Northeast Florida Healthy Start Coalition

2009-2014 Healthy Start Service Delivery Plan: Achieving healthy pregnancies through a life-course approach

The Life-Course Model

The health and socioeconomic status of one generation directly affects the health status — and reproductive

health capital — of the next one.

Interplay of biological, behavioral, psychological and social protective and risk factors contributes to health outcomes across the span of a person’s life

Examine cumulative effect of health status, life events at different stages rather than risks, behaviors and services once a woman becomes pregnant

Healthy Start & The Life Course• MISSION STATEMENT: The Healthy Start Coalition leads a

cooperative community effort to reduce infant mortality and improve the health of children, childbearing women and their families in Northeast Florida.

• The life-course model broadens the focus of maternal and child health to include both health and social equity.

• Key factors affecting health outcomes:> socioeconomic status > race and racism> health care > health status> stress > nutrition and weight> birth weight

2009-2014 Healthy Start Service Delivery Plan

• Tracks progress over the last five years in addressing maternal and infant health needs; guides the development and funding of Healthy Start services through 2014

• Life-course framework has both programmatic and policy implications:– Content of case management and related services moves beyond

health, e.g. addresses education and poverty– Services organized and delivered in ways that build resiliency and

social capital, and reduce dependency (e.g. group activities, self-care). – Requires inter-disciplinary, inter-agency collaboration and

cooperation to address the complex needs of at-risk families.

Strategies• The Healthy Start program: individual case

management and risk reduction services, not directly responsible for addressing social determinants.

• Plan strategies developed on two levels: – What actions can be implemented through Healthy Start?– What partnerships are needed between Healthy Start and

other organizations working to address social equity?

• Looks at four phases: – Infancy– Childhood & Adolescence– Preconception– Pregnancy & Childbirth

Health Status & Services

INFANT MORTALITY Declining, but still higher than

state and national rates Black and other nonwhite babies

die at 2X the rate Hispanic infant mortality rising

HEALTHY START Infant Screening rates have

declined More intensive, face-to-face

services but fewer served Fewer substance-exposed

newborns served (loss of funding for Azalea Project)

BREASTFEEDING: Optimal start & reduces child- and adulthood obesity. Initiation has increased but not duration. No hospitals in NEFL are Baby-Friendly (WHO).

SAFE SLEEP: Sudden Unexplained Infant Deaths (SUIDS) leading cause of postneonatal (28-364 days) deaths; most preventable.

LOW BIRTH WEIGHT: Disparities in low and very low birth weight place more minority children at risk of life-long physical and development handicaps. NICU stays and costs are rising.

19,268 babies were born in Northeast Florida in 2007, 8% of the 19,268 babies were born in Northeast Florida in 2007, 8% of the births statewidebirths statewide

Infancy

Social DeterminantsLOW-INCOME MOTHERS: More moms on Medicaid, fewer graduate HS

– 43% of moms on Medicaid in 2007 up from 33% in 2003– 16% of babies born to white moms with no HS education; 20% of

black moms– 25% of moms in Baker County lacked HS education in 2007

SINGLE MOTHERS: Growing number, impact on family income– 40% of babies born to single moms; 60% of black babies– Two-parent families earn more money– Fathers’ info on 60% of birth certificates; play vital role in

development, economic status

ENVIRONMENTAL TOBACCO SMOKE (ETS): Risk factor for SUIDS, asthma

— 10% of babies born to mothers who smoked during pregnancy; higher than state— 9% exposed to second-hand smoke 1hr+ a day— White moms smoke at higher rates — Healthy Start: smoking cessation

Goals & StrategiesREDUCE: Infant mortality, infant mortality disparities, postneonatal mortality,

LBWINCREASE: Breastfeeding initiation and duration

HEALTHY START STRATEGIES:– Increase screening, initial contact rates.– Provide more-focused education and support – Include fathers in services.– Improve continuity of care (NICU, other prenatal high-risk moms).

CRITICAL PARTNERSHIPS: • Screening rates: Area hospital council, Florida OB/GYN Society (FOGS)• Fathers: Jacksonville Children’s Commission, Jacksonville Urban League,

WorkSource, area health departments, Healthy Families programs• Hispanic outcomes: Council of Spanish Speaking Organizations, Mayors

Hispanic Advisory Council, Spanish Association of North Florida Inc., Jacksonville Hispanic Lions Club, Hispanic media, and Hispanic Chamber of Commerce

• Breastfeeding: NEF Breastfeeding Collaborative• Poverty: Family Foundations, WIC, Healthy People, Healthy Communities

Health Status & ServicesCHILD DEATHS

Accidents are leading cause; homicide is second-leading cause for 15-19 year-olds (2X state rate)

OVERWEIGHT 30% of 1st graders overweight or at-risk Insufficient physical activity

CHILD ABUSE Regional rates higher than state rates Leads to future negative behaviors

STIs & HIV/AIDS High rate of teen STIs, especially Duval County Duval has one of highest rates of teen HIV/AIDS cases

TEEN PREGNANCY Teen pregnancy and repeat births decreased slightly

SUBSTANCE ABUSE Teen rates decreasing, more prevalent among whites

HEALTH INSURANCE: Lower rates of Medicaid, Florida KidCare in region

HEALTH CARE: Wolfson Children’s Hospital had the most ER visits; Nemour’s provides specialty care

SCHOOL HEALTH SERVICES: Funding higher but varies greatly by county, as do health classes and nurses

About 329,000 children ages one-19 live in Northeast Florida. Children About 329,000 children ages one-19 live in Northeast Florida. Children in the region comprise about 8% of children statewidein the region comprise about 8% of children statewide

Childhood & Adolescence

Social DeterminantsPOVERTY: 12% of families with children <18, more than 50% of families

in Baker County with mom as head of household and kids <age 5SOCIAL SERVICES: Food Stamp enrollment rising; cash assistance down HOUSING: Older in NEFL; Duval has older housing, higher lead poisoning

rates, while almost 90% of Baker County homes have septic tanks

SCHOOLS: Students in NEFL fare worse than their counterparts statewide

High School Graduation Rate, NEFL & Florida, 2006/2007 & 2007/2008

  2006/07 2007/08

Baker 77.9 77.5

Clay 75.3 77.6

Duval 64.3 65.9

Nassau 80.7 81.5

St. Johns 78.3 89.4

NEFL 69.6 72.5

FLORIDA 72.4 75.4

Source: JCCI 2008 Quality of Life Report, 2006/2007-2007/2008

Goals & StrategiesREDUCE: Body Mass Index in 1st Graders, Teen STI Rate, Repeat Teen Pregnancies

HEALTHY START: Promote breastfeeding; Address poverty in case management (GED, EITC); Link teen moms to prevention services; Address murder rate, health education through partnerships

CRITICAL PARTNERSHIPS :• Education: School Board, Achievers for Life, Learning to Finish, AWARE School

for Teen Parents, the Jacksonville Community Foundation’s Quality Education for All, Jacksonville Commitment.

• Poverty: The United Way, Real $ense.• School success: Jacksonville Urban League (Head Start), the Early Learning

Coalitions, Episcopal Children’s Services, Jax Children’s Commission.• Tobacco use: County health departments, SWAT.• Uninsured: Department of Children and Families, AHCA.• Crime, IM: Jaguars Foundation, Media, JCCI.• Teen pregnancy, STI rates: Youth development programs, local churches/faith-

based organizations, barbershops, salons.• Nutrition, obesity: WIC

Health Status & Services

PRE-PREGNANCY Maternal health and prematurity: greatest

proportion of fetal & infant deaths Pre-existing conditions (diabetes and

hypertension; STIs; obesity and poor nutrition) are factors

UNINTENDED PREGNANCIES: More than half of pregnancies are

unintendedUNHEALTHY HABITS: 20% smoked prior to pregnancy STI rates are 40% higher in NEF (pre-term

birth, other poor outcomes) HIV/AIDS rates are high, especially for

black women

PreconceptionIn 2007, there were 283,865 women of childbearing age (15-44 In 2007, there were 283,865 women of childbearing age (15-44 years old) residing in Northeast Florida. The number of women age years old) residing in Northeast Florida. The number of women age 15-44 years old is expected to reach nearly 300.000 by 201415-44 years old is expected to reach nearly 300.000 by 2014

BABY SPACING: 25% had birth intervals <18 months - shows lack of contraceptive use, need for family planning services, counselingFAMILY PLANNING: Medicaid waiver underutilized; health departments provide most servicesOVERWEIGHT: 40% overweight or obese prior to pregnancy; black women impacted moreACCESS TO CARE: One-third are uninsured prior to pregnancy.FOLIC ACID: Only 40% of women take a multi-vitamin with folic acid daily; but 77% know pre-pregnancy consumption reduces birth defects

Social DeterminantsDOMESTIC VIOLENCE: Most victims are women.

– 60% higher rate of health problems– NEFL consistently exceeds statewide rates– Shelters in the region served 1,400 women and children

in 2007-08NEIGHBORHOOD CRIME & VIOLENCE: Homicide rate in NEFL is

70% higher than state rate– Disproportionately impacts poor and minorities

Homicide Mortality Rates, NEF and FL, 2007

11.7

5.4

15.7

4.3

2.8

11.9

7

13.7

4.3

6.9

3.11.9

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12.7

31.3

17.2

14.6

29.0

18.2

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10

15

20

25

30

35

Baker Clay Duval Nassau St Johns NEF FL

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White

Black & OtherRaces

Goals & StrategiesREDUCE: Preconception tobacco use, STI rate, INCREASE: Preconception folic acid consumption, interconceptional intervals

of 18 months or greater

HEALTHY START: Promote multivitamin use; Increase interconceptional counseling, smoking cessation services; Promote use of family-planning waiver; Provide info on family planning services for families, men.

CRITICAL PARTNERSHIPS: • Family planning, waiver: OB/GYNs, State Agency for Health Care

Administration (AHCA).• Preconception health, folic acid info: Universities and private colleges

(Flagler, JU), community colleges, juvenile justice programs, outward bound, half-way houses, the Tiger SHOP, foster care group homes; WIC; March of Dimes.

• Tobacco use: Florida Quit Line, Area Health Education Centers (AHECs).• Medical homes for uninsured: Hospital Emergency Room Alternatives

Program (HERAP).

Health Status & ServicesPREGNANCY

More births to women age 20-24; and fewer to mothers over age 35

St. Johns: most older mothers; Baker & Nassau: most age 17 and under

PRENATAL CARE 2x receive late or no prenatal care in NEF

black women have highest rates Women on Medicaid more likely to receive

no prenatal care Most care provided by private doctors

C-SECTIONS Regional rates are higher than the state Shands Jacksonville has lowest rate in the

state; Baptist Medical Center—Nassau has one of the highest

Pregnancy & ChildbirthThere were more than 19,000 deliveries in Northeast Florida in There were more than 19,000 deliveries in Northeast Florida in 2007. Fertility rates (births to women age 15-44 years old) in the 2007. Fertility rates (births to women age 15-44 years old) in the region rose from 65.9 to 67.9 between 2005 and 2007region rose from 65.9 to 67.9 between 2005 and 2007

SUBSTANCE USE: Impacts Fetal Alcohol Spectrum Disorders, asthma; Tobacco use high in NEFINFECTIONS: Associated with poor birth outcomesPRE-TERM DELIVERIES: Prematurity 2x higher for blacks; Late pre-term deliveries rising.MATERNAL MORTALITY: Consistently higher than state rate, particularly high among non-whitesHEALTHY START: Prenatal screening rates low; more intensive, face-to-face servicesBIRTH CONTROL: Post-partum birth control use low; Higher % of women unable to pay for it in NEF

Social DeterminantsSINGLE MOTHERHOOD: Higher rates of poverty, reduced social

support; More than 40% of births in the region were to unmarried mothers in 2007—33% white, 46% Hispanic and 62% of black mothers.

FATHERS: Feelings about pregnancy affects role in pregnancy and child’s life.

SOCIAL & ENVIRONMENTAL FACTORS: Arguing excessively with partner, financial difficulties, loss of partner or friend, maternal or paternal incarceration, abuse

MATERNAL STRESS: Linked to pre-term labor

RACISM: Creates disparate affect on black women and contributes to their poor birth outcomes

Goals & StrategiesREDUCE: Proportion delivering with late or no prenatal care, tobacco use

during pregnancy, maternal deaths, single mothers

HEALTHY START: Implement outreach in hospital ERs; Promote simplified Medicaid enrollment; Promote breastfeeding; Collaborate with chronic disease prevention; Provide info on consequences, impact of single motherhood; Increase screening rates, initial contacts and intensive, face-to-face services; Provide group prenatal care and case management

CRITICAL PARTNERSHIPS• C-Section Rates: Delivering hospitals and OBs• Tobacco use: American Lung Assn.• Birth control: Family planning providers in the community• Medicaid eligibility, coverage and enrollment process AHCA & DCF• Healthy Start screening: OBs, prenatal care providers• Father involvement: Jacksonville Urban League Head Start, county health

departments, other community-based initiatives• Postpartum obesity: WIC• Chronic disease, maternal mortality: Healthy People, Healthy

Communities

Community Perspectives• JCCI Town Hall meetings: five diverse groups (60+

participants) discussed causes and what to do about black infant mortality

• Focus groups: what does community know?• Common themes:

– Need for education, information– Impact of stress, lack of trust– Impact of poverty– Lack of awareness, concern among leaders– Need for personal support, community involvement

What does the plan tell us?Today’s babies are tomorrow’s mothers and fathers.

Significant improvements in infant mortality, low birth-weight and other MCH indicators unlikely to occur unless the health and social status of NEFL residents is addressed across the life-course.

We can improve the effectiveness of Healthy Start in impacting individual risks and behaviors in and around pregnancy.

There are opportunities to focus and expand the content of case

management to address social determinants.

Collaboration and partnerships are critical to reducing social and environmental risks, building resiliency and achieving health equity.

Partnerships• Collaboration essential to address complex needs of families

• Supports coalition’s commitment to collaboration and to addressing infant mortality within a broader community context.

• Builds on community engagement efforts:– Friendly Access– Black Infant Health Practice Initiative– Black Infant Health Community Council– Magnolia, Azalea Projects– St. Johns Infant Mortality Task Force

Thanks!

2009 Planning Committee

Thomas Bryant III, ChairCarolyn ArnisterKaren ColemanRev. Alton Coles

Monica Floyd-Cox, RNLinda Hemphill

Heather Huffman, RD, IBCLCDave Malone

Lisa Pelle