2017 State of Health Equity at CDC Forum Part 2


>>I’m a clinical child
psychologist by training, and I started my career in a regular old mental
health clinic in the Bronx. We were focused on
early childhood, and so kids would come in,
maybe 4, 5, and you say wow, that’s so early, that’s so
preventive, and I say oh, they had four years of
exposure to toxic stress and community violence
and two years of exposure to domestic violence, and it was
way too late, from what we know about brain development. And the disproportionately
receptive brain development that we see in early childhood. It’s a sponge. It picks up the good, and
it picks up the bad, right? And that’s why your two
year old can learn Spanish in a quick minute, and you’re
still struggling with “Hola, como estas,” [laughter] but
it’s also why your two year old exposed to two years of domestic
violence is disproportionately negatively affected, right? So when I asked the parents
of these 4- and 5-year-olds who are showing up at this
mental health clinic, you know, “I wish I would have seen you
sooner, did you tell anybody about this before coming here?” And they almost always say
yes, I told the pediatrician. So well why don’t I go sit
next to the pediatrician then. If you’re going to the
pediatrician all the time, and you seem to like to
go to the pediatrician, because when you don’t come
to see me and I ask you where you were, you said you
went to the pediatrician, then why don’t I go sit by the
pediatrician and reduce some of that stigma attached to
get mental health services, and really tackle these
problems early on. So, I share with you,
as the title of my talk, age 3 is middle age, when it
comes to brain development, which comes from Jack Schoenkopf
at the Center for the Developing Child at
Harvard, and it just sort of encapsulates it for
you, the imperativeness of getting it right
in these early years. So, like any good person, I will tell you what
I’m going to tell you. We are going to review
the importance of two-generation interventions. Just as Dr. Braverman said,
there is really no point in me treating a 2-year-old and
sending that 2-year-old back into a community in a family that doesn’t have the
supports they need. I’m wasting my time, right? The impact of adverse
childhood experiences are aces on these families, toxic
stress, and I will present to you one possible
answer to start to moderate some
of these effects. The Healthy Steps Program. The national model, I’ll
show you a few things that we’ve done differently, and
go through our interventions, our teaching, some of the
challenges around billing and policy, and how you
might bring this to scale. I’m program agnostic. I’m not here to say
that, you know, this is the one way to do this. But I am a little
biased about platforms. There is something
pretty extraordinary about primary care. Primary care is a remarkable
platform to do this. So, a few years ago,
the American Academy of Pediatrics put out
this policy statement on toxic stress, which hopefully
you all are familiar with. And they spoke about this
two-generation intervention, right? They spoke about the critical
need to provide targeted support for parents and caregivers, if
our goal is to identify and work with children at high
risk for toxic stress. Again, from the Harvard
University Center around the Developing Child, they talked about that
inter-generational transmission that Dr. Braverman talked about. That it begins with the future
mother’s health before she gets pregnant. It’s the best predictor of
how that child is going to do, and that lifetime of well-being
for that child, right? So just so we’re speaking
the same language, this comes from the Ascend
Network at the Aspen Institute. What is this two-generation
continuum? And people get worked up
about this, and say well, how about three-generation? Fine, multi-generation, right? Two-gen just has a nice ring
to it, I think, quite honestly. So that is why people
like to say it. But it is multi-generation. And it is not serving solely
the family, the parent, right? So it’s just job training. And it’s not serving solely the
child, so it’s just child care. It is really bringing
all of that together. And if you want to
know a little secret, if you want to find
parents of young children, there is one place that you
can universally find almost all of them regardless of
their racial, ethnic, socioeconomic status,
background, and it is in the primary
care pediatric setting. Right? If you have
young children, or you once had young
children, or you know anyone who has young children,
you know you are at the pediatrician 13 times in
the first three years of life, even if you’re perfectly
healthy. We don’t have any
other system like that in this country,
where everybody goes. They go pretty often. And it’s non-stigmatized. I even sometimes think it’s
positively stigmatized, you’re a good parent if you take
your kid to the pediatrician. Almost no matter,
your community, or no matter your
beliefs, right? You’re a good parent if you take
your kid to the pediatrician. Now, contrast that with
the mental health system, which suffers from a
great deal of stigma. Nobody wants to take
their kids there. So why don’t we bring them
together, and start solving some of these problems you
see up on the screen, which is that children of
all ages exhibit symptoms of mental health problems,
and a very low percentage of them receive care from
the specialty mental health care system. But 50% of mental health
diagnoses show symptoms before age 14. So, if we can prevent
it, if we can predict it, then let’s get started. If this was any other disease
state, I would argue to you that we wouldn’t stand for this. If I told you that only
a quarter of people with cancer actually went
and got cancer treatment at the right cancer
hospital, you would say “Well, we need to do something
drastic!” But we seem to stand for
it with mental health, because we don’t think
it’s quite as critical, or we don’t think it’s
quite as important, or maybe we don’t trust that we
can fix it, as Dr. Adams said, early this morning, his brother
is incarcerated right now, and he attributes that to
untreated mental health. So let’s get to work. So the National Model
of Healthy Steps, Healthy Steps started back
in the mid-90s up at Boston, and the idea was that you
would bring another person into the pediatric office. If any of you are
a pediatrician, or you know pediatricians, you
know that they have 15 minutes, at this point, to
do like everything under the sun and then some. Everything from bicycle
helmets, to fluoride, to checking if you’re
actually growing, to deciding what shots you
need, to actually saying “Hi, how are you,” you know, and
all those sorts of things. And doing it on their
medical record. You know, so adding this
Healthy Steps specialist into the pediatric
primary care team, and that Healthy Steps
specialist might be a clinical social worker. It might be a child
psychologist. It might be a nurse. And they are going to co-manage
the well child care of that baby for the first three
years of life, because there are
13 visits, remember, and because it’s important
with that sponge-like brain to get it right, and because
it’s universally accessed and non-stigmatized, right? We are going to do all sorts of developmental
screenings for the child. We’re going to do home visits. We’re going to have
parent groups. We’re going to have this thing that they call a Child
Development Telephone Information Line, which
sounds very exciting. It’s a voice mail,
as far as I can tell. It’s a phone, with some
voice mail, with somebody who answers it, and
answers your questions. And all sorts of written
materials, and all sorts of linkages to community
resources. That is the national model. Things that we do
a little different in the Bronx is that
we go to age 5. We do lots of parent
mental health screenings, as part of our screening,
because there is no– well there’s no health
without mental health. There is certainly no
child mental health, without parent mental
health most often. Right? And really focus on that. I’m going to show you, if
it works, a brief video. Because there is nothing better
than just sort of seeing it in action, not hearing me
talk about it, but hear one of our families talk about it.>>The family that I grew
up in was pretty rough. There was a lot of abuse. I would never want that
for another person. For another child. Two months before our
wedding was set, I found out I was pregnant. I was told that it would be a
good idea for me to abort him because carrying him
could be detrimental to my health and his. I looked at the doctor and
said “I’m having this baby.”>>Motherhood didn’t come as
naturally as I thought it would. When she came, we did not
feel totally prepared, and her birth was rather
sudden and tumultuous.>>I was scared. Every time I had a
contraction, I was afraid that I was going to rupture. I made it to the day they
scheduled my C-section, and my uterus gave
out on the operating table. Being able to take him home– I
was so happy, all I kept saying to him was, “We made it.”>>Even after we came
home, it was kind of rough. I felt horribly guilty for
what Caroline had gone through, that I hadn’t been able to,
you know, take care of her. She’d been alone in
the NICU for a while. Family wasn’t really
available to help or willing. I went through a lot of
depression at that point.>>It was like, I was so scared. I felt like every
negative thought. We’re not supposed to be
here, we beat these odds, something is going to go wrong.
And a knock at the door came, when I took him to his
first appointment and it was Janelle from
the Healthy Steps program, and she said, hey,
do you have a moment. I was like, I don’t know who you
are, but you’re like an angel.>>Healthy Steps is the
integration of health and parental support
right here in pediatrics, starting from that very
first newborn visit. It’s stressful to be a parent, and it’s isolating
to be a parent. Especially for people who
have a history of trauma.>>That was scary, you
know, you’re pregnant, and I’m thinking, yeah, but
just go to sleep and not wake up again, and that’s
when I was like, I should just not be alone right
now I don’t even want those thoughts.>>When we talk about
parent anxiety disorders, post-partum depression, not
a lot of people are asking about that in pediatrics. Healthy Steps asks
those hard questions.>>I think when we
show genuine interest in a parents’ well-being,
they start to build trust, and through that trust, we
can really work together to talk about the baby.>>As soon as the nurse
puts you in the waiting room for the doctor, the Healthy
Steps Specialist will come in, and she usually has
a questionnaire for whatever kids at the visit. When you finish that,
she’ll go over it with you, and they ask you if you
have any concerns or issues.>>For a while, just
watching these milestones, and because he was premature, we were just constantly
worried about that. And she held our hand
every step of the way. I was in a very unhealthy
place, worried every single day that something was
going to happen, instead of just allowing him
to be one and a half years old.>>Raising a child is
hard, and it’s uncertain, and unpredictable, and they’re
vulnerable, when that happens.>>I just find myself, and
it’s all in my mind, you know, you feel like, it’s
something like me, I’m broken, I’m not handling this stuff. She was like, you’re
doing great, for the circumstances you had.>>We work together to kind
of reassure the parent, and ask them about those
instincts that they’re feeling. I do think the reassurance,
that it’s okay, you know, they can really trust
themselves, and what they think is
best for their baby.>>They feel so good about
themselves, after our visit, that they want to come back.>>The best part of my job is
knowing that someone who came to the doctor for their flu
shot, or for a well child visit, also got an opportunity to
talk about the other things that are hard for them. Whether I’m directing
people towards resources in the community or whether I’m
having a session with a parent, when they got to relieve a
little bit of their stress, or take a little bit
off of their plate. It’s that they came here
for their kid, but the family was served.>>I think the most beneficial
aspect to Healthy Steps is that it’s my life, it’s
just to provide reassurance, and will he help find
in me the answers that I’m kind of seeking for them, and have the confidence
that I can do this. I am the child’s parent,
and I have everything I need to be this child’s parent,
to do a good job at it.>>It has allowed me to be the
type of mom that I wanted to be. It has allowed me understanding
and peace of mind to raise Lake to be this
natural, normal kiddie self. I’m not afraid anymore,
like when he was first born. I look at his birth story now
as, yeah, I went through that, but in the process
I got sweet Janelle, and I got to have someone
that I considered a partner in my parenting process. I feel stronger as a
parent with Healthy Steps. [ Music ]>>So we are in the Bronx. The Bronx, there are 62
counties in New York, and the Bronx usually
ranks somewhere around 62nd on most health outcomes. There is a congressional
district in the south Bronx that is the poorest urban
congressional district in the country. We are dealing with very high
rates of asthma, obesity, etc.– So if we can do this in
a place like the Bronx, where poverty runs very deep,
and risk runs very high, and ACES, adverse
childhood experiences, are almost universally
impacting our families, I want you to remember that
at no point did Brittany say that this solved her poverty
or it solved, you know, her current circumstances. She said it “allowed
me to be the kind of parent I wanted to be.” It wasn’t our agenda of what
kind of parent she should be, and just like Dr. Bregman
said, nobody chooses to raise their child in
adverse circumstances, right? So I just want to
tell you a little bit about how we got there, share
a couple of research results with you and then we’ll move on. So we have really redefined
the patient as the dyad. It’s that two-generation. It’s no point in pediatrics
just focusing on the baby. We have two levels of
care, a more intensive arm, for our families, where parents
had really high ACES scores, really high adverse
childhood experiences, and a less intensive
light-touch arm for families that just need a
little bit of guidance, about how to get Johnny
to sleep at night. We focus on parental
mental health. Again, you want to find parents? They’re in the pediatric
practice, right? I know that doesn’t make sense,
it doesn’t sound obvious, but you know, when is
the last time you went for your well check? Nobody has to raise their hand,
you don’t have to tell me, but I doubt it was 13 times
in three years, right? They’re known for
their kids’ checks. No matter what else is going
on, families make it to that. Right? And we, like I told
you, expanded our age range to the fifth birthday. So this just shows you, we’ve
got this enhanced care as usual. We do so much screening in the
primary care pediatric practice. We are screening for parental
depression, and screening for ACES, like I told you. Universally screening. All of our 90,000
kids every year. For their parents ACEs. Because if you can predict
it, you can prevent it, right? So if I can predict that
parents’ experiences of abuse and neglect impact their
child’s well-being, then why are we not getting
involved long before the child gets kicked out of
preschool, right? This short-term treatment
is really short-term, it’s like one session to talk about how you actually
get that kid to sleep. Then that intensive services, where we co-manage every single
well-child visit alongside the pediatrician. We enroll the babies up
until they’re 18 months, because we really want to keep
those slots for real prevention. And PMH stands for
parental mental health. So remember, I told you treat
the parents’ mental health right there in pediatrics, because
if dad has significant trauma in his background, and you’re
trying to sleep train an infant, and the very idea
of that child crying for 20 minutes is triggering
for dad, you can forget about sleep training the infant. You’ve got to treat
that trauma, right? I said we like to screen. I wasn’t kidding. This is our screening schedule. If you hear anywhere that if you
think about policy or you think about change that pediatricians
don’t like to screen, they will screen, if
they have the resources to deal with what they find. They know this is the new
morbidity of pediatrics. They know that they’re not
so much looking for measles, mumps and rubella anymore. They know that if you’re working
in a place like the Bronx, you know that equity and
social justice is at the heart of the health care
that you’re providing, and so you better be
screening for it, right? The ages and stages
questionnaire is a social emotional screening tool,
and also a cognitive and motor screening tool. You see autism on there. And then in our school age kids,
we screen for internalizing, externalizing, and
intentional issues, and then ACEs as
you see as well. The screening work flow
involves the whole practice, the front desk staff gives
out the screening tool. The nurse might score
it and load it up into the electronic
medical record, and only then does the
physician get involved, and with all due respect to
the physicians in the room, all of my physicians tell me, if you want like a good quality
improvement program to work in a primary care practice, don’t put it all
on the physician. Involve the rest
of the practice. I’m not going to belabor
the issue of documentation, but just to let you know that
we have met with legal teams, and we have figured it out. We document in the
child’s pediatric chart. You may be familiar with some
guidance that came out from CMS in May of 2016, that said you
could even document the parents’ depression score in
the child’s chart, and that best practice would
then be to treat that parent and that child together. We provide a confidentiality
disclosure. That we’re going to share
this with the pediatrician. So far, you know, I
can count literally. We’ve been doing
this since 2005. So 12 years, I can count on
two hands the number of people who said “Oh, can you actually
make my notes be private?” And they are all people who
were employed by that practice, and they don’t want their fellow
nurses seeing what was going on, but otherwise people
say “I don’t care, I know this is what is driving
my kid’s health and my health, and let’s talk about it.” We are trying to bill under Medicaid Health
and Behavior Codes. But I will get into
that in my next slide. We have a health care system at
this point that is predicated on billing for a diagnosis. And everything I’ve
described to you is trying to prevent mental health
diagnoses from ever happening. And so although we can get
reimbursed for screens, it averages about $7 per screen. It doesn’t quite
cut the mustard. It’s better than zero dollars,
but I’ve got 90,000 kids in my system, like $7 per
screen isn’t quite going to get me there. And we don’t get reimbursed for a Healthy Steps visit
unless someone has a diagnosis, and it has to be the
patient, not the parent. So even if mom has a
diagnosis of Major Depression, and we all know how
incredibly impactful that is for that kid’s brain
development, we know the relationship
between maternal depression and child language
development, right? We can’t bill in baby’s chart
based on mom’s diagnosis. Does that make sense? So we’ve got some
work to do on that. So this is your ACEs visual. Remember that adverse
childhood experiences lead to all these things,
even early death. It has since been after the
wonderful study from the CDC that is kind of having
a second life now. It has also been replicated
prospectively by colleagues down in New Zealand, and again,
what we want to do is look at these ACEs and not
just say oh, well, if you’ve got four ACEs
then you’re more likely to inject IV drugs, cancer
and heart disease and so on. Let’s get before these ACEs,
and get underneath these ACEs. So I’m going to show
you two research slides, then I’m going to wrap up. So, I’ll show you
quickly a design of we took two matched primary
care pediatric settings, and we enrolled, we
gave Healthy Steps to one, and not to the other. They’re both in the Bronx. They’re both staffed by
our general pediatricians, and our enrollment criteria
were first-time moms, and the baby had to be
less than two months old. And so you either got this
Healthy Steps specialist in your visits, like you
saw Janelle, with Brittany and Lake, or you didn’t. Right? And what we
wanted to know, did mom’s ACEs predict the
child’s social emotional development at age 3? Social emotional development
really being the foundation of mental health
and wellness, right? Talk to any kindergarten teacher about what kid is
going to be successful. It’s not the kid who is
necessarily reading the fastest, it’s the kid who can
like, sit in circle time and get along with the others. That social emotional
development, right? So we just wanted to know about
mom’s ACEs, and then her report on the ASQSE, the most
widely-used screening tool for social and emotional
development at 36 months. We asked dads as well. We didn’t have enough to include
in the sample and get power, but we certainly
know that is going to be a relevant
factor here as well. So I’ll walk you through this
slide from your left to right. Our outcome of interest here
is the ASQSE Mean Score. You want a low score
on this tool. A high score means you’re at
risk for problems in social and emotional development,
the foundation of mental health, right? And so when we look at
comparison group kids, where mom did not
experience abuse or neglect, and I want to be very, very– there’s something very
important on this slide. We didn’t include all 10 ACEs. We only included the
abuse and neglect, right? We didn’t include the ones that are called household
dysfunction, a parent who is incarcerated,
or a parent with mental illness, because they were
too ubiquitous, okay? We wanted to look
at the big stuff, the abuse, and the neglect. So if mom had experienced abuse
or neglect in her own childhood, her 3-year-old social emotional
development was way off the charts at 90.4. The cut off is 59, that big, black line across the
middle, you see that? But if mom hadn’t
experienced abuse or neglect in her own childhood, the baby’s
social emotional development looked good down there at 28.3. Go over to that red bar, mom
had experienced abuse or neglect in her own childhood, but she
got the Healthy Steps program, and look, that baby is
doing really well in terms of social emotional development,
nice under that cutoff bar. That pink bar is important too. Because those babies got healthy
steps, but mom didn’t have abuse or neglect, and even if
you’re not a statistician, you know that 28.2 is pretty
much the same number as 28.3, so we didn’t have
much of an effect with kids whose moms
didn’t have abuse or neglect in their own childhood,
and that’s good news. Because we didn’t need to
have much of an effect. Even in the Bronx,
where risk runs so deep. We don’t have to give
this service to everybody. Can get kind of depressing
when you think about if we have to give some service to
every, you know, all six or seven million
children growing up in poverty in this country. No, because of differences in
how resilient children are, we’re learning more
about genetic makeup. We are starting a study with– to look at biomarkers for
toxic stress in two month olds, next month, I mean, we’re
learning a lot about the ways that different kids contribute. So it tells us that also we
can do some short-term mild intervention with some
of these families, and they’d be just fine. So that is the slide
I’ll show you next. These are those development
in behavior consults. So that’s an average
of 1.4 sessions of interventions with a family. So if you didn’t screen at
risk on the ASQSE, at age 5, about 21% of those
kids had a BMI at or above the 95th
percentile, right? If you did screen at
risk on the ASQSE, but you received an average of
1.4 sessions of intervention, that short-term intervention,
only 16% of those kids at age 5 had a BMI at or
above the 95th percentile, compared to 42% for kids
who screened at risk, did not get the service,
then at age 5, 42% of these kids had a BMI at
or above the 95th percentile. Yes, there is a self-selection
bias here, right? It’s the parents electing
to take up this service. But this is a pretty
extraordinary finding. This is a program not– you
know, we don’t say we’re out there to cure
childhood obesity, but early childhood obesity is a
parent-child relationship issue, in the absence of any
medical things going on. Right? So you’re wondering,
well how do you do this? How much does it cost? And holy moly, this sounds
like how much are we going to have to spend on that? I’ve been taught not to say that
it’s cheap, it’s affordable. So for that short-term light
touch, we’re spending about $50, five-zero, total dollars,
per family per year. I spent more on that on
the cab on the airport to my hotel last night. And $450 per family per year
for intensive services, right? Which is about what
my flight cost. I will close just by saying
this is our community. Thirty percent of people
in the Bronx live at or below the poverty line, and 40% of children are below
the poverty line, right, 68% of our residents
are overweight or obese. So if we can do this in the
Bronx, where social determinants of health are everywhere we
turn, we have overcrowding, we have crime, we have
community violence, and we also have very
resilient families who want to do it better. I’ve never met a family, no
matter how badly it’s gone with previous children, who for
a little moment didn’t have a window of hope that it was going
to go better this time around. And if we can get there with
those families, at that time, then we can really change
that trajectory, right? And where they are is in
the pediatric practice. We work with families from
everywhere, and we’re trying to learn every day
about what it means to have healthy brain
development if you’re from Bangladesh. It means something different than if you’re from
the DR, right? Turns out they told us that
folks from Bangladesh told us that serving kids
sufficient amounts of fish was what they thought
was going to be most important. All right, well then let’s work
with you and figure out how to get you to what you
need to get to right? We’re just making the point
that this is adaptable, everyone is coming to
pediatric primary care. So I would suggest to you
that this is an ideal setting for population-based prevention. Again, 90,000 kids and
we’re able to do this. The two generation,
your ideal vehicle to break the inter-generational
cycles of risk and trauma. This Healthy Steps specialist is
almost working as a quarterback, sort of helping to
coordinate care, and ensure positive outcomes,
and just, as Brittany said, help her to be the kind of
mom that she wanted to be, and that we need to continue
our work on payment and policy to really make this be an
intervention that we can spread around the country to
really bring some care. So thank you. [ Applause ]>>So I want to be
mindful of the time. We got a little bit
delayed this morning, and I want to be
respectful to the panels that are this afternoon, so can someone tell me
how much time we have for quick discussion
and some questions? Ten minutes, okay, so I
will cut my part short. But first, let me just start
by really thanking Dr. Brace and Dr. Braveman, again, for
even being here [applause]– and really giving us
a really solid summary of the science base
in this area. And let me just reflect that
as you’re discussing, you know, the charge of the day
is really, you know, in the name of the forum, even, it’s Healthy Start,
Healthy Life. The Building Blocks
to Healthy Equity. I would suggest that it is also
the building blocks to health, to well-being, to productivity,
and even to prosperity. So then it is our charge, the charge of public
health researchers, public health leaders,
public health practitioners, to really assure the conditions where children can
really thrive. That children can be healthy
and well, and recognizing that children are all
of their biologies, all of their characteristics,
their histories, the historical trauma,
the culture. All of that, you know, when
they come into this world. Then we have the environment. The physical environment, but also the sociopolitical
environment, the context with which
these kids are raised. And we talked about,
it’s not deterministic. It’s not that things happen,
and they set us on a pathway, and oh, you have high ACEs, you’re going to have
poor health. It means that we need to really
boost the protective factors, the protective relationships,
the protective environments, the protective contexts, to really change those
trajectories for kids. And I would say that means
we need to be assuring safe, stable, nurturing
relationships and environments for all children if we’re
really going to be strategic about achieving our
public health goals. So it doesn’t matter if
you’re in the business of preventing mental
illness, if you’re, you know, preventing infectious disease. If we have healthier children,
healthier communities, we will have a healthier,
more productive nation. So that’s just some
context to keep in mind. And as I reflect on some of
the really excellent, you know, programs, policy levers, that
kind of were touched on today, again, recognizing that preventing early
adversity before it occurs is a two-generation approach,
a strategy, to really achieve
our health goals. So, if we know that there is
about a 19-year difference in life expectancy between those
who have high, measured six or more, versus those
who have no ACEs, okay? 19-year difference in life
expectancy is a greater life expectancy and equity than we
see in most any other injury, illness, or geographic
comparison. Almost 20 years of
life lost, okay? But we know that is just
the ACEs we measured. That’s just the stuff
that we asked about, that we had data for. Of course we have this context. We didn’t measure poverty, we didn’t measure social
iniquities, all of this, you know, complex
interplay between risk and protective factors,
resources, etc. And if we know that ACEs affect
our health outcomes, and now we have more
recent data that say that ACEs also impact our
ability to graduate high school, through the brain function
and development effects, endocrine system, epigenetics,
how our genes express, so now you have this
double whammy where it is affecting
our health, but it is also affecting
our ability to have these life opportunities
that are protective of health. It is our charge to invest in preventing early
adversity before it occurs. So all of that is the context
to say we are just so thankful to really raise up this work
of healthy equity as the charge of all of us in this room,
certainly in our, you know, prevention of childhood abuse and neglect, and
ACEs in general. This is something that is
really an intentional priority, for the injury center, and for
division of violence prevention. But as I reflect on what
that means, let me– and posing a few questions
to start us off here in our 8 minutes that are
left, I want to say that as we, you know, do strategic
plans and logic modeling across the agency, right? We usually recognize that
kind of big thing, okay, the goal is health equity. But we put that in our models and the distal outcome
section, right? Something that we are working
toward, but we don’t expect to be held accountable
for 10, 15, or more years. So my first question is really
for researchers, practitioners, public health leaders in
this room, I would look to doctors Braveman and
Briggs for their advice on what are the metrics that
are more proximal, the measures, the indicators of really that we
could be tracking along the way, to assure that we’re
chipping away at really progressing
toward that end goal. I think that’s the
first question.>>Well, that’s a
great question, and especially because, I mean,
with health equity, I mean, it may not even be–
we might not be able to measure the end point that
we want, even in 15 years. It could be decades and it actually could be
generations before it comes. So it’s absolutely essential
that we are always thinking about the intermediate
measures and we are referring to the literature, that ties
those intermediate measures with our ultimate outcome. And I mean, those– so those
intermediate measures are going to be different to some extent,
they’re going to be different for different health
outcomes, and I think we just– we need to do these logic
models, and sort of maps, of which, you know,
which way the arrows go. The, you know, the kind of maps that I showed are
incredibly simplistic, because it’s not just the things
that weren’t even on the map, that are important, but
also the interactions between the different
elements that are on the map, and interactions of
the things on the map with things that are outside. So it is really challenging. But I think we have to
think in those terms. And to the best extent possible, and think about the
resilience factors. What could make a
difference along the way. It’s a slippery slope. And I mean, it’s one that I’ve
confronted throughout my career, and I would think everybody
here who has struggled with it, it’s like you do, you know,
you have to be accountable for showing something, you
know that’s the progress. But that’s not going
to be enough. And sometimes does that
deflect you from doing something that would have more of a
chance long-term at getting at the upstream thing? And I think we just have to
struggle with that every time.>>I think that’s
an excellent answer. I would add to it, you know,
in our work, we look at things like birth weight, and birth
spacing, and NICU stays, and then child language
development, and secure attachment, and
parental mental illness, and then social emotional
development of the child, and then kindergarten readiness, and then third grade reading
scores, and emergency, you know, so all of that are just
gross mean averages, right? And the work that I’m
most excited about gets to this individual
difference in susceptibility, so some of this dandelion orchid
work that Tom Boyce, and others, have put out– work in
the biomarkers is going to be looking at individual
children and their variance on some of this resilience or
risk susceptibility sensitivity because I think in order
to do our work best, we need to know who needs what. How much of it do they need? And when do we know when
they’ve had enough, right? And we can throw a program
at a group of folks, because we think that’s a good
match, but there are going to be people within that group who have different
resilience profiles, and don’t need as much of it. So when we incorporate some of
this biological understanding of real risk and resilience,
I think we’re going to get much further in some
of that outcome measurement.>>If there are questions,
please approach the mics. I will ask a second one,
in the interest of time, we have three minutes. But you know, as I reflect
on what you all have shared, and think about the resources
that we’ve developed recently in terms of prioritizing primary
prevention of early adversity, like violence, in achieving
multiple goals, you recognize that there’s primary prevention,
but of course, we need secondary and tertiary prevention
efforts as well, that are trauma informed. We need trauma informed systems. You know, and all of this
is a very complex interplay between risk and protection. But I would ask, ask the
panel and others, for thoughts on what are the sort
of policy levers that you see in this space? We’ve recently gone
through this exercise of developing these
technical packages, based on the best available
evidence and the one for preventing child
abuse and neglect, or preventing early
adversity in general, really prioritizes policy level. Interventions or strategies
first, and then norms, and then goes to the kind
of programs that, of course, that’s where most of
the evidence base is, because we’ve been
trying to program our way out of these problems
for decades. But we know that we’re going to
need to like, shift our focus, and really, you know, one
of the major ones that we– that is in our technical
packages really, you know, providing economic
supports to families, through your family friendly
business policies, for example, paid family leave,
things like this. But I’m just wondering,
from your view, what are the policy
levers in this space that can really help
us on our way to reducing these
health iniquities?>>Until we pay for prevention
it’s going to be sparse.>>Yeah, yeah.>>We were 100% grant funded for the first eight
years of our existence. We were raising about
a million dollars of grant funds every single
year, and most people don’t have that capacity, that
energy, that drive. So, until we figure out
how to pay for prevention, we are not going to see
widespread prevention programs, no matter how evidence-based
they are, no matter how impactful
they are, no matter how comparatively
affordable they are. The return on investment when
you intervene early is profound, compared to intervening later. But until we figure out a
payment mechanism, I think, you know, that’s the policy
lever that I always look to.>>Well, the policy
levers that come to my mind are the
Earned Income Tax Credit, and the Child Tax Credit,
and both of those are on the chopping block in the administration’s
proposed budget. But those have actually
been evaluated, I mean, including with some
child health outcomes, and they have been very–
they’ve been very popular, so I think it’s critical to
preserve those, and to expand and then in addition, these sort of center-based early childhood
development programs have, you know, there have been a
number of randomized studies, of some of these programs, and the outcomes have just
been incredibly impressive. And the business community
has gotten behind this, that the business round table, and other major business groups
have come out for universal– and when you say universal, that
means it’s going to be paid for, by the people who
can’t pay for it– universal high quality child, early childhood development
programs. And the– it’s the,
I think, I mean, there is an opportunity there. There has almost been no
other major intervention with health implications
that has gotten so much support and
diverse support. And the, you know, this has
been acknowledged many times, with the obstacle, it’s
not a lack of science. The obstacle is political will.>>Yeah, yeah.>>Well, thank you, and unfortunately
we are out of time. We want to be respectful,
but I encourage you to seek out our speakers
after the panel, thank you again [applause
begins] to Drs. Braveman and Briggs. [ Applause ]>>We’d like to ask for our
second panel to come forward.>>Our second panel this
morning is going to focus on strengthening programs
to ensure health equity, as a component in interventions
that support healthy children. Our first presenter this morning for this panel is
Dr. Paul Jarris. Dr. Jarris is Chief
Medical Officer and Senior Vice President,
Mission Impact, at the March of Dimes. His overall responsibility
includes advocacy, Maternal Child Health,
Consumer Education, Professional Training,
and Perinatal Data Center, and the NICU Family
Support Program. Dr. Jarris is a
nationally-recognized expert in health care policy,
clinical quality initiatives, public health, and disease
prevention and wellness. He previously served
as Executive Director of the Association of State and Territory Health
Officials, ASTHO. Prior to his role at ASTHO, Dr.
Jarris served as Commissioner of Health for the
State of Vermont, where he led public
health, mental health, and substance abuse for
the State of Vermont. Dr. Jarris has a distinguished
career, spanning 20 years, leading policy and
care initiatives to improve public
health, at the local, state, and national levels. He is a Board Certified Family
Physician, with over 20 years of clinical practice,
and received his BA from the University of Vermont,
his M.D. at the University of Pennsylvania School
of Medicine, and MBA from the
University of Washington. Our second presenter for this
panel this morning will be Dr. Zakiba Henderson. Dr. Henderson is a Medical
Officer in the Maternal and Infant Health
Branch, in the Division of Reproductive Health,
here at the CDC. She is a Board Certified
Obstetrician, Gynecologist, and leads the division’s
activities in support of state-based perinatal
quality collaboratives, which currently provide
support to 13 states, and the national network of perinatal quality
collaboratives. In this position, she also
provides clinical input into the research
agenda for the maternal and infant health branch,
including activities and pre-term birth, and pregnancy-related
morbidity and mortality. Dr. Henderson received her
B.S. degree in Biochemistry from Oakwood University
in Huntsville, Alabama, and her medical degree
from Harvard Medical School in Boston, Massachusetts. Our discussion for the second
panel is Dr. Colleen Boyle. Dr. Boyle currently serves as
Director of the National Center on Birth Defects, and Developmental
Disabilities here at the CDC. Dr. Boyle began her
career at CDC in 1984, as part of a large effort to
study the adverse health effects of exposure to Agent Orange, and herbicide used
during the Vietnam war. Following that project,
Dr. Boyle joined CDC’s work on birth defects and
developmental disabilities, holding various positions
of increasing responsibility until her appointment as
Center Director in 2010. Her interests and expertise
span a number of areas related to child health and development. She has contributed widely to
the field of newborn screening, guiding CDC’s work
in newborn hearing, and congenital heart disorder
screening, and has served on the Department
Secretary’s Advisory Committee on heritable disorders
in newborns and children. She has also led the development
of CDC’s autism research and surveillance activities that
have documented that changing, preventing autism in
the United States. She has twice received
CDC’s highest award for scientific excellence,
the Charles C. Shepherd Award for Outstanding Scientific
Publication. Please join me and
welcoming Dr. Jarris. [ Applause ]>>Well, thank you very much. It’s really a great pleasure
to be back here at the CDC. It feels like coming
home to family. And also I want to thank
Lee Anders for inviting me, and the March of
Dimes, to speak. And also for the
leadership you provide for many years here at the CDC. So I also am very pleased
with Dr. Fitzgerald, that she will have a real
interest, I mean, yes, it’s about brain development, but she will also have a real
interest in health equity and I’ve worked with
her for years on that. And, in fact, as you may
know, she and Dr. Montero are in the U.S. Virgin Islands
in Puerto Rico this week, where we clearly have
equity issues and problems, and frankly are not treating
our citizens there the way they should be treated. And again, it’s a pleasure
to be on the panel with Kiva, who we worked so
closely together with on the national network
of perinatal quality centers, an important initiative, to make
sure women actually get the care they need, when they need it,
which so often is not happening. And Colleen, thanks. It’s great to be
up here with you. So I’m going to start
a little bit, and three things
I’ll talk about. And actually I wasn’t
even nervous until Jerome mentioned
my name [laughter], then I became nervous, and
like, now I’ve got to live up to this [laughs], but three
things I want to talk about. One is brain development
doesn’t start at birth. Brain development
starts way before birth, and childhood development
starts way before birth. And it is very interesting how
many people conceptualize it all about from birth on,
and early childhood, when in fact things go back. And I will have a few
slides to show you on that. I’m going to also talk to you about the national
collaborative we have, which is the prematurity
prevention collaborative. We have over 300
different organizations. CDC is very involved. I want to thank Eve for
your leadership in that. And Dr. Braveman is
leading in one area, also, and we’re very fortunate to
have her resources with us. So I’ll tell you a
little bit about that and what is driving it. Because that is all
about equity. And thirdly, just to talk
about how we built equity into that initiative, because
we know, and we wish and we have to get to the place where
working on equity is part of what every public
health professional does. Both working– using the World
Health Organization’s terms Goodness, what are we
trying to do in terms of lowering pre-term birth, or improving child
health, but fairness. What are the gaps there, and
how do we close those gaps? And we need those two
things to go hand in hand. We also know we’re not
there yet, as a country. And so recently, for
example, a wonderful– about a year ago or
so, maybe two now, a wonderful report was put out by the IOM called
the Vital Signs, which was to develop
a measurement for population health
that we can use across the whole country, an agreed upon measurement
standard, and if you read it, they said that they decided they
weren’t going to actually break out a special measure for
equity, that it was going to be embedded in
every other area. That is our aspiration. But when it was released
to the National Press Club, I think I spoke on the last
panel, and it wasn’t until I, and George [inaudible] who
was on that panel spoke, in the entire production, that
health equity even came up. And they are now
working on measures, and they’re picking
one measure per– one measure per area
they’re measuring. That one measure means
you don’t have a goodness and a fairness measure. So you know, we’re
just not ready yet. We have to recognize that
equity is a specialty, where we have academia. We have governmental leaders,
practitioners, and we need that. But we also need to build
it into everything else. We did a lot of research
back with ASTHO on the State Health Agencies,
and around their work in equity. And found that those that
were most funded by the Office of Mental Health, those that
were most effective were those that had somebody at
the commissioner level, or show level, who
was the expert and led equity throughout
the entire organization, as an internal consultant, and
they had a unit that worked on health equity specifically. And so that combination
of overall leadership, with embedding it everywhere, I
think is the way we have to go until we’re ready for it
to be everyone’s work. So showing you this, to
give you some context. Because March of
Dimes, as you know, works on equity in
pre-term birth. Or you may not have known
the equity part of it. That is where clearly we are
going as an organization. If you look at this, you’ll see
the green bars are the rates of pre-term birth, based
on last menstrual period, which is how the United
States did it until 2014. And now we switch
to the blue bars, which is how we use what is
called obstetrical estimate, or a based upon an
early ultrasound. But what you can see is a number
of years, about eight years of declining rates of
pre-term birth in this country, which is excellent, but what
happened in 2014 and 2015? We actually had a statistically
significant increase, and I will show you a little
bit more about that increase. 2015 to 2016 a 2% increase. That represents about 8,000
additional pre-term babies being born. So not only do you see an
inflection in the curve, but we see a worsening. And as I think that maybe
Dr. Braveman mentioned, compared to any other
highly developed nation, the United States is
probably in the bottom 10%. We are just above Oman in
most of these measures. So we do poorly internationally and we’re getting
worse nationally. But there is more
to it than that. It’s even– and I hate to
be a downer, but if we look at the change between 2014
and 2015, the increase was in non-Hispanic, Black
women and Hispanic women. So less goodness, less
fairness, 2015 to 2016, you can see on the right side
of the slide that all racial and ethnic groups increased, but higher increases among
women and people of color. So this is a big wakeup
call for our country. The reason we took a
look at pre-term birth, because pre-term birth and
the conditions associated with it are the biggest killer
of children to age 5, globally, as well as in the United States. So if we’re looking at infant
mortality, we’ve got to look at pre-term birth, as
well as other things. The fact that we are doing
so poorly, and that one in ten babies in this
country is born pre-term, with all that means for
them, it’s mind boggling that the biggest
killer of children through age 5 is not an
issue in this country, and one of the things
we’re trying to do is to make it an issue. How do we talk to people
so people recognize it? And the fact that we
have these disparities in maternal mortality and infant
mortality and pre-term birth, and that there is about
a 31-year historical lag between black infant mortality
and white infant mortality. That is outrageous. And what are we doing
about it as a country? Art James, who many of you
may know, as this great slide that says Do Black
Babies Matter? Because we’re not
closing that gap. So this, to us, was
a huge wakeup call. And that is what led to the
collaborative we’re doing. Now, the 2017 report cards came
out, because we’re now working with the CDC, and folks in
Wanda’s Shop and the March of Dimes Perinatal
Centers to say, you know, why is the increase? What we do know is
that it is widespread. So, in fact, 45 states
had worsening of pre-term birth rates. That is terrible that
that is happening. Now, we are looking at a number of different factors including
we do know it’s late pre-term, between 34 weeks and 37
weeks, so we don’t know if we’re slipping on
the progress we had made on early elective deliveries, and preventing non-medically
indicated deliveries. But we still don’t
know the reason. And like so many
of these things, there are probably many reasons, and our science isn’t good
enough to capture certain things like increases in stress
among women right now. Which his a very stressful
environment, particularly for people of color
or, so, you know, that is going to
be hard to show. So this is basically
the map of the country, to show the red is
the poor states. There are four states who have
hit tremendous 8.1% pre-term birth rate, and Washington
State is quite a diverse state, so it also can be done
in the state diversity. We calculate a disparity ratio. So this is a methodology adopted
from Healthy People 2020. And what it does, we
basically look at the racial and ethnic group with the
highest rates of pre-term birth and compare them to the
average of other groups. There is no good, perfect way to
measure disparities or equity. You can criticize
any one of them, but we think this
is the best we have. And someone asked the question
about measurement before, we really do need to sit down
with people like Brian Smedley and Tom Laviste who are the
experts in this area, and come up
with something nationally. But the point here is, we got
worse as a nation, as we saw, in the other statistics,
worse as a nation in terms of our iniquities. And this is a map, now, of
the iniquities, and according to the disparities index
across the country. Some of these states
you would expect. Look at Washington
State, very interesting. They were the state that had the
best rates of pre-term birth. But they are doing
poorly in terms of equity. So one of the reasons we
think this is so important is to get back to the message
of goodness and fairness. To say to Washington State,
don’t rest on your laurels. You still have an issue here
that you have to look at. And what you’re doing
overall may be working well, but it’s not working for
lots of populations there. So we get a lot of
attention out of this. And it really is a– we
released it last week, and it’s a great
opportunity to start talking about social determinants,
structural racism, and the impact of that. The other thing that we
continually stress is in this country there is either
an implicit or explicit bias that these iniquities are based on either some pre-determined
genetics or group flaws. And we’re very clear that this
is not pre-determined genetics, and there are studies,
like inner growth 21st that will show women of different racial ethnic
nationalities around the world, if they’re in optimal
health, with optimal care, do approximately the same. And the differences
between the groups is bigger than the differences– uh,
within the groups is bigger than between the groups. So we don’t believe this is
genetically pre-determined. But we also don’t believe
that this is a matter of group behavior, and
I don’t think anyone in public health would
believe that, frankly. But the rest of the world
doesn’t necessarily know. In fact, even YouTube
of political leaders at the governor level
making comments like, well if those people
only behave more like the majority we
wouldn’t have these problems. And I won’t mention the person’s
name, because I might get shot, but you would know the
name of this person. So we have got to
change that narrative. Part of what we’re doing, so we
can recognize that this is due to the toxicity we have
created in this country. And that this is baked into
our nation, the racism, the historic structural and
systemic racism is built in, that is causing these stressors,
that affects epigenetics, and as Dr. Braveman
also went over, also affects the allopathic
load, and the immune system, and all of these other things. It really makes great
sense biologically, it’s very plausible, and March
of Dimes is leading research into the effect of stress on
epigenetics, and expression. So I put this in
here, because I know that Dr. Fitzgerald is now your
director, and I’ve been talking to her for years, and she
actually now has extended to include prior to
birth in her initiative, at least the last time
I saw her present it. But long-term cognitive
impairment is affected by prematurity. So as we see, this is a life
cycle approach we have to take. There are a couple of
things that are very clear. We don’t make healthy
babies in nine months. We’re trying to change
that narrative. You can’t take sick women,
give them nine months of prenatal care, now
matter how good it is, and expect to have
healthy babies come out. So 40%, these are children
born very pre-term or pre-term. And you can see the
definitions there. A 40% increase in the risk of
significant cognitive deficits of school age, and then the– even if they don’t have a
neurological event, like a bleed or something else going on,
they still have a greater chance of having cognitive impairment. One of the explanations
possibly for looking at this is that normally a brain
will develop in the– well, while the baby
is still in mom, in the most natural environment
for that baby, and there’s lots of neurological development
going on there. No matter how well
we support a baby in an extrauterine
environment, in the NICU, it’s just not the same. And it does affect, we believe,
to use Dr. Braveman’s theory, research to demonstrate that the
extrauterine environment does alter the developmental
trajectory. Smaller cortical area,
microstructural abnormalities. There is probably some
threshold at 28 weeks, where before 28 weeks, the
brain development is much more severely affected, but any
decrease from the full-term baby at 40 weeks is going to
impact brain development. So we really want to make
sure that moms make it, and babies make it as
close to term as possible. Which is why these early
elective deliveries, that are scheduled
deliveries at 37 weeks, or scheduled C-sections,
are just not a good idea, unless they’re necessary for
the safety of the mom and baby, and unfortunately they’re
happening way too often, and often a woman isn’t
even given a choice. We’re scheduling your C-section. And it made me wonder
about that prior video, why was that C-section
scheduled for a woman who had never had a baby before? So visual spatial
reasoning, visual memory, slower processing speed,
less cortical white matter, smaller thalamus
which are involved in sensory and motor signaling. These are significant things
that affect these babies. And to look at it another way, the risk of special education
needs, by gestational age at delivery, and you can
see that look at 37 weeks, which we consider term, for
some-odd historic reason, it’s still three to four
weeks early, so I don’t know who decided that is term. But 40 weeks is the
referent group where you have the lowest
rate here, but you know, even at 37 weeks, you have a 36%
greater odds that there is going to be needs for special
education. So it’s very important that we
address pre-term birth in terms of the trajectory for the child. This is something
called the brain card, the March of Dimes developed
as a way to show people in a simple way the difference
between– in brain development, and why it’s important
to continue. Now, the brain does develop, you
know, if a baby is born pre-term and cared for, but again, that extra-uterine
environment is not the same as it is naturally developing,
and it does have consequences. So that is just my pitch. Please remember, no matter what
you’re working on, and I’m just as guilty of this as anyone
else, I worked for years on chronic disease, and
started to think about kids with type 2 diabetes at 18 years
old, five or more when you’re over 65, I personally didn’t
think about the impact of the birth process
on chronic disease. Pre-term babies have a
higher rate of hypertension, higher rates of diabetes,
we need to start including that baby’s development
before birth in all our work. So we pull together,
based on this challenge of seeing worsening
going on, and this was after the 2014-15 increase, we
said there is something going on here that is not right, and we knew for many
years the disparities in our heart rates compared
with other nations, and things, right, so we did a process where we first did key informant
interviews, for about 15 leaders in government, in clinical
medicine, and public health, community groups, organizations, where we asked them what
is it this, as a country, we need to do, as a field
of maternal child health, if we’re going to turn the
corner, start lowering the rates of pre-term birth again, and
start closing these iniquities. And so you can see
some of the groups that were here were very
grateful for the CDC support in this, and currently,
Wanda Barfield and I co-lead this
collaborative. But very important, all
levels very important that we also have
parents in the room who can experience it,
and can talk to us. So you’ll recognize
these groups here, and these are obviously
very influential groups. The central challenge,
this was very consistent with what the key
informant interview said, surveys of maternal
health professionals, and what the group came
up with, is that we have to approach equity and
pre-term birth hand in hand. You cannot separate the
two in this country. You can’t work on
one or the other. I mean, you know, for example,
you could close disparities by worsening the rates of
those who are doing better. We don’t want that. Like Washington State, you
could have great rates. But there’s big disparities. We don’t want that either. So we have to, in this
country, work hand in hand. And it was very gratifying,
oh man, five minutes! Did that work for any
other panel [laughter], so to go through this
again, this is critical, this is what we’re
trying to achieve. And we have a steering
committee that I will tell you about in a minute, about that. We came up also–
this is what happens when you only have
five minutes left, with other areas we are going to
work on, we have a group looking at clinical and public health
practice, and how do we do more of what we need to do? There are so many evidence-based
interventions, 17P, for women with a
prior pre-term birth. Aspirin. A free, well almost
20 cent pill given to women who have risk factors or
history of pre-eclampsia. We have not found a single
system in this country, and we’re going to
ask, or go looking, that has taken aspirin
on systematically. And the problem there is nobody
gives you a piece of pizza or a sandwich for a 20-cent
pill, so maybe we need to make it an orphan drug, and
then we’ll see it being used. But so often, Oregon’s study
of 17 hydroxyprogesterone, which is a steroid, given
and how many women received that who had a history
of pre-term birth. They only used four shots
rather than the full series, gives at 36 weeks,
between 18 and 36 weeks. Guess what percentage of women in their Medicaid data base
received even four shots in this series if they had
a history of pre-term birth? Less than 10, and that is in what is considered a
pretty good health system. And I could keep going
on with other states. It’s quite problematic. So if we are working on this,
and I’ll get a little bit more into it later if I have time. Across the board, I’ll
go through this stuff. But again, as we’ve
heard so much, we have to look at
the life cycle. And I think– I don’t
remember who said it. You can’t have a healthy baby
unless you have a healthy mom. And so– and believe it or not, that’s a challenging
notion in this field. We also know that we have to include families
in the communities. Healthy Start, City Match and
Stork’s Nest are part of this. We need to know how
to work with people in a culturally sensitive way
where they live, and the data. There are lots of issues around
setting goals for health equity, and again, I don’t have
time to go into that. But we are working on that now. The Health Equity Work Group was
the first group we got together. So we brought about 30
health equity specialists from academia, from practice, from community organizations
together, to spend two days looking at
how do we take the science and practice of health equity
and apply it to pre-term birth? And this group is led by Arthur
James, Fleta Mass Jackson, Diana Ramos, these are
names you probably know. And they are working
on several things. But the concept here
is let’s bring a group of experts together to
support all the other groups. Guiding principles
for those groups? How do you take an
equity approach to the work you’re doing
in all those other groups? A glossary, because there are
so many terms and definitions and how do we use them,
and talk about things? And then they are working
on a consensus statement, basically saying, you know,
as we’ve heard before, this, we need multiple sciences
to come to the table. This is not just about biological science,
clinical sciences. We need economists,
sociologists, anthropologists, women’s study specialists, to come because they each
have a way to approach this, and as…I can’t think it was
Paul said, you know, I think it was you, who said
basically this is equity– healthy equity is much more
than health, and we’ve got to approach this in other ways, meaning the sciences have
got to come to the table. Even if all– so we have over
300 organizations, like ACOG, and AWAN, and AAP, and ASTHO
and HO, even if all we did was to influence those
organizations, and there are probably a million
constituents and members, we would have accomplished
something. But of course, we want to
go much broader than that. So that was the first group. Clinical and public
health group, I won’t go into all the details. They are working on
low-dose aspirin. They’re working on 17P, they’re
working on intentionality and birth spacing, still
45% of the pregnancies in this country are unplanned. Planned pregnancies are
healthy pregnancies. And they are doing
that specifically with an eye toward
populations that are geographic, racial and ethnic, that
have been underserved. So, again, the equity
there is clearly– it’s very interesting
to see the excitement of ACOG’s Executive Director
around this equity approach. I was a little surprised,
frankly, but he was passionate about it. Policy and communications
workshop. There are policies
in this country that are simply not
conducive to health. Certainly we have all the
history of the Jim Crow Laws, and we have history
of redlining, which now is much more
subtle, but still does happen. But the policies, for
example, around social– other social determinants,
for example, we know that paid parental
leave, maternity leave, is associated with
lower infant mortality. We know that if we really
want women to be able to care for their children, we have to give them an adequate
minimum wage. We have to make sure they have
sick time off, so they can go to the doctor’s office. So we are working on a
number of those things. We’ve invited housing to that. We are going to expand
beyond it. Then the communications, the idea here is how do
we make this an issue, that it should be, and how do we
talk to different populations. So, for example,
with contraception, we know there is
historic coercion. So how do we reach people
in a way that is sensitive to that historical coercion, and the justifiable reaction
they may have based on that. Now, this I stole from Paula. The research group, and she
is really the thought leader in this area. I won’t go through all this, but
the idea here is we have a view, and I bump into this a lot,
that it is all biologic. And unless you understand
the biologic mechanism, you just don’t know what to do. That epidemiology, all
those other sciences find associations, they’re not causal and so you don’t
know what to do. So basically Paula and other
renowned scientists are going to write a paper
addressing that, saying this isn’t
just all biology, that this all takes place within
the context of environment and social setting,
and therefore, we need to bring
those sciences in. And that may sound
like not a big deal, but to get that published in
a prestigious medical journal by prestigious biological
researchers is going to make a big statement. So that group is beginning
to work on that there. So the approach here, and I’m
out of time, you don’t have any out of time ones do you? Good, oh, no, you do [laughter],
shouldn’t have invited it. The approach here really is,
we have a specialty, a science and practice of equity. And we absolutely have those
specialists, we need them to support and work with
everybody else, in this case, in the collaborative,
and in public health. But that’s not enough. You can’t just have this
be the job of people in six cubicles over there. They’ve got a spread to the
organization, and everyone in public health must
learn to work in this way. We need to set those goals
for goodness and fairness, and view the world through
a health equity lens. We have embedded the
health equity experts in every work group. So that they’re there at the table during the
discussions and helping them. I think this is going to help. I know it’s shifting
our organization. It’s shifting the prematurity
collaborative, and you know, I suggest that specialty
with embedding is an approach that you all take a look at. And it’s not easy. This is my last thing I’ll say. It’s been a real
struggle working with some of the communication
staff, and people like that who just don’t know
how to talk about it. Or they believe, well you know, a lot of the press won’t
want to talk about this. And we’ve got al of
training to do of people. So with that, I’ll finish
and thanks very much. [ Applause ]>>Good morning. I know we are approaching
the lunch hour, so hopefully I’ll be able
to hold your attention, and that your stomach growls
will not deter your attention from my talk. I’m really excited to be here. I’m excited, because this
work that I get to tell you about is something
very personal, something that I think really
makes a change and an impact on the care of women and
infants in this country. I am really excited
to talk to you today about a program supported
by CDC that focuses on truly giving children the
best start by improving care and outcomes for pregnant
women and newborns. I know that there are different
aspects of tackling the problem of disparities in health equity,
and I’m going to be talking about the health care aspect, because it is an
important aspect that once patients
do access care, that they are receiving
equitable care, and that the care
that we provide is of the highest quality. So, I’m going to first give you
a little background information on the need for improving
perinatal health, and then talk to you about how perinatal
quality collaboratives work to improve health and outcomes, and I’ll also discuss some
examples and opportunities to reduce perinatal
health disparities, and to improve health equity
for pregnant women and newborns. So the seeds of success in every
nation on earth are best planted in women and children. Maternal and infant morbidity
and mortality are key indicators of a nation’s health status, and
are associated with a variety of factors, such
as maternal health, access to high quality care,
public health practices, and socioeconomic conditions. And this graph of infant
mortality rates, of organization for economic cooperation
and development countries, you see the number of deaths
of children under the year of age expressed per
thousand live births for the countries listed here. I know you can’t see the names
of the countries, however, I would draw your attention to the United States,
which is in red. With an infant mortality rate of
5.8 at the time of this ranking, and as you can see, the United
States falls at the bottom of this ranking of developed
countries, despite spending more on health care per capita than
any other country on this graph. The good news, however,
is that since 1980, the nation’s overall infant
mortality rate has declined approximately 52%. This includes a plateau
from 2000 to 2005, followed by a decline to
5.82 in 2014, however, there was a slight rise
from 2014 to 2015 to a rate of 5.9 infant deaths per
1,000 live births in 2015. However, this national decline in infant mortality
has not been equal. While we’ve seen
encouraging declines in infant mortality
among African Americans, a critical gap still persists. In 2015, black infants died at 2.3 times the rate
of white infants. One of the main causes for the
higher infant mortality rate in the United States compared with other industrialized
nations, as discussed by Dr. Paul Jarris, is the
relatively higher number of pre-term births
in the United States. The pre-term birth rate
rose significantly by more than one-third from the 80s to
the early 2000s, but then fell for eight straight years
in a row to 9.57% in 2014. However, the pre-term
birth rate has risen again. For two straight
years since 2014. As with infant mortality, there is also marked racial
disparity in pre-term birth. In 2007, the pre-term birth rate
among black infants was still higher than that for any other
race or Hispanic origin group, and was more than 1.5 times the
rate in non-Hispanic whites. And in 2015, the rate of pre-term birth among black
women was still about 50% higher than a rate of pre-term birth
among non-Hispanic white women. Although there has been a
decrease in pre-term birth between 20– excuse me,
between 2007 and 2015– most of the decrease in
pre-term births has been due to a decrease in
late pre-term births, and not early pre-term births, which contribute to
higher mortality. Another measure of our nation’s
health, deaths to pregnant or recently pregnant,
women has been on the rise. As you’ve probably seen
recently in the news media, this increase has been seen
significantly in all races, but particularly has
impacted minority populations. Although this increase may
be partially attributable to better identification of
maternal deaths over time, maternal mortality does not
appear to be decreasing, and this increasing trend has
been consistent when you look at data from the National
Center for health statistics, and also from our national
surveillance system of pregnancy related deaths. The pregnancy mortality
surveillance system, which includes deaths
of women while pregnant, or within one year of
termination of pregnancy. As is the case with
infant mortality, there are striking
racial disparities in pregnancy-related
mortality in the United States. Black women have a three- to
four-times higher risk of dying from pregnancy complications
than white women, and this trend has
persisted for over 25 years. Also, while maternal deaths are
relatively rare sentinel events, severe complications
of pregnancy are about 100 times more
common than maternal deaths, and the disparity exists
also with maternal morbidity. Substantial components of our
nation’s health are influenced by decisions made in
health care facilities, and by health care providers. Collectively, these decisions
comprise our health care delivery systems, and there is
definitely room for improvement. State perinatal quality
collaboratives, or PQCs are multi-disciplinary
networks of perinatal care providers and public health
professionals working together to improve pregnancy outcomes by advancing evidence-informed
clinical practices through continuous
quality improvement. PQC members identify processes
that need to be improved, and use the best available
methods to make changes and improve outcomes
as quickly as possible. They do this by working with
local clinical hospital teams, experts, and stakeholders to spread best practices
using rapid data collection and feedback of data to
meet goals to improve care. State PQCs include key
leaders in private, public, and academic healthcare
settings, with expertise in obstetrics and neonatal care,
and in quality improvement. Strategies of PQCs include use of the collaborative
learning model, such as the breakthrough
series collaborative model, developed by the Institute
for Health Care Improvement, use of rapid response
data to provide feedback to clinical teams on their
progress, and the provision of quality improvement
science support and assistance to
clinical teams. The ultimate goal of state
PQCs is to achieve improvements in population level
outcomes in maternal and infant health
throughout the state. Although individual institutions
and organizations have been able to achieve some improvements
in perinatal care outcomes, regional PQCs serve a unique
role, because they take on the responsibility
of improving outcomes for the entire region. They understand the regional
network of perinatal care, and they collaborate among
teens in both hospital and community settings. And they have the ability
to compare the performance of hospitals that are operating
within a similar context. Members of a regional perinatal
quality collaborative represent a community of change. And this model has been
shown to be successful for rapid dissemination of evidence-based
protocols and processes. There is growing evidence
of how PQCs have contributed to important changes
in health care delivery and how their work has led
to significant improvements in perinatal outcomes. Such evidence includes
reductions in elective deliveries without
a medical indication prior to 39 weeks gestation, reductions in healthcare
associated bloodstream infections in newborns, reductions in severe
maternal morbidity, increases in appropriate
use and documentation of use of antenatal corticosteroids
to improve fetal lung maturity and improvements in the
use of progestin therapy for prevention of
pre-term births. CDC has been providing support to state perinatal quality
collaboratives since 2011, and the main goals of CDC support has
included providing support for funded states to expand
their ability and their efforts within a state to improve
perinatal outcomes, by enhancing their ability
to collect timely data, increasing hospital
participation in the PQC, making the PQC truly
representative of the entire state, and also
expanding the range of neonatal and maternal health
issues addressed by PQCs. CDC has also worked to transfer
experiences and knowledge gained from established PQCs to
help additional states, including a webinar
series on various topics with expert presenters
throughout the country, the development of a resource
guide to provide assistance to states that may wish to form
a PQC, or may have challenges with PQC development, and also
support for the development of the national network of perinatal quality
collaboratives. In 2011, CDC’s division of
reproductive health entered into a cooperative agreement with three established
perinatal quality collaboratives in California, New York, and
Ohio, to improve perinatal care through a quality
improvement model. And in 2014, CDC
support for PQCs expanded to include three additional
states in Illinois, Massachusetts, and
North Carolina, to further support
shared learning and collaboration among states. As of September 2017,
CDC now provides support to 13 state PQCs, as well
as a new coordinating center for the National Network of Perinatal Quality
Collaboratives. The states currently being
supported include: Colorado, Delaware, Florida, Georgia,
Illinois, Louisiana, Massachusetts, Minnesota,
Mississippi, New Jersey, New York, Oregon, and Wisconsin,
covering key states in all of the major regions
of this country. As you can see by this map,
most states currently have a PQC in varying stages of
development, as indicated by the darker colors on the map. There are some states that are
further along in the development of the infrastructure
and activities for an ongoing statewide
perinatal collaborative, and there are other
states that would benefit from further support
and assistance in expanding their efforts. In collaboration with
the March of Dimes, CDC has supported
the development of the National Network
of State Perinatal Quality Collaboratives. As a consultative and mentoring
resource to increase capacity in states to improve
maternal and infant health. This network was officially
launched in November of 2016, with participation of 48 out of
50 states in over 20 partners. The National Institute for Children’s Health
Quality was recently awarded to coordinate the activities of this network as
of September 2017. The goals of this network
are to strengthen leadership and state collaboratives,
to identify and disseminate best
practices for establishing and sustaining PQCs,
and identifying and developing tools, training,
and resources necessary to foster the sharing
of best practices to support a sustainable
PQC infrastructure. And the ultimate goal
is to reduce maternal and infant morbidity and
mortality in this country, making it the best place
to give birth and be born. The central mission
of this network is to support the development
and enhance the ability of state perinatal
quality collaboratives to make measurable improvements
in statewide maternal and infant health care
and health outcomes. Here are some examples
of maternal or obstetric focused
initiatives undertaken by PQCs. As you can see, there
are a variety of efforts spanning
the prenatal antepartum and post-partum periods,
and including efforts that impact both maternal
and neonatal outcomes, and allow for collaboration
among both obstetric and pediatric care providers. There are also a large number
of neonatal focus initiatives that include optimization of
care, in the delivery room, in the neonatal intensive
care unit, as well as efforts to improve well newborn care. In addition to efforts to
spread best clinical practices, PQCs have also undertaken
efforts to improve data, excuse me, to improve
data quality, and to make administrative
data more useful for scaling up of quality improvement
projects statewide and reducing the burden
of data collection. Now as we move forward with
our next set of awardees, these are the initiatives that the current CDC supported
collaboratives are addressing. Some clinical topics have
multiple states working on them as indicated by the
numbers in parentheses, which presents further
opportunity for sharing between state PQCs. PQCs that are supported by
this program are encouraged to integrate the cross-cutting
issue of health equity into their quality
improvement initiatives, as much as possible. While aiming to improve
outcomes for all patients through quality improvement
initiatives, it is possible that the disparities
between different groups can simultaneously widen. In addition, certain initiatives
would be most successful if the highest risk
groups are targeted. So, it is encouraged that all
state collaboratives make sure they pay special attention to how their efforts are
impacting disparate groups. I’ll now discuss a
couple of examples of how CDC supported PQCs have
incorporated health equity into their work. Pre-term birth is the number
one cause of newborn death in the state of Ohio, and progesterone is an
evidence-based therapy shown to reduce pre-term birth
by more than 30% in women with prior pre-term
birth, or with a history or identification
of a short cervix. The Ohio Perinatal Quality
Collaborative, or OPQC, OPQC has tested strategies for
implementing this intervention with outpatient obstetric
clinics, and successful strategies are
currently being disseminated to other obstetric practices
throughout the state of Ohio. The aim of this project
is to reduce the rate of pre-term births in the state
by increasing the screening, identification, and treatment
of pregnant women at risk for pre-term birth who will
benefit from progesterone. Because the rate of
pre-term– excuse me. Because the rate of pre-term
birth is highest among black women in the state, they were
targeted for intervention. There are many barriers that
have been identified for women to receive progesterone therapy
to prevent pre-term birth, including health system
factors, provider factors, and patient level factors. The Ohio Progesterone
Project focused on addressing the
patient provider and health system
barriers to improve uptake of this important therapy. As part of their efforts,
excuse me, an important part of their effort was
the development of various culturally-competent
informational brochures to educate patients and
providers about pre-term birth, infant mortality and how
progesterone can help prevent an early delivery. The Ohio Progesterone
Project was associated with a sustained reduction in pre-term birth before
32 weeks gestation in Ohio. Births before 32 weeks decreased
in all hospitals by 6.6% and births before
32 weeks to women with prior pre-term
birth decreased by 20.5% in all hospitals, by 20.3%
in African American women, and by 17.1% in women
on Medicaid. Another example is
an ongoing initiative to reduce unnecessary
caesarean births. Caesarean section– excuse me, caesarean section
delivery increases risk for both the mother and the
infant, and the rapid increase in caesarean birth rates
over the last two decades, without clear evidence
of concomitant decreases in maternal neonatal morbidity or mortality has raised
significant concern that caesarean delivery
is over-used. The California Maternal Quality
Care Collaborative has developed a new toolkit to
support vaginal birth and reduce primary caesarean which is a comprehensive
evidence-based how-to guide designed to educate and motivate
maternity commissions and teams, apply best practices for
supporting vaginal births, and to reduce unnecessary
caesarean section births among first-time mothers with
pregnancies that are term, singleton, and in a vertex
presentation, also referred to as NTSV, or low-risk
first-birth caesareans. Black women in the state
experience higher rates of low-risk first
birth caesarean. In a recent study in
California, black women were about 30% more likely to have a
low-risk first-birth caesarean section compared to white women. Implementation of this
improvement project will include targeting, and addressing
this disparity in California. CDC is working with PQCs to actively monitor how their
quality improvement initiatives incorporate health equity. Increasing attention
is also being given to how perinatal quality
improvement projects impact disparities, and how
interventions can be targeted at the most vulnerable groups. Efforts include education
campaigns for both parents and care providers, improving
access to care, and provision of higher quality
equitable healthcare. In addition, the National
Quality Forum, an organization that sets standards for
healthcare quality measurement in the United States is
particularly seeking composite and outcome measures, and
measures that are sensitive to the needs of vulnerable
populations, including racial
ethnic minorities, and Medicaid populations
that may be used for further quality
improvement efforts. Although the work of PQCs mostly
focuses on the health system, patient level, and provider
factors that contribute to disparities, the
real challenge lies in addressing the structural
factors, as listed here. As PQCs grow, and move outside of the inpatient hospital
setting for their work, there may be more opportunities to address these
factors as well. Partnerships, collaboration and sharing are what make
the PQC model so successful. The National Network of
PQCs provides a forum where successful
strategies, tools, and metrics can easily
be shared, and significant improvements
in population level outcomes and health can be realized. Multiple partners
working together to reach this common
goal is more effective than each individual
entity working alone. As this program moves
forward, it is crucial that we include partners
to help us remain committed to making sure that
health equity is a priority and that initiatives
include special effort to improve the health of those
who have experienced social or economic disadvantage, so
that all mothers and infants in this country receive
the best care, and to give children the
best start at a healthy life. I’d like to take this time
to thank the California and Ohio Perinatal
Quality Collaborative, that has provided leadership
in this work and leadership in providing assistance to other
states throughout the country. I’d also like to acknowledge Dr.
Barfield, the Division Director, for her support of
this work, and Drs. Callahan, Shapiro,
Mendoza, and Olson, also for their support
and input. And also the rest of our team
who have put a lot of work into this work, Daniel Suchtab, and Emily Johnston. I also would like to
thank Dr. Fitzgerald for her support of this work. It is because of her
support of improving care through State Perinatal
Quality Collaboratives that we have been able
to grow this program and to support our National
Network to provide support to states throughout
this country. Thank you. [ Applause ]

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