Milton Kotelchuck, PhD, MPH Harvard Medical School Massachusetts General Hospital

1. The Maternal and Child Health Life Course Model:Introduction and Opportunities for Public Health Nutrition Milton Kotelchuck, PhD, MPH Harvard Medical School Massachusetts General Hospital Center for Child and Adolescent Health Policy October 12, 2010

2. Goal of Presentation • Provide an understanding for the current new emphasis on life course and social determinant models • Introduce the MCH Life Course paradigm and briefly note its scientific underpinnings • Review its theoretical principles • Present an MCH Life Course strategic framework for the Title V MCH Bureau • Provide examples of MCH Life Course related public health research, program and policy, partnership initiatives • And explore barriers and opportunities for MCH life course use by public health nutritionists

3. Ideas and Slides Freely Adapted From my Colleagues Amy Fine Michael Lu Cheri Pies Deborah Allen Neal Halfon

4. Richmond & Kotelchuck, 1983

5. 75th Anniversary of Title V of the Social Security Act • MCHB will initiate a new strategic planning effort – using MCH Life Course and Social Determinants as its guiding framework • October 20, 2010

6. Life Course is not new to MCH “MCH does not raise children, it raises adults. All of tomorrow's productive, mature citizens are located someplace along the MCH continuum. They are at some point in their creation either being conceived or born or nurtured for the years to come. There is very little genuine perception that mature people come from small beginnings, that they've had a perilous passage every moment of the way. All the population, everybody of every age were all at one time children. And they bring to their maturity and old age the strength and scars of an entire lifetime.” Pauline Stitt, MCHB 1960

7. Why a new strategic approach? MCH health status is not improving -- existing MCH programmatic approaches are not sufficiently effective The current balance of clinical & public health practices relative to social environmental practices and policies seems out of kilter There is substantial new life course research to guide new initiatives Reasserts the Children’s Bureau/Title V MCH leadership mandates New political and programmatic opportunities Prior 5 year strategic plan expired and on life supports

8. MCH Populations Health Status Not Improving Perinatal health is not improving IM stagnant; LBW rising; PTB raising; C-sections increasing Child Health Status is not improving Obesity rates sky rocketing Maternal Health Status is unknown Too much post-partum weight gain, rising rates of diabetes High rates of parental depression Family Health is straining Less family stability MCH racial/ethnic disparities remain and may be rising US International health status rankings declining We have to do something different

9. Low birth weight US, 1996-2006 Low birth weight is less than 2500 grams (5 1/2 pounds). Source: National Center for Health Statistics, final natality data. Retrieved February 22, 2010, from www.marchofdimes.com/peristats.

10. Adequate/adeq+ prenatal care US, 1992-2002 Footnotes available in notes section. Source: National Center for Health Statistics, final natality data. Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994; 84: 1414-1420. Retrieved February 21, 2010, from www.marchofdimes.com/peristats.

11. Failure of Enhanced Prenatal Care to Reduce Racial Disparities or Improve Birth Outcomes • “You can’t cure a life time of ills in nine months of a pregnancy” • Failure of late 20th Century movement to reduce Infant Mortality through increased access to comprehensive prenatal care (WIC) • Renewed search for understanding of disparities • New scientific knowledge • Paradigm shift in MCH – to MCH Life Course

12. Current programmatic approaches • Pay insufficient attention to social and environmental/root causes of illnesses • Focus on increasing access to medical care, quality of health care services (while reducing costs), changing individuals’ behavior, building service systems for treatment of specific chronic conditions • Utilize life stage not life course approaches, with limited child to adult to aging adult continuities

13. Need for Change • The old MCH/PH practices are not working sufficiently • New 21st Century Science emerging • New or renewed scientific/causal theory emerging

14. MCH Life Course Scientific Basis The challenge is to understand how the social environment gets built into or embodied into our physical bodies – which manifests itself in our health and disease status. To bridge the world of our intuitive social understanding of the causes of ill health (poverty, malnutrition) with our understanding of its clinical manifestations and treatment To better link downstream with upstream health (or to move downstream further downstream (root causes))

16. LCHD and Birth Outcomes White Reproductive Potential African American Pregnancy Age

17. LCHD and Birth Outcomes White Reproductive Potential African American Pregnancy Age

18. Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

19. The MCH Life Course Perspective: Moving from Research and Theory to Practice • There is a convergence of similar life course frameworks in related health fields • Reproductive life course models • Child development models • Chronic Illness models • The knowledge base for the MCH Life Course Perspective is strong and getting stronger

20. Underlying Scientific Basis for Life Course Models • Reproductive Health • Cumulative Stress Impact / Weathering • Early Programming (Epigenetics / Set Points) • Intergenerational Reproductive Health Effects • Child Health and Development • Brain Development / Developmental Sciences • Early Childhood Interventions • Chronic Illness / Obesity Onset • Teratogens • Chronic Disease Models • Fetal Origins of Adult Diseases

21. New Science Underlying MCH Life Course: Reproductive Health • Cumulative Impact • Cumulative multiple stresses over time can have a profound direct impact on health and development, and an indirect impact through associated behavioral or health service seeking change (Weathering) • Early Programming • Early experiences can “program” an individual’s future health and development, either directly in a disease or condition or in a vulnerability to a disease in the future

22. Epigenetics Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

23. Prenatal Programming of Childhood Obesity

25. Neurons to NeighborhoodsEarly Environments Matter and Nurturing Relationships are Essential • Parents and other regular caregivers in children’s lives are “active ingredients” of environmental influence during early childhood • Children’s early development depends on health and well being of parents • Early experiences affect the brain (the focus on the 0-3 period begins too late and ends too soon) • A wide range of environmental hazards threaten the developing central nervous system • The capacity exists to increase the odds of favorable development outcomes through planned interventions

26. Drawing by Tom Prentiss In: Cowan MW 1979. The development of the brain. Scientific American 113; 113-133 Als, H. 1986

27. Human Brain Development - Synapse Formation Language Sensing Pathways (vision, hearing) Higher Cognitive Function Conception -6 -3 0 3 6 9 1 4 8 12 16 Months Years AGE C. Nelson, in From Neurons to Neighborhoods, 2000.

29. 2004 National Research Council and Institute of Medicine Report

30. IOM/NRC Definition of Children’s Health (2004) “Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” From Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

31. WHO Definition of Community Health • A healthy city or community is…”one that is continually creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all the functions of life and in developing their maximum potential” Hancock and Duhl, WHO Healthy Cities Papers No.1, 1988

32. Life Course Chronic Disease Epidemiology Adolescent Origins of Adult Diseases Childhood Origins of Adult Diseases Fetal Origins of Adult Diseases • High blood pressure • Diabetes Mellitus • Coronary Heart Disease • Cancer • Obesity The Barker Hypothesis: Historical Cohort Analysis

33. Barker HypothesisBirth Weight and Insulin Resistance Syndrome Odds ratio adjusted for BMI Barker 1993

34. Barker HypothesisBirth Weight and Hypertension Law 1993

35. Barker HypothesisBirth Weight and Coronary Heart Disease Age Adjusted Relative Risk Rich-Edwards 1997

38. MCH Life Course Model Posits a new scientific paradigm for the MCH field Addresses enduring health issues with new perspectives (e.g.,disparities) Requires new longitudinal and holistic approaches to MCH programs, policy and research Provides an integrated framework for facilitating the MCH policy agenda Links the MCH community to adult and elderly health and social service policy development

39. Social Determinants • The social determinants of health are those factors which are outside of the individual; they are beyond genetic endowment and beyond individual behaviors. They are the context in which individual behaviors arise and in which individual behaviors convey risk. The social determinants of health include individual resources, neighborhood (place-based) or community (group-based) resources, hazards and toxic exposures, and opportunity structures. Camara Jones, 2010

41. Health Equity Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. World Health Organization Commission on Social Determinants of Health

42. Human Rights ….these commitments (human rights) provide a useful framework for shaping national laws and policies, provide a useful tool for ensuring accountability and point to approaches useful for promoting public health. Gruskin and Dickens, 2006, American Journal of Public Health; 96:1903-1905

43. Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.

44. MCH Life Course • Could it be true? • Could we really transform disparities into equity? • The WHO Nutrition Standards

46. WHO Multicentre Growth Reference StudyBackground / Context • Current growth curves developed from 1930’s Fels longitudinal studies (White middle class sample) • Should there be separate norms for each cultural / racial group? • Fierce debate among MCH Epidemiologists, especially given major LBW racial disparities in U.S. • Issue arose in Guatemalan INCAP study of the effects of malnutrition on mental development (since Guatemalans were shorter, why use U.S. norms?)

47. WHO Multicentre Growth Reference Study Purpose of Study • Goal: to assess optimal child growth (and motor development) and create standards usable throughout the world • Distinction between standards and norms • Ideal vs.. actual growth curves

48. WHO Multicentre Growth Reference Study Methods I • Sample selected for optimal growth • All upper middle class families • All infants exclusively breastfed for four + months • All full-term births, with no birth defects • Longitudinal (0 – 24 months) and cross-sectional samples (18 – 71 months) • N=1743 longitudinal, N=6697 cross-sectional (N=8440) • Six sites chosen around the world • U.S. (Palo Alto), Ghana (Accra), Oman (Muscat), India (South New Delhi), Brazil (Pelatos), Norway (Oslo), [China dropped out]

49. WHO Multicentre Growth Reference Study Methods II • Standardized measurement protocols, very well trained and supervised staff • Physical measurement recorded • Length / height, weight, weight for height, BMI • Monthly thru12 months, bi-monthly thru 24 months, then 4 times thru age 5 • Motor development milestones • Sitting with support; hands and knees crawling; standing with assistance; standing alone; walking with assistance; walking alone • Measured at same age as above thru 24 months, plus utilized mother’s reports • All measurements were home-based

50. WHO Multicentre Growth Reference Study Detailed Results • Physical Growth (standards) • Essential similar everywhere (data combined) • Only 3.4% inter-site variations; 70% intra-site variability; 26% error • Motor Development • No sex differences • 5/6 of motor developments sequential • No relationship between infant size and motor development • Birth Characteristics • Modest variations 3,300 mean birth weight (3.1-3.6 Kg range) • 3.2% LBW (vs.. national estimates (up to 30% in India)), shows powerful impact on SES on birth outcomes