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Improving Policies and Services for Birth Equity

Joia Crear-Perry, MD BMBFA Beyond the Mom 2016

Mission

To reduce Black infant and maternal mortality through research, family centered collaboration and advocacy.

Goal Reducing black infant mortality rates by 25% in the next 5 years in cities with the highest numbers of Black infant deaths and to reduce Black IMR to at or below the national average in these sites in the next 10 years. Our vision is that African-American infant will celebrate a

healthy first birthday

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Black White http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Deaths: Final Data for 2013. TABLE 20 Note: Data are presented here by race only; data on Hispanic origin of mothers were not routinely collected until 1989

Infant Mortality Rate by Race, U.S., 1980-2013

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Black: White IMR Gap: Persistence of Disparity:

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http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Deaths: Final Data for 2013. TABLE 20 Note: Data are presented here by race only; data on Hispanic origin of mothers were not routinely collected until 1989

Infant Mortality Rate by Race, U.S., 1980-2013

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“…Our ability to prevent infant deaths and to address long-standing disparities in infant mortality rates between population groups is a barometer of our society’s commitment to the health and well-being of all women, children and families.” SACIM, January 2013

http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Deaths: Final Data for 2013. TABLE 20 Note: Data are presented here by race only; data on Hispanic origin of mothers were not routinely collected until 1989

Infant Mortality Rate by Race, U.S., 1980-2013

As the primary thrust of NBEC’s goal, the Campaign

involves innovative research, parent-centered collaboration, and advocacy to effectively reduce Black infant mortality in the cities with the highest burden of

Black infant death.

Save the Date:

Campaign for Black Babies National Report

April 2017

Campaign for Black Babies

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•  Center the voices and experiences of Black women and

families •  Conduct innovative and rigorous independent research

informing a national report to be released to local stakeholders and policy-makers

•  Encourage collaboration by convening local and national stakeholders committed to disaggregating data, customizing strategies, and advocating for systems change

•  Promote evidence-based culturally appropriate interventions effectively reducing Black infant mortality.

Active Campaign Sites: Baltimore, Chicago, Cleveland, Detroit, Memphis, *Mississippi, New Orleans

Campaign Activities Campaign Sites

AMCHP

Anthem

Black Mamas Matter

Black Women’s Health Imperative

Health Connect One

Institute of Women and Ethnic Studies

March of Dimes

NICHQ

National Action

Partnership to Promote Safe Sleep

National Collaborative for Health Equity

National Healthy Start Association

Planned Parenthood

Tulane University Mary Amelia Center

Urban Strategies

W.K. Kellogg Foundation

Partners and Funders

Social Determinants of Health Inequities:

Infant Mortality

Infant Mortality Rate, U.S. 1)  Congenital malformations, deformations and chromosomal

abnormalities (congenital malformations), accounting for 21% of all infant deaths

2)  Low birth weight was the second leading cause, accounting

for 17% of all infant death 3)  Sudden infant death syndrome (SIDS), accounting for 8% of

infant deaths 4)  Maternal complications of pregnancy (maternal

complications) (6%) 5)  Accidents (unintentional injuries) (5%)

Leading Causes of Infant Death

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Leading Causes of Infant Death

•  Maternal Age

•  mothers aged 30–34 (5.00)

•  mothers aged 40–54 (7.75)

•  teenagers (8.84)

•  teenagers <15 (13.56)

•  Smoking

•  Lack of access to prenatal care

•  Birth intervals <18mo,

•  increase odds of infant mortality by 83% and

associated with adverse neonatal outcomes

487

156 98

53

159 118

50 28

Preterm-related causes

Congenital Malformations

SIDS Unintentional Injuries

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orta

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Infant Mortality Rates for Selected Causes of Death Among Non-Hispanic Black and Non-Hispanic

White Mothers, 2010

Non-Hispanic Black Non-Hispanic White

Disparities in Infant Mortality in the U.S.

SIDS: Sudden infant death syndrome CDC/National Center For Health Statistics, Linked Birth/Infant Death Data Set, 2010 *Preterm-related causes includes a combination of short gestation and maternal complications that lead to preterm birth

Infant mortality improves for all groups, yet racial gaps widen

The Challenge RacialDisparities:Wemadeitthisway? Weoftenperceiveracialhealthdisparitiesasconsequencesof�nature�.Assuch,weconvinceourselvesthatthesedifferencesare�>ixed�or�hardwired”;apartofwhatisdifferentaboutusaspeopleandthereforecannotbechanged.However,thesedisparitiesaredifferencesthatwecreated,differencesthatoccurasaconsequenceofsystemsthatweputintoplace.Therefore,weknowtheycanbechangedandwouldsuggestthattheirpersistenceisinpartbecauseofourunwillingnessto�undo�whatwehavedone.

A R James

Racism/Low Expectations Anxiety/Stress/Weathering

Health Access/Quality Economic Opportunity Housing/Environment

Educational Opportunity Safety/Legal System

Significant Factors in Infant Death

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Jim

Crow

246 yrs.

62% of time

99 yrs.

25% of time

Since

CRA*

52 yrs.

13% of time

*CRA: Civil Rights Act Art James

Timeline of African American Experience

87% of the AA experience either as Slaves or under Jim Crow

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Institutional

Personally Mediated

Internalized

Levels of Racism White

Supremacy framework

Redlining is the practice of arbitrarily denying or limiting financial services to specific neighborhoods, generally because its residents are people of color or are poor. Banks used the concept to deny loans to homeowners and would-be homeowners who lived in these neighborhoods. This in turn resulted in neighborhood economic decline and the withholding of services or their provision at an exceptionally high cost.

Redlining: 1934-1968

While discriminatory practices existed in the banking and insurance industries well before the 1930s, the New Deal’s Home Owners’ Loan Corporation (HOLC) instituted a redlining policy by developing color-coded maps of American cities that used racial criteria to categorize lending and insurance risks. New, affluent, racially homogeneous housing areas received green lines while black and poor white neighborhoods were often circumscribed by red lines denoting their undesirability.

Redlining: 1934-1968

“Particularly disturbing is

the relationship between

redlined areas (upper left hand

corner of this slide) and

infant health outcomes

(lower right hand corner).”

– Kirwan Institute

http://kirwaninstitute.osu.edu/wp-content/

uploads/2015/06/ The-History-of-Race-Real-Estate-Cuyahoga-

County-Final-Report-February-2015.pdf

Detroit, MI

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Despite the data, there are many who believe that the Black IMR

cannot improve…that it is as high/bad as it is because of group level flaws amongst those of us who are

Black.

School drop outs

Dead beat dads Welfare Queens

Drug addicts

Teen-ag

ed pregnancies

IPV

Genetics

Black people don’t love their babies as much

Clinical Social

Doulas, Support Groups and Lactation Consultants bridge this gap.

Art James

•  Cultural/Race •  Social Interactions •  Health Access and Quality •  Economic Opportunity •  Safety/Housing/Environment •  Education Opportunity

•  Anxiety/ Stress (from all of the above)

Women with high stress are 4.12 X at risk for preterm

delivery

Social Risk Factors for Infant Death Wealth Gap

Environments can lead to the stress and anxiety, causing the adverse biological responses that can lead to poor birth outcomes. It is very important to the health of discharged NICU babies

“The broader environment- biologic, physical, and social- strongly affects the capacity to be healthy”

Fine & Kotelchuck, 2010 “Black women living in highly segregated areas, near freeways, and living in poor communities have worse birth outcomes than

their counterparts” Dr. Gail Christopher, 2013

Environment Weathering hypothesis- Arline T Geronimus ScD

“The health of an African American woman may begin to deteriorate in early adulthood as a physical consequence of cumulative socioeconomic disadvantage and increased insults to health”

Maternal Stress

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Focus on Social Determinants Determinants of health inequities such as built environment, stress/anxiety, residential segregation, and indicators of institutional racism account for a greater amount of the variance in poor outcomes than well-understood clinical risk factors (prenatal care, smoking, etc.)

Why we focus on Social Factors? Qualitative Research brought out social risk factors Recurring themes •  Trauma/ stress •  Race/ social perception of race •  Poor transportation •  Inadequate/unstable housing •  Economic insecurity •  Quality of grief and counseling services •  Quality of care/accessibility of care

Lessons Learned from NBEC Campaign

Policy and Service Improvements for

Equity in Birth Outcomes

N.E.S.T Parent and community centered advocacy to

improve the practices, policies and systems affecting Black infant mortality

Safe Landing

Culturally appropriate support of families’ journey transitioning a high risk infant from the NICU to home

care

Other NBEC Programs

Mobilizing African American Parent Leadership N.E.S.T. (Nurturing and Educating Sisters Together) is a curriculum model that can be used for different parent and preconception health trainings. NBEC’s Campaign for Black Babies sites will be trained to identify and cultivate parent leaders who are equipped to advocate on behalf of black babies at the local, state and national level.

N.E.S.T High-risk Home Based Intervention for NICU

Babies Safe Landing is NBEC’s home-based intervention model targeting at-risk infants leaving the Neonatal Intensive Care Unit (NICU). Facilitators provide culturally appropriate support to at-risk families through the infants’ first birthdays by conducting regular home visits, connecting families to social services. Providing training in culturally appropriate home-visitation practices to home visitation staff working through insurance companies and managed Medicaid providers.

Safe Landing

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Relationship between Breastfeeding and Infant Mortality Doulas in Action = Success

Questions How did the doula in this scenario work with parents and the community? What aspect of this example can be applied to your work?

A Doula Helps Change Law about Mandatory Erythromycin Ointment

Influencing Policy using Community

Action Teams Changing Current Conditions with Teamwork and Action

Identify Problem

Method

Mobilize to influence

community and political action

Equity Solutions: Moving from Conversation to Action Systems-level change requires a team to develop an action plan

Institutional

Organizational characteristics, formal rules and operational regulations

Community

Networks and relationships between organizations and institutions

Public Policy

Local, state and national laws/policies

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Community & Stakeholder Engagement for Advocacy

Each NBEC site is led by a local partner responsible for coordinating the local Campaign for Black Babies. NBEC partners will be coached by NBEC to develop and lead local coalitions of stakeholders committed to reducing Black infant mortality. NBEC’s National Coalition for Black Babies mobilizes the nations leading maternal and child health organizations and African-American civil rights institutions towards the goal of reducing Black IMR by 2025.

Campaign for Black Babies CHAMPS NOLA Baby Café Baby Café USA- a free resource for pregnant and breastfeeding mothers to get support from specifically trained staff and to share experiences with other moms

Benefits: Education Community collaboration Support

Normalization of breastfeeding

“In New Orleans we have at least 65% women of color and we have low breastfeeding rates. Normally we have people come to the hospital, but to have something in the community to support breastfeeding is a transformative idea.” – Dr. Crear-Perry

Focus Groups Safe Sleep Rebranding Campaign- In Cleveland Ohio, we partnered with Sisters of Charity Foundation and TWIST Creative to evaluate and rebrand safe sleep messaging in the community. Pregnant women, expecting fathers and influencers gathered to share meaningful experiences and perspectives Focus Groups: Community engagement Real-time feedback Valuable input New data Continuous relationship and coalition building

•  Unconditional support •  Help implementing systems what work for the family’s specific

needs •  Advocacy for mothers and provider-patient communication •  Healthy mother and baby •  >30% decrease in use of Pitocin •  >30% decrease in risk of C-section •  9% decrease in use of pain relief medication •  14% decrease in risk of newborns being admitted to special

care nursery

Doulas and lactation consultants & birth workers have produced birth outcomes better than the

national average

You bring _____ to the table

COMMUNITY ACTION IDEAS Institutional Community Public Policy

•  Skin-to-Skin support policies

•  Breastfeeding Friendly certifications

•  Safe Sleep home prep/visiting

•  Teen mentoring

•  Preconception wellness classes

•  Prenatal health

literacy •  Financial literacy

•  Affordable housing/home ownership support

•  Public breastfeeding legislation

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A Doula facilitates Skin-to-Skin in the Operating Room

Doulas in Action = Success Collaboration

Unified progress on a complex social issue by a multi-sectoral group

Why Community Action Teams? Characteristics

ü  Leadership ü  Citizen participation ü  Passion about a topic ü  Quick efficient

communication

� Connect with the parent community � Get support � Choose a movable problem

Working the Community Action Team

u Begin a slowly growing committee of parents interested in social action

u Active listening and reflect together on what is said and what isn't being said

u  Identify focal issues to address

u  Identify potential partners and advocates

Connect with the Parents

u Garner multi-sectoral support

u Build relationships with “movers and shakers” of the community

u Keep a log of contact participant info and addresses u Set up meetings when needed

Get Support u Research to learn about the problem and how to solve it

u  Invite community partners to team meetings

u Collectively take steps toward goal

u Celebrate each victory!

Choose a Movable Problem

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No single organization has the resources, scope of influence or expertise to improve infant mortality or eliminate racial

disparities by themselves…it takes all of us.

Maintains the culture and social networks of the existing community

Involves residents in the decision making process

Rejoices in winning small victories for birth equity

It takes a Village…

Advocacy can be challenging, but you are an activist at heart. Push your comfort zone to make the greatest positive impact for the

families you serve