can start addressing some of these social determinants like the availability of mental health services and shelter beds and parks and recreation. Now when you think about it, you know, in west side of Los Angeles we have more than 1,000 acres of parks and recreation, there’s less than one acre in South Central. And we’re also starting to talk about health and nutrition in many of our communities.

There are more fast food restaurants and liquor stores than there are healthy grocery stores and healthy restaurants, and obviously cause a lot more in disadvantaged communities and the quality of food is a lot less. So we got to start to address all of these different social determinants of maternal and child health. And we also have to start addressing the public policy that could have a profound impact on birth outcomes. For example, we know that most pregnant women work during pregnancy and we know that work that involves a lot of standing, a lot of heavy lifting, work that’s shift work or work that incurs a lot of human fatigue is associated with pre-term birth. In a lot of European countries they actually have adopted social legislations to protect working pregnant women. In fact, in France, after adoption of these social legislations, they seen their pre-term birth rate decline by more than one-third, and their very pre-term birth rate decline by almost two-thirds within the last 20 or 30 years. Now of course we can say that that decline is completely attributable to these social legislations, but what the French experienced points to is the possibility that you can actually do something about improving birth outcomes and eliminating disparities through public policy. And finally, you can’t not talk about racial and ethnic disparities without talking about racism, especially institutional racism. Now racism can be institutionalized in differential access to goods and services and discriminatory medical care and any residential segregation and so forth.

And I want to call your attention to some courageous and innovative effort that’s going on at the local level, such as at the Boston Health Department, and at the national level, such as the initiative spear-headed by the organization called City Match to undo racism for social justice, to make racism a public health issue. So there you have it. This is a list of proven and promising strategies that could potentially prevent pre-term birth and eliminate disparities. And just look at this list and see how different this list looks from our current list of interventions, and this shows the work that we have ahead of us. Now I think if we do all of these, we’re still not going to close the gap overnight, and that’s because we know that pre-term birth is really the outcome of not just what happens during pregnancy, but what also what happens before it. It’s the consequences of not only differential exposures during pregnancy, but also of differential life course experiences that create differential vulnerabilities, and this is the life course perspective that’s been taught to many of you over the past several years. And as you can see, prenatal care might be able to narrow the gap somewhat, but certainly you would have a tough time closing the gap completely. Now in the interest of time, I’m not going to go over the theory around the life course perspective, but I think the important implication of the life course perspective as they do in prenatal care is just not enough. What we need to do is also to include preconception and interconception care on our list, and there are actually models that’s been developed around preconception and interconception care. In fact, a demonstration project in Denver has shown that interconception care can reduce the recurrence of very low birth weight by one-third.

Now I think even if we do preconception and interconception care, we’re still not going to close the gap completely. What we really need in this nation is an integrated life core strategy to help prevent pre-term birth and eliminate disparities, and we don’t quite know what that strategy is yet in looking forward to the Maternal Child Health Bureau to provide a leadership in the resources to help us develop this life core strategy. So in conclusion, is MCH up to the challenge? Well, a lot of that depends on you. So think of what you do on a daily basis, think of the poor functions of Public Health and Maternal and Child health. In the assessment, can you start to include some of these social determinants and life course factors? And can you start to invest in data infrastructure that allow you for data linkages, not only from one pregnancy to the next, but from one generation to the next. In assurance, can we assure that all women, regardless of the color of their skin, receive the same high quality maternal child health services? In policy development, can we start thinking outside of the box instead of looking for quick fixes and silver bullets, can we start to do some of these things that we know that really matter: male involvement programs, increasing social capital, building collaborative partnerships between public health and academia between public health and community, and taking on racism as a public health issue? I will leave you with this one model that’s developed by Dr. Richmond and Dr. (inaudible).

Dr. Richmond is the father of the Head Start Program. They proposed that for any real social change to occur, you need three ingredients. You need a knowledge base, you need social strategies, and you need political will. Well, we have a knowledge base that’s growing and we talked about some of the proven or promising social strategies this morning. The question I want to leave you with is, do we have enough political will in the United States to actually do something about eliminating racial and ethnic disparities in pre-term birth? And the other question is, if you don’t provide the leadership, then who will? Thank you very much.