HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Life Span Approach to Perinatal Women's Health

DAWN MISRA: Thank you, Holly. Thank you all for coming. I'm really excited to give this talk. I spend a lot of time giving very, very academic talks, and this is an academic talk, but the audiences are important to me. It wouldn't be important to me if my framework just sat on a shelf and was read by my students and read by other academics. I'm really hoping that it will change maybe some of the ways that we go about trying to improve things in maternal and child's health and women's health.

As Holly said a lot of the ideas and things that you all have done with these concepts have been very exciting, and we try to incorporate them into some of our latest iteration of this work.

So I wanted to start by giving ‑‑ I need to start by lifting the mike since Holly is a lot shorter than I am. It will make it easier. I want to start by giving you some background on the perinatal framework and where we were before and how we have been kind of evolving towards looking at weight as an issue.

Why do we go and develop a new perinatal health framework? The Maternal Child Health Bureau asked us to think about some creative ideas we had to improve perinatal health. And as we sat and worked ‑‑ and I should also acknowledge our two other colleagues, Bernie Guyer and Adam Alson at John Hopkins University who worked on this first iteration of framework.

When we looked at the history of things, we saw that perinatal health had failed to improve, and we really thought, you know, if we look at the key indicators, and I'm sure this is all familiar to all of you, they have really been stagnant and some of them have even gotten worse in the last decade, and the US continues to rank near the bottom compared to other developed countries, which is not where we want to be.

Prenatal care does not yield the desired benefits. I am a big fan of prenatal care, I think there's a lot of good things it can do, but in terms of solving a problem for us of our perinatal health outcome, it certainly hasn't done it yet, and that's despite lots of expansions or wonderful expansions and have gotten a lot more women to get prenatal care, but it still hasn't fixed the problem. And so we have access and utilization but not the improvements we want.

And there's also continuing problems that result from the fragmentation of women's and perinatal health.

As Holly said in the introduction, some of our impetus of this was trying to think of ways that women's in perinatal health or women's in maternal child health overlap with each other and where they really have the same goals. And it's obvious but yet it gets complex, when you try to actually work it out of where the money is and what we can do about it.

So what is the new framework? The framework tries to integrate a lifespan approach of the multiple determinants model. We will talk about what that is.

So in terms of lifespan, the rationale for why do we think we need a lifespan or life course model, it's that when we read the literature and thought about the key issues, as we realized there were a lot of very powerful influences on pregnancy outcome that occur long before pregnancy begins.

And I just highlighted a few examples here, and then I think we have as a reference on one of the slides we have a paper from 2003 in the American Journal of Preventative Medicine that goes through this in detail.

But nutrition, we certainly all of you know about folic acid and the importance of folic acid in the periconceptual period and in the preconceptional period and having a strong influence on birth outcomes.

Chronic diseases, one of the things we go through in the paper is really looking carefully and the literature on chronic disease when you take as a whole, you can really see the importance of women's health and chronic disease on perinatal outcomes, both the women's outcome and the infant's outcomes.

And sexually transmitted infections. And in the paper we talk about this both from the angle of sexually transmitted infections increase in the risk of premature birth for infants when the mothers have this in pregnancy, but also the epidemic infection of sexually transmitted infections in the US has led to increases in infertility, and with the infertility, then women have sought treatment with reproductive technologies which has led to the increase of multiple births.

So one of the important issues too of the framework that I want to point out is we tried to think about all of public health and all of the populations in this framework and the work that we're doing because while a lot of my work focuses on racial disparities and socioeconomic disparities, and I'm very interested in those issues, I also think that in terms of perinatal health we're not doing very well for any groups.

We have problems even for the well‑off populations, and I think this example we are going to go through today of obesity, it's another example where it's not just about poor people, it really isn't just the poor who are suffering, they are suffering more under this, but we have plenty of middle class and upper middle class women who are having problems with obesity and the health problems that it brings.

And then the other issue that made us really think hard about why we need a lifespan and life course approach is the unintendedness of pregnancy in the United States. We have ‑‑ no matter what definition you use of this of mistimed, unplanned, unwanted, we have very high proportions in the US of that, and we don't plan our pregnancies and time them.

So in terms of you want to make changes and you think they are important in the early parts of pregnancy, if you wait until you won't know about it, because it's too late by the time it starts and women aren't planning ahead.

This is actually the schematic for the framework. Basically it's taking you through trying to look at different periods of life with the life course on top. And the bottom and then the preconceptional period is that big huge period on the side. This is a period we identify before any pregnancies have occurred.

There's also a strong showing here of what we call the interconceptional period so that with each cycle of pregnancy in either childbirth or loss that you start again to be not pregnant, and the big thing we want you to take away from here is that most women spend most of their lives either in the preconceptual or interconceptual periods; we're not pregnant most of the time. And so if you are thinking about exposures and exposure time to women, that really is where the bulk women of time in reproductive health is spent.

What we did here is a model three pictures of the early childbearing, late childbearing, late childbearing, and then there's finally non childbearing on the top. And one of the points we have here is that we don't know which group women will fall into. These do not represent every group, they are just a couple of examples.

But we really don't know whether women are going to be in the later childbearing years or they are going to be not childbearing at all, you don't know, so there's a potential for all of this for all women.

So again, focusing on the preconceptional, interconceptional periods as targets for intervention, and because women will spend the bulk of her years, and it's also we did this as an underpinning for the framework, and so I don't know if you call that the framework or not, but it's the idea of really getting to think about the life course and where women are and where they spend their time before we think about what the factors are that are important, so I think of that as being the sort of what's;s underneath the next figure you're going to see.

So multiple determinants. There are multiple social, behavioral, environmental, biological factors all shape pregnancy. Pregnancy is not just about the environment, it's not just about social. And what our model tries to do is integrate those multiple individual factors together to think about them at the same time, think about the interrelationships between them in terms of strategies and then illustrate pathways by which some factors might influence.

And so while these seem kind of complex and a little bit dry, I think as should try to think through examples, which Holly and I tried to do of what we can do with the framework and strategies we can do, looking at it and thinking about these interrelationships matters when you're trying to set up a program. It matters in terms of research, too, but I think it matters in a different way.

So this is the perinatal health framework that we developed, and we have different levels of the factors and various factors intersecting with each other and then outcome.

What I want to focus on for this group is the outcomes included both maternal and infant, and we have both short term and long term. And if you look at that time paper what you will see is that we do a pretty good job in the US monitoring a lot short term outcomes, and mostly short term infant outcomes.

We don't do much in terms of monitoring longer term outcomes, not so much in terms of maternal outcomes, and then the health and functioning and well being outcomes we do even less with.

This also might be a familiar figure to those of you who read the field model work by Evans and Stoddart and what we did is we tried to adapt actually their model of how to produce health to focusing on the perinatal arena. But perinatal in this case means both infant and maternal.

So the implications of this framework is a focus on distal and proximal factors. So if you look up here, we have both distal and proximal, things that are far away from the outcome, and things that are a little bit closer into the outcome.

And those are beyond the prenatal period. And so again, it's just trying to shift our attention. We're so used to putting all our bang for the buck, not just in prenatal care but in focusing on what we can do once a woman is pregnant and trying to move our focus away here.

And emphasizing that strategies to address these factors must be across the life course. And childhood and adolescence becomes an important part of how we think about the framework.

So I want to talk now about developing strategies here, spotting the challenges to perinatal health and how we can use this life course multiple determinants framework.

One of the things that pushed us, and I guess I change it from being rationale of trying to think about how our framework encompasses these things, I think our framework does a good job encompassing some demographic changes that have happened in the last decade or two, and I just want to highlight a few here. Things are different now than they were before.

Older age at first pregnancy, and this gets repeated a lot, but I think it's important to think about on a population basis.

The current diseases and conditions that may affect pregnancy outcomes increase with age. Just about every single chronic condition there are more people with it at every age, even something like asthma which typically has a big peek in childhood, there are still cases of asthma that occur across the lifespan, but things, particularly hypertension, diabetes, the older you get, the more likely you are to get these.

And also the older you are, the longer you have been living with one of these conditions, and the more potential it has of taking a toll on your health, it may have an effect on your pregnancy outcome, both the maternal and infant outcomes.

And then potentially shorter interconceptional periods. Now, this is because if you delay your first birth and you're still going to have two to three children, you're not going to wait as long typically between them perhaps as people might have in the past, because you are kind of running out of time in terms of childbearing time.

We also, and this is a big focus obviously in the strategies discussions we are going to have, we have an increased prevalence of obesity and overweight in the United States. And the prevalence of sequale in these conditions increase with age, and the pregnancy may contribute to the problem for women.

I'm going to show you a little bit of evidence this morning. There's some increasing literature on whether or not women getting pregnant is part of what leads women to become obese.

Clearly that's not the explanation for men, and we have an increasing rate of obesity for men, but it is certainly a vulnerable period for women. It is a time when we expect them to gain weight, and then they are confronted with an infant afterwards who needs a lot of care and really how do we manage that time period for them in terms of the risk.

So think about obesity in the context of the integrated women's and perinatal health framework.

I want to start with a little bit of terminology, and hopefully that way you'll forgive me as we give the rest of the talk. We talk about a lot of healthy weight within the public health arena these days, and it's been sort of an important shift to make.

I think in some ways it's a little bit like the shift we try to make from accidents to injury, and when I give my lecture in my intro MCH class over here I have to make a big point to the students that there are no accidents. We have injuries; we do not have accidents.

And I think we're making the shift a little bit in public health in terms of the obesity discussion is we don't want to talk about obesity anymore we want to talk about healthy weight. And I think there's a lot of really good reasons for this in terms of strategies, in terms of changing the health for the population, people's habits, all those are very good things.

But in terms of the actual research on outcomes and what's going on, people don't look at healthy weight versus not healthy weight. People look at obesity and overweight. And so in the literature that you're going to see relating to pregnancy outcomes and women's health, you're going to see these factors used.

And I also wanted to highlight here, the adults we have it's based on body mass index, with obese being greater than 30 and overweight classified 25 to 29.9.

But children, this is something that even took me a while of I had gotten used to sort of the adult categories. We don't actually use similar categories for kids. It's actually based on percentiles for kids, it's not based on the computation of their BMI being above a certain cut point, and that's because children with their growth rates and other things don't really fit into the formula that we have for adults.

But in children there's a category called overweight, which is being greater than the 95th percentile of your the BMI sex specific for your age. And the second one is at risk for overweight, and this is actually an important and growing category, kids are over the 85th but not in the 95th percentile yet. So these are both pretty big categories, and I'll show you some data on how much that's increasing among kids.

So we have seen overweight and obesity increasing over the past 25 years has gone up every single year and, as I said, pregnancy might contribute to obesity and then, hence, future morbidity and mortality and obese women are increase risk for morbidity and mortality. And I'm going to show you the data for each of these.

So based on NHANES data, women in the 20 to 39 year old age group, and this is the best group I could take in terms of overlapping of what we consider are women of childbearing age, they don't really actually report anything of women of childbearing age through NHANES, so this is a closest we can get.

You can see the obesity percentage and the 76 to 80 NHANES data is about 12 percent and then by '99 to 2002, we're close to a third or 29 percent. So they really jump up in that age group.

This is another interesting piece of data. We don't really have good data actually on pregnant women so much and where we are going with obesity there, but I think this is one of the best sources we have for this.

Did a study a few years back where they listed Alabama perinatal database, and this is one of the best cases I've seen sort of a perinatal database and what you can get out of one. A lot of times there's not incredibly detailed data that you can collect through perinatal databases through medical centers, but this is something where it was very basic data that was tracked.

And they found that actually they looked at women's weight at their first prenatal care visit, not the prepreganancy but the first prenatal care visit, so yes, there might have been some weight gain in the beginning period, but we are starting with the same time period for all the women.

And we saw a mean weight over the 20‑year period about that they had, the mean weight of that first visit increased 20 percent, which is another big jump up here.

Women who weighed more than 200 pounds increased 20 percent. Now, that's not a BMI calculation, and they didn't have as good data as they would have liked to on height measure, but knowing what women's general heights are in the United States, it was somewhat surprising you would have expected an increase in women over 200 pounds, which is generally in the overweight to obese range for most women, no matter what their height is.

And we also I think the one that's most concerning some ways is a 10‑fold increase in women who weigh more than 300 pounds. So that was another group that's very vulnerable to or average outcome and a big increase there.

And this is the next one that I think we should really, this group has particularly, MCHers are really concerned with, and I think it's the place where we hold the most hope in making changes but we also where the data is very concerning. There's an increased prevalence in overweight in our children. And what we see from MCH data, from '99 to 2003, if you look at girls 6 to 19 years of age 30.3 percent of them are in the overweight or that at risk for overweight group number, the over the 85th percentile.

I also want to point out, I'm not going to put data up here today, but there are definitely racial and ethnic disparities where African‑American and Hispanic girls are ‑‑ is higher prevalence of overweight and at risk for overweight than white girls do and they use socioeconomic disparities.

So even within race and across race, the less education you have, the higher your prevalence of overweight is. But I will point out that when you look at the data, I just had all the BRS data up for my students a couple weeks ago, even in people who are college educated and white, the prevalence of obesity and overweight is really growing quite a bit both in children and adults.

Finally, pregnancy might contribute to obesity in women who are not obese prior to pregnancy. Some work by Sally Lettermen and others showing that women weigh one to three kilograms more at 6 to 12 months postpartum compared to women who did not experience pregnancy, so it's not just getting older, and each live birth it appears to add about half a kilogram on average to women's weight.

And Gunderson Angrams did a review of looking at a lot of this literature and estimated about 14 to 20 percent of women weigh at least five kilograms more 6 to 18 months postpartum.

And then this is another statistic I kind of dug out because I wasn't really happy with sort of the data we have on trying to figure out what the prevalence of obesity in pregnant women and what risk does pregnancy give to women of becoming obese.

There are guidelines about how much weight women should gain in pregnancy and there's lots of debate about what those guidelines are and attempts to do better science about them. But we have some rough guidelines at least at present, where basically women who are not underweight to begin ‑‑ the women who are underweight are the only ones who are instructed to gain more than 35 pounds. Everybody is else is in lower limits in terms of recommendations.

But according to the birth statistics, the vital statistics every year for about the last two years, at least about a third of women when they are pregnant are gaining more than 35 pounds. And I would hesitate to believe that a third of women in the US are underweight when they become pregnant.

So unless you believe that, I would say you probably have a good proportion of women who are gaining more weight than we are recommending currently during their pregnancy.

And the excess pregnancy weight gain and failure to lose pregnancy weight in the first six months postpartum are the strongest predictors of long‑term weight gain in women according to one study that actually followed women for a very long period of time, for several years to try to look at what predicted their long term weight gain.

We also know that obese women are at increased risk for maternal morbidity, mortality, a lot of the previous work we done on the 2003 paper focused while we talked about everybody's outcomes a little bit of the push of the work was on the infant outcome side, and we delved more recently as part of a project we were doing on safe motherhood into thinking what the risks were for women.

And certainly the literature is very supportive that being overweight and obese is also harmful to women's health during pregnancy, not just the health of their infant. We see increased risk for complications of pregnancy, like gestational diabetes, preeclampsia regardless of the woman's prepregnancy health.

A lot of people thought if you were overweight but you were healthy, say you were exercising, you didn't have any chronic health conditions then maybe you were just healthy and overweight and it wouldn't cause any burden or any problems for you being pregnant, and it does not seem to be the case.

There seems to be growing evidence that being healthy and overweight you are still at risk in pregnancy for more of these complications, and I think that's something, another take home message to think about.

Also, increased prevalence of chronic disease prepregnancy. So you have the women who are healthy but overweight but a lot of those women are not healthy and overweight, they are overweight with a chronic medical condition. And those women experience more maternal morbidity mortality, and it seems to be linked to their chronic condition.

So if you come into pregnancy and you're overweight and you have diabetes, you have even more problems.

We see also an increase incidents of intrapartum problems including higher C section rates, and this is literature that's just beginning to emerge, a lot of interest. Some of this appears to be secondary to pregnancy complications and length of labor that obese women are having a longer length of labor and whether that has biologic reasons, mechanical reasons, what the reasoning for that is, is still not well understood, but certainly fair amount of paper suggesting a longer amount of labor, more macrosomia, the baby being too big when women are overweight leading to problems in labor.

But there also seems to be some increased risk regardless again of antenatal and preconceptual health, so there have been some papers showing even if women were healthy before they got pregnant, if they were overweight but healthy, didn't experience any complications during pregnancy, don't seem to have any of these things going on, they still have more problems during the delivery, so again suggesting that it's not just a matter of saying, well, if you can be overweight but still not have these other health problems it will be okay, it seems that actually it's not going to be entirely okay, there is still an increased risk for maternal morbidity, mortality.

This is an interesting area. Holly is going to talk a little bit about this in terms of strategy, and I think it's important to think back to this. Obese women may have lower rates of initiating breast feeding in shorter duration. Again, this is literature that's just starting to emerge, not a lot written about it.

We don't know whether it's physiologic, whether there's differences for women who are obese and in terms of milk production and how they are able to breastfeed, whether it's physical, whether women have more difficulty positioning the infant at the breast if they are overweight, or social factors of being less comfortable with their body and less comfortable with the idea of breast feeding because of body issues.

I think all these are important to think about. What we would like to see is this prevention aspect that we have for women that are obese. But this in some ways if we don't deal with this and we want to use breast feeding as a way to health the next generation, this is a generation who are particularly at risk.

Children who are born to obese women are more likely to become obese later. This is a group we most like to intervene with in terms of breast feeding, and I think there may be more barriers to it than we realized.

Now cost and economic effects. There's been very little done on this, but some pretty nicely done papers in recent years. The cost of prenatal care in overweight women was 5 to 16 times higher than increase with the level of obesity, and I think based on previous slides you can guess why this is, because they are more likely to experience these prenatal complications which obviously is more time more time in terms of clinician time, in terms of clinical care time.

The cost of the antenatal, intrapartum, and postpartum hospitalization together why five times higher for overweight women. And postpartum hospitalization also takes into account what happens intrapartum, and some of these complications of pregnancy can develop into morbidity problems in the immediate postpartum period might lead women to stay in the hospital longer.

Okay. I'm going to turn it over now to Holly to talk about some system challenges and the strategies.

Are there any questions before I do that? If you wanted a clarification on any of the sort of scientific background rationale.

UNKNOWN SPEAKER: (Inaudible)

DAWN MISRA: You mean do we use like data from children in the year 2000 versus back a lot? CVC just did a big revamping of the growth charts, and I believe that the ones now are from about 1990, so there's not a lot of debate about those or whether breast‑fed children should be in there separately, whether we should be using breast‑fed children as the ideal across them, but they did update them somewhat, which would make it even actually fewer kids overweight, if you updated the statistics.

And whether we should keep doing that is debatable question, so obviously we get to make ourselves look better because we just keep shifting the percentage.

UNKNOWN SPEAKER: (Inaudible)

DAWN MISRA: I don't ‑‑ actually I don't actually remember from those recent papers what they are using.

UNKNOWN SPEAKER: (Inaudible)

DAWN MISRA: That's what the paper shows. These are the only two ‑‑ this is the only research really published in this area. I did not see other papers trying to replicate this or look at different issues, so I would say it's a pretty new and limited area of study and how to do that. I'm not a health economist, it's pretty complex what you are going to count, what you're not going to count, what you're really going after.

UNKNOWN SPEAKER: (Inaudible)

DAWN MISRA: Yes. Actually I wouldn't be, you know when I think about the cost of medical care for one emergency department admission or just overnight stay in the hospital because your diabetes or hypertension is out of control, I could easily imagine it getting up there.

But, yeah, I don't recall actually the details of the economic studies this much, but this particular author is the one who has published the most in this area. Other questions? Okay.

HOLLY GRASON, M.A.: Great. Thank you, Dawn. Well, in follow‑up actually to Bill's comment about he would think the Blues would be after this, actually we were at a meeting earlier this year where there were different large health plans and insurers who, yeah, were more interested than we thought I think in some of this, because it's I think they do know that, and they are willing to think about an offer of suggestions for what they might do, so actually it's something that I think will come up in a while.

So I think Dawn has really summed up very neatly and compelling arguments for why we need to male to perinatal and women's health, why we need to be concerned about perinatal outcomes with respect to obesity and why we need to have an intergenerational focus.

I think one of the things that really excites me about working in this sort of life course thinking is that from a policy perspective, I am forgive me for complaining for a minute but endlessly frustrated with the hitting of women versus children, pregnant women versus older, you know, non pregnant women, men versus women, you know, older people versus ‑‑ it just makes me crazy, and I think one of the very compelling things is when you look at this is that it really is all the same and we really have to do it all, if you will, and that intervention at any one time is probably not going to get you what you want.

And so I really appreciate the work that Dawn has done to help us walk us through that. So why is ‑‑ have I summed up the system challenges as too little, too late, too fragmented? Well, there's lots of reasons.

It's too little because we focused, as Dawn said, on the medical and clinical interventions and we know from the multiple determinants approach and from your experience base in maternity and child health and over the years that it's really not just about physiology and medicine, it's so much more, it really is outside of that. So if we focus just on the medical we're by definition going to be doing too little.

Let's face it and my apologies to the physicians a other clinicians in the room but most women don't spend a whole lot of time with their doctors unless they are married to them and we spend as little time in doctor's offices as we possibly can, although sometimes we are challenged in that.

But there's a whole lot else going on we spend our time and we really need to work as MCH field I think to focus on that. Another reason why there's too little is there's a lot of us outside of the system, you know, the system, medical care as a lot of people who don't show up so we really need to focus on that if we're going to change population health. Why is it too late? Well, I don't really know the answer to that per se but one of the things we do know is just give an example with tobacco and the fact that I'm sure all of you in this room are convinced that you know smoking is a pediatric problem, well obesity is a pediatric problem as well and if we start worrying about, you know, healthy weight until women show up in pregnant, you know, with being over 300 pounds or whatever, we really set the bar too high for what we might accomplish in the medical field or the public health field so we really need to start on primary prevention. You know on a population level thinking about why we are too late at this, you know in public health we have been focusing very much over the past few decades on alcohol, tobacco and firearms and they were important issues and we need to continue with those, we have been, you know, focusing on immunization challenges on bioterrorism and I think this epidemic just snuck us you have up on us. Is

Too fragmented, well that system I don't need to tell you why we are too fragmented, we have, you know, highly diverse medical specialties in our country, we have a real split and difficult communications between public and private sectors in health and then within public health we have our own sort of challenges to effect among our see lows of children's health, women's health, maternal health, family planning and so on and

So what's an MCHer to do? Well, I don't know. This is a collective problem and I challenge you to help us think through that. But one of the major systems challenges, if you will, is and you've taught me this and I have learned this when I was sort of working in the states is just totally overwhelmed with trying to sort out all the information like you know the cost, the risk factors, the risk factors of children, the risk factors in this racial group or this ethnic group and so forth, how do you sort out all the information both scientific and political and put it in a way that you can sort of sit down with your staff and think this through and say okay, we have a five year plan to do for our block ranch, you know, what is it we can do. And so we're hoping that the framework can help sort of organize the information, we don't see it any more in terms of the strategy part than a tool sort of to help do that, to synthesize, to help point out gaps in knowledge, gaps in action, opportunity points and so forth. And we also hope that it will sort of help us think about, help us collectively think about how to Mary the sort of clinical aspects with the public health population base and quite frankly outside of health sector, you know, activities.

So I'm going to sort of refer you the very back page of your handouts there has a blown up sort of figure and I'll talk you through that in a minute but you may want to refer back the little slides aren't going to help you and we actually had to break up the figure, the life course multiple determinants figure for this particular talk to get out on the slides. But I'm going to talk briefly about how one might sort of apply this framework in the practice world am then we'll want to get your feedback. So I'm going to talk about obesity related strategies for girls in childhood, for adolescent girls and young women in their 20s and see how this works.

So this figure that I pointed you out to ‑‑ pointed out to you, as you can see from the title it says safe motherhood. This figure actually is from another talk at another meeting but will soon be published in this particular context and it, too, is evolving and we'll get some changes between now when you see it in print in a few months we're working on it. But what this is it just shows you quite obviously across the top we have different time periods.

You will notice and in fact we are aware that it's missing sort of the fetal sort of perinatal birth time point in time and we do know that there are fetal ore engines of all of this that we are talking about in health but we were trying to get away from the circles and try to go for the lines for a while and so we have left fetal out of there. But certainly one could put it in.

And we ended here at the 30 plus, but you could carry out obviously this framework for any number of decades given what it is you are trying to think through. And then the ‑‑ along the left happened column you have the various factors from the multiple determinant framework and we start here with the distal factors that was in that very large sort of field and Stoddart model and then in going to my next slide the bottom of your handout page there, you have the proximal factors with both the risk factors and the processees that impact on health outcomes.

In the middle, sort of the guts of this, is actually sort of an interventions, and this is not scientific by any means but it is sort of informed by various interventions we know of both from the field and ones that have been tested and are reported in the literature and so forth.

But again it's sort of a map that we hope can be useful in sort of organizing, thinking and planning.

Okay. So clearly there's lots of intervention points. So what we have used to sort of inform the interventions map is actually a set of strategies to in a generic sense to try to again be an organizational guide and the strategies that we have sort of jumped, used as a starting point have been information strategies, administrative strategy strategies, financing provider strategies, nongovernmental strategies and environmental strategies.

I just want to say two things, you know the stuff, two things I would note in thinking about this is that just this week as I was going over my talks I think another strategy I would be want to ad to this list and perhaps we'll work on it is a family strategy. Yes. Good.

I get a little endorsement if the back there that actually that might be a way of further synthesizing and integrating what we do in regard to these kinds of problems and our policies and programs.

The other thing I would note in anticipation of some questions given some of my prior work, where did these strategies come from, why didn't you use the public health functions framework, you know the 10 essentially services of public health to sort of organize your thinking about strategies, one could do that, it wasn't really a big, you know, hair pulling decision that we made that day.

I'm not even sure we sort of considered it, but I think one of the ‑‑and you might want to try to work that through, but one of the benefits I think here is that over the recent years I found that when we used the 10 essential services in a framework where we want to engage people outside of the health arena, where we want to engage the community and policy makers to put to use that kind of public health lexicon may not be the right place so if we could sort of go generic in our thinking about policies that may actually be more helpful.

So some examples of how we ‑‑ and all this information, by the way, is in a paper that's forth coming in women's health issues and I think Dawn would agree that we would be happy perhaps next month, once we get our final edits to share the prepublication version if any one wants to get in touch with us.

So we have written up some of these. But some examples if looking at the framework, information strategies you can see in a number of areas, so what we would want to do thinking about information strategies is thinking about the target populations for the information action, it could be those at risk, it could be providers, it could be those policy makers and others who influence the system. There are different types of information approaches, interventions to package information differently, you foe, use of the media, some of that kind of work that has been evolving, social marketing work in public health an beyond.

We use different venues for commuting information to women across the lifespan and I think there's been a lot more attention to that among MCH programs and beyond going to magazines, media, the entertainment industry and so forth.

Information transfer across health specialties for individual women and over time I think one of the concerns we have with system challenges is this issue of continuity of care no longer probably being a realistic ‑‑ it's certainly a goal how realistic it is, I'm not so sure because of the way our health system's working, but we really do need to think about how information transfer across health specialties and across health and non health entities specific to individual women can be really important in this regard and then other information strategies being for example use of performance measurement, quality measurement, report cards and so forth are also examples of different kinds of information strategies you might pursue.

Some of the examples for administrative strategies actually come from some folks in the MCH field that not in the room at the time but I did warn and that in Florida I would take her name in vain and the thought being I mentioned earlier about see lows and our MCH silos and so one of the things we might think about doing is actually reorganizing moving the boxes around, moving the people around, changing the ways that we get our work done in MCA to not just be the child health specialist talking to the child health specialist and so forth but really organize our units and our work processees in ways that will sort of integrate lifespan will integrate expertise and so forth.

Another area of example is provider strategies, and you'll see some of those on the framework in a number of areas but for example under proximal factors we talk about training a lot and this is one of my own pet peeves if you will, but the real need to focus on training clinicians ‑‑ intervening with clinicians during early in their training because once clinicians are trained, whether they are doctors or nurses or whatever, it's really hard to change what they do.

So if we want on the traditions to worry about women's weight and what that means after her pregnancy or whether she might develop hypertension, she might be more at risk, what she does during the day, where they works, what her settings are and so forth, we really need to sort of get in there early. If approximate we want internist diabetes or other conditions, thyroid disease or whatever that may contribute to overweight, we need them to be thinking about, you know, pregnancy related issues, about reproductive health planning, you know, pregnancy planning and so forth and to work with women who see them.

We have to sort of intervene at every point we can, in order to do this we really have to get providers sort of their clinicians there with us, in order to do that, I really believe we need to get to them early.

And there's a literature on that and actually I'm involved in the study of interventions and pediatric residency programs not to do with obesity, but beginning to see that even residency may be too late. So at least for some folks. So hopefully we can do that.

More comprehensive guidelines for post par dumb care, something we might want to think about, Dawn was mentioning how woman who have experienced pregnancy are greater risk for retaining weight so that's another provider strategy area we might think about, and then pursuing changes that are not dependent upon medical professionals.

We might want to think, for example, about coaches, women who are on supports teams, ultimate Frisbee and volleyball, whatever, people who interface, people in the gyms, women who go to, what do you call them, health clubs or whatever, they are better educated about some nutritional issues, about pregnancy and so forth, how can they contribute and be part of the larger team.

Dawn wants to interrupt. Of course you can.

DAWN MISRA: (Inaudible) thinking about talking about getting the people too early and having to retrain them, and something Holly we haven't released this report yet are the schools of public health, but there's a big change that happened about a little bit more than 10 years at the University of Michigan, which is where I am, where they basically eliminated their department of population and health, whatever it used to be called, MCH, where the training was done, and the idea of having these concentrations where students across the school, no matter what department they were in, could do certain concentrations departmental degree.

And one of the concentrations is actually in reproductive and women's health, and it's really the only school that chose to do that route to doing it, and there was a lot of worry and anxiety that that (inaudible maintaining your turf and keeping your stuff going on and can we work together, MCH become this consultant thing and all the other divisions will stay and help them.

And I think it actually is changing the way our students are thinking, they are doing those disciplinary areas and then they are learning about as they come out into the field, I don't know whether the way they are going to approach these problems are going to be different because they have thought of women's health as being this broader thing that kind of cuts across everything.

And so we think about the training thing, Holly and I focus a lot about training medical professionals and the other people we have to change how they think about early on, but sitting here and looking out at all of you and thinking about who we are sending out to practice I'm wondering whether we get to be in the public health schools working on changing the way we are doing MCH training and thinking about where MCH people are.

HOLLY GRASON: Great. So you can see how this work goes, every time we talk about it, we come up with a little idea, more to do.

So applying this sort of matrix, if you will, looking at strategies by in the little girls I call it little girls instead of child but the little girl sort of age stage, some environmental strategies, you know, the stuff making neighborhoods safe and amenable for physical activities, a provider strategy during this age grouping, increasing pediatrician practice of taking family histories.

We know obesity has features of intergenerational risk so the more the pediatrician knows about the family history related to weight and relate problems the more helpful they can be on the watch as they watch ‑‑ as they guide the child and the family through health issues over early childhood.

Administrative strategies, focusing on food policies and education ‑‑ food places, and education and day care and preschool setting so again examples of different ways you can sort of organize your thinking around what you might do in this sort of timeframe of little girls. You will notice that interventions obviously in this childhood area are more to the distal, thank goodness and less to the sort of proximal risks and processees kind of areas of the framework.

So for adolescent girls, so again you can sort of go back and look at this more carefully and insert your own ideas. I'm sure you have a lot you can give to us or share among each other but one of the things that you know we need to keep in mind clearly with adolescent girls is that they have different influences.

So the developmental, the human development or developmental psychology aspects of this life course framework is really important and this really is a very good example, so for example in the school setting while you might want to intervene in schools with, you know, young girls it could be sort of more important to sort of have the teacher who is the authority figure and who, you know, the child will really pay attention to and so forth for the actual intervention.

Well, by adolescents as we all know peers are more important, so we might want to think more about peer approaches to the interventions that we might wanted to pursue in school settings.

Breast feeding education I'm going to get to that in a minute but that's something else that we want to think about bringing in with adolescent girls.

Another sort of area that becomes particularly important as we leave sort of little girl hood into adolescence is the issue of information transfer across, you know, between health professionals.

This is when you know the girls stop going just to their pediatrician or their adolescent medicine primary care provider, may go to a family planning clinic, may go to a dermatologist or whatever, but they begin to have this sort of multiple providers element and so we have been very unsuccessful, as you all know, as a country of sort of getting the coordination and information transfer thing working well.

So you might want to begin thinking about ‑‑ thinking more about, we thought about this, but thinking more about the importance of having the woman or the girl sort of become responsible or become more responsible and giving them tools for transferring information among providers about their own health.

Breast feeding. So again, school strategies, this is an example that we did find written up in the literature, New York State has in fact a breast feeding education program in this their elementary and middle schools, so here we go outside of the health setting, you know, to do a health intervention.

We're talking about breast feeding which is something that hopefully doesn't ‑‑ well isn't needing to be occur in adolescents or little girlhood, but in the primary prevention it's probably the best time to intervene around breast feeding when social norms are formed and so forth. So there are some curriculums that are out there being implemented and tested. I think of a lot of interest here is the fact that it's oriented not just to the girls but to little boys as well so that as we know that it's very important to have that kind of support for women who are breast feeding and to again integrate health and healthy weight issues and momhood, motherhood, familihood into many areas of the curriculum.

So moving along in the life stage to young women in their 20s we might think about expanding the provider base. I think I mentioned earlier about who else might we find to intervene, since women hopefully aren't spending a whole lot of time in doctor's offices, who else is going to be, you know, present the opportunities for education for support and so forth in terms of maintaining healthy weight and healthy life styles, assuring information transfer across providers and overtime continues to be highly important.

If a child becomes obese early on by adolescence she may have developed type two diabetes, they maybe seeing an endocrinologist, if she gets pregnant an OB and nurse practitioner, she has a primary care physician and so forth and so on, so all these folks need to be talking to each other to make sure their goals and their work is all focused on the best outcomes for this individual young well and what she needs.

And then ‑‑ I'm going to sort of leave it at that and let your imagination go. So hopefully you get the sort of Gestalt of what we are trying to do here in organizing thoughts.

I mentioned earlier that Dawn and I first started talking about this probably if you will, at a conference in may that was convened by the Jacobs institute amounted as part of that conference and I think some of you were there, we had some working sessions to really and it was really a mix of clinicians, public health folks, health plans, doulas, there was doulas, consumers, doulas, it was really quite a mix, journalists, feds from many parts of HHS. But we had some work sessions to really discuss some of these ideas and clearly there are a lot of opportunities and I think you know that or you wouldn't be sitting in this room, but one of the ones that came out was actually from I don't think it was from the Blues but another health insurance group which said gee, we could pilot test some of our consumer directed health plans that are being ‑‑ that are evolving in the field now, they are evolving to try to reduce cost and so forth and put more of the responsibility on individuals for keeping health costs down.

But that also might be a benefit, we also might be able to use some health funds for things that are needed, lactation specialist or whatever or doulas or whatever, but various supports that ordinarily insurance and just changing insurance policies per se or Medicaid is not going to influence necessarily, there's clearly national intention and nutritional health am physical fitness, there is a lot of attention to health education promotion in schools these days and there are model strategies out there that we can draw on from any number of realms.

There's the centers for excellence in women's health that is funded by the federal office of women's health where there are models for team care, there's models for bringing in ancillary non health services into health settings to make them accessible and so forth. So a lot of opportunities that we think are really pretty exciting here.

Some of the policies directions that were recommended at this meeting were expanding or maximizing state holder positions of employers and industry. I know you know this, I hear it from you when I, the you, the large you, the MCU is large us, when I am pending more one on one time is that when MCH we extend not to, though we know we should, work nearly as much with large employers, with insurance companies as we really, really might if we were to want to affect the field.

So I think that was actually the primary recommendation that came from this group and I also think it was from, as I recall, the folks from the health plans saying we want you, we invite you to come and tell us how we can do this and work on this.

Improving utilization of local, state and federal governments is models of work force health promotion. Perhaps this is my own bias, but ‑‑ and to some extent I think thinking about where I work and what the health policies include and don't include I'm probably also a bit guilty, but should state MCH units be really working to negotiate what's in the health plans for state government employees or for local government employees?

You know, what can we do to really influence the systems that we are in to really test models and to sort of move the field forward.

And then of course we have legislative action and congressional directives where we might seek to ‑‑ advocates might seek to build in some statutory requirements for pilots amounted so forth, as well as some money, if there's ever money again.

So pursuing and evaluating and con, and medical savings account, how can we talk, you know, on the idea of you know, involving consumers, what if, you know, women thought about, well, gee, you know, I think it would be really helpful to have a you know doula present because I have these particular concerns about the birth of my twins or whatever, the birth of my single to child and you know, but gee, doulas, they don't necessarily come cheap not at least in the Washington area, so using medical savings accounts to provide lactation sport is another example of where we can think about getting consumers and women to use those opportunities in front of them, using performance measures as incentives and enhancing and developing I think I mentioned before stake holder groups, bringing in men more for our discussions, men are the folks with the power, let's face it in most corporations, in most government but not all, but we need to sort of ‑‑ it's not just about us, it's about us women, it's about all of us collectively, employers, environment health and you are began planning. But I know you've all thought about that.

Some practice directions, exploring group visits, creating teams, better Dawn mentioned that both in the private and public sector, adopting electronic and technological tools to support quality of care.

So conclusions, so a lifespan approach we believe demands attention to consistency and continuity with respect to health information and health care. The idea being that this sort of figure, if you can take it and think about if the goal is to achieve healthy weight in little girls and women in their 20s and women in their thirties in the children that they bear, in the families that they raise, you know, helping their spouses to maintain healthy weight and so forth, we need to have consistent messages, a shared goal that we are sort of pursuing at every possible opportunity.

As I mentioned before, than continuity of care no longer appears possible, our employers change held plans, we have to change our provider, you know, we have to have multiple specialists in order to accomplish one sort of goal, you know, getting an annual checkup for a woman involves at least three I think at my age, anyway, different medical specialists just for a usual primary prevention kind of visit.

So continuity of care is you know very, very unusual these days, we don't have just one doctor that's following us over time in our family and so we really need to think about patient centered approaches for information sharing and population based approaches to reach women across the lifespan, both in the health field and non health field.

So with that, we're only five minutes ‑‑ oh, no, we have 10 minutes. Okay. Great. We are just a little worried about the timing here.

We would like to answer any questions you have, but we have some questions for you, and we hope, I know you are hungry, but if you are willing to stay and chat for a little bit and I know this is just new to some of you, your thoughts would be really appreciated to what extent, if any, and in what ways to the framework and application strategies presented resonate with what you do or what you would like to do, you know, what are the opportunities and constraints that you perceive in attempts to interest implement some of this, you know.

And I say loosely some of this. And if you were to pursue implementation or use of this sort of life course multiple determinants framework for thinking about your MCH work and we can talk specific to obesity, or if you want to go outside of that topic area that's fine, too, what would you tackle first and why?

So with that, we'll turn the session over to you, I bet this mike disattaches if we need it, although we are a small group and we can be informal. Any questions? Yes.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON, M.A.: All right. We are bartering here.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON, M.A.: Between theory and reality.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON, M.A.: Yeah. I think, you know, I have two sort of reaction thoughts am actually Dawn and I were talking about this earlier this morning, what is the deal with the schools, why can't MCH just sort of make them do what they are supposed to do, we know what ought to be happening in had schools, they should have more than 20 meds exactly. So we had just that discussion just this morning. Be and it's funny.

I want to speak to that for a minute. But also from a personal sort of standpoint I have grown children now and thinking about very similar kinds of challenges and processes around tobacco, smoke education and around environmental consciousness and so forth, it's been a whole generation, you know, you know, when I think about it.

And so these challenges are not things we are going to fix, you know, overnight or whatever, they are going to continuing, so we do have to have that long perspective. So that's the first thing.

Also as you know, though, and I'm not giving you a solution so much as sort of acknowledging the challenge in Maryland last year there was legislation this was proposed to increase ‑‑ do a number of things, but among them was to increase the time for physical exercise in the school days and who is it opposed by, the only people who opposed it were the school district, the local boards of education, you know.

And so we got a partial, you know, success, we got some little minor successes in this particular, you know, area of schools, children and schools and healthy weight and so you know the structure of our system such as it ‑‑ some of this boils down to money with the vending machines, another example.

The school systems are locally funded, they are locally controlled, they need money because in society we don't put enough money into education as needed, so they need vending machine money. So you go on, and on an and so. There are strategies but they are multiple but again I think it supports the, you need multiple interventions over time, you know, to continually sort of trick away at those things.

I don't know if I answered but I hope I validated. Phil has a thought. Your best answers are going to be among your colleagues. Phil, go ahead.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON: Absolutely. Thinking about Maryland again, I was lucky enough to witness a part of that whole legislative discussion or happenings last year, a group of preventative medicine residents, sort of mayor wrist a couple of things we were talking about, but preventative medicine residents who decided to take on this position of healthy weight, physical activity in schools as a project, a project around which they could learn and practice advocacy, but anyway at the hearings where they were presenting there were parent and PTA groups, you know, speaking and the preventative medicine residents did go out and sort of peek to the PTAs, so I think Phil has, you know, some good ideas. I'm sure there's others. Other question. Yes, Lisa.

UNKNOWN SPEAKER: I think that the (inaudible) and some of them are utilizing strategies that are (inaudible) environment the physical environment, and on the other hand I have had some inquiries from particular professionals (inaudible)

HOLLY GRASON: Great. So we have some more emerging models that their evaluation requirements to your grant program, Lisa.

UNKNOWN SPEAKER: Yes.

HOLLY GRASON: This is Lisa King who is from the federal child health bureau talking about the integrated. But can you name ‑‑ I want to make sure it gets on the audiotape actually.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON: Innovative approaches to promoting. All right. Thank you. Dave.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON: MCHB has the best practices committee I think the organization themselves, that might be something that they are not doing and we would be happy to talk with them about what we know, for sure.

DAWN MISRA: The positive side of the intergenerational issue. I was actually thinking we were talking about the local schools and Holly and I were talking about this morning in partnerships. One of the other projects Holly and I did a lot of work together on was the fetal infant mortality programs and one of the ‑‑ you know, as many of you in this room know the big push there is at the local level, it's the idea of community level reviews of this, and so that's actually a group that really has developed an infrastructure at the county level which is a level at which many of the school district operate.

And if we sort of make the case that this is an issue of weight is important in terms of birth outcomes and perinatal outcomes, perhaps groups are a place we could think about working with where they have really been trying to, you know, struggling with developing recommendations and trying to do things locally and where maybe they could have some (inaudible), to our knowledge, I don't think I could think of too many of them that brought the education groups to the table too much but I think they are open to that. They have been used to bringing different groups to the table besides the health field and maybe that's a group to think about working with.

HOLLY GRASON: We are out of time but well take one more hands up. Yeah.

UNKNOWN SPEAKER: (Inaudible)

HOLLY GRASON: Actually ‑‑ well, Bill in Rhode Island is, and again the question was are there examples about family planning programs. The other family planning programs I know of is in Maryland actually and the federal maternal and child health bureau had some grants and I think they still may that did help support family planning clinics and other women's health providers to expand, you know, in an integrated way beyond the actual service of family planning.

So in Maryland and the person's name is Diana Chang who is in charge of that, and they have tested some models.

Okay. Well, thank you very much for staying and feel free to contact us if you know we can ‑‑ you have thoughts particularly give us back thoughts about what else we need to pay attention to. Thank you so much.