Maternal, Child and Adolescent Health Report San Francisco Health Commission Community and Public Health Committee Mary Hansell, DrPH, RN, Director September 18, 2012
Presentation Outline Overview Emerging priorities Program highlights PHN, NFP and BIH Policy work Challenges
A Vision for San Francisco a world renowned international City that celebrates diversity and leads the way in job creation, innovation, education, healthcare, and the environment for our future generations Mayor Edwin M. Lee
MCAH Focus in a SF Vision San Francisco infants, children and adolescents grow up to become healthy adults in supportive families, safe neighborhoods and thriving communities San Francisco women are healthy when they become pregnant, deliver healthy babies, and parents have the capacity and confidence to care for their children well
MCAH Mission To protect and promote the health of all women of childbearing age, infants, children, adolescents and their families
MCAH Goals Improve outreach and access to quality health and human services Improve maternal health Improve infant health Improve nutrition and physical activity Improve child health Improve adolescent health
Resource constraints MCAH selectively offers Program services Policy efforts Focus Low income Non-English speaking and African American Children with chronic illness or disability Families during the perinatal period (vulnerability and opportunity)
Sources of Revenue Other Sources, $635,659, 3% CA State, $2,711,154 11% SFDPH General Fund, $6,469,352 28% Federal Funding, $13,552,037 58% MCAH 2012-13 Funding By Source
MCAH Serves SF Children and Families Field PHN 3000/ year Nurse Family Partnership 200 planned Child Health & Disability Prevention 3453/ year California Children s Services 2000/ year Medical Therapy Unit 325/ year
MCAH Serves SF Children and Families Foster Care WIC Nutrition Program Child Care Health Project Black Infant Health Service Quality, Epidemiology Policy Development 1300/ year 15,400/ month 4000/ year 80/ year
Pressing Issues Incorporating the Life Course Perspective Early identification of children with special needs, appropriate intervention Access to health services pre-conception Promoting Health Equity - integration of concepts of place and race in work Providing 10 Essential Services of PH to improve MCAH Workforce Development and Capacity Collaborating
Key Life Course Concepts USDHHS, HRSA, Maternal and Child Bureau, November 2010 Today s experiences and exposures influence tomorrow s health. Timeline Health trajectories are particularly affected during critical or sensitive periods. Timing The broader community environment biologic, physical, and social strongly affects the capacity to be healthy. Environment While genetic make-up offers both protective and risk factors disease conditions, inequality in health reflects more than genetics and personal choice. Equity Key epidemiological indicators represent the health and well-being of our children, the conditions of our communities, and the trajectory of our future
Life Course Perspective in MCAH Pregnant Infant Early Childhood Child Care Health Project Young Adult Late C Childhood H Adolescent D P
Early Brain Development 16
Early Prenatal Care Percent First Trimester Prenatal Care 100 90 80 70 60 50 86.6 84.7 75.8 65.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year SF CA SF Black CA Black HP 2010: 90%
Overweight (%) 100 90 80 70 60 50 40 30 20 10 0 32% 40 33 22 Asian Black Latino 38% 32% 56 58 53 48 46 41 39 40 25 28 22 18 2 to 4 5 to 8 9 to 11 12 to 14 15 to 19 Age (y) Data source: PedNSS 2009. Note: White, non-hispanic, Filipino, Pacific Islander and Native American children accounted for less than 3% of the PedNSS sample, Overweight = BMI>=85%.
Birth Outcomes Disparities Preterm births Low birthweight Very low birthweight (% of Live Births) 20 15 10 5 0 SF CA ALL White Asian Latino Black 15 10 5 0 SF CA All White Asian Latino Black 3.5 3 2.5 2 1.5 1 0.5 0 SF CA ALL White Asian Latino Black Neonatal deaths Postneonatal deaths Infant deaths (Deaths per 1,000 live births) 10 8 6 4 2.9 2 0 SF CA ALL White Asian Latino Black 6 5 4 3 2 1 0 SF CA ALL White Asian Latino Black 18 16 14 12 10 8 6 4 2 0 SF CA ALL White Asian Latino Black
Chlamydia Reported Chlamydia Case Rates for Females Ages 15-19, 2005-2007 Reported cases per 1,000 120 100 80 60 40 20 30.8 38.9 25.1 22.9 111.5 0 SF, 1998-2000 SF, 2005-2007 Bay Area, 2005-2007 CAL, 2005-2007 SF Black, 2005-2007 SF DPH MCAH Title V SOW 2011, Draft v2 7/14/2011
Child Abuse Foster Care Rates by Ethnicity, San Francisco and California, July 2010 Rates per 1,000 80 70 60 50 40 30 20 10 0 73.5 73.2 SF CA 24.4 16.6 10.2 9.9 5.5 3.6 4.8 5.1 2.4 1.4 ALL Black Whi Lat Asian/PI Nat Amer Source: CWS/CMS Dynamic Report System (http://cssr.berkeley.edu)
Program Highlights Nurse Family Partnership built upon Field PHN Black Infant Health Policy Development
Program Highlights Nurse Family Partnership built upon Field PHN Black Infant Health Policy Development Work
Field Public Health Nursing Home visits Prenatal and postpartum women and their newborns Chronically ill children and adolescents 3200 referrals and 10,500 client encounters / year Caseloads of 25-40 high risk families Trusted professionals Almost 30% of women report IPV/ DV at first visit Women self refer
Overview 26 Nurse-Family Partnership is Nurse Family Partnership An evidence-based, community health program Transforming lives of vulnerable first-time mothers living in poverty Improving prenatal care, quality of parenting and life prospects for mothers by partnering them with a public health nurse
Overview 27 Program Goals Improve pregnancy outcomes Improve child health and development Improve parents economic selfsufficiency Key Program Components First-time, at-risk mothers Registered nurses Intensive services (intensity, duration) Focus on behavior Program fidelity Why Nurses? Knowledge, judgment and skills High level of trust, low stigma Credibility and perceived authority Nursing theory and practice at core of original model
Overview 28 Home Visit Overview Personal Health Health Maintenance Practices Nutrition and Exercise Substance Use Mental Health Functioning Environmental Health Home Work, School, and Neighborhood Life Course Development Family Planning Education and Livelihood Maternal Role Mothering Role Physical Care Behavioral and Emotional Care Family and Friends Personal network Relationships Assistance with Childcare Health and Human Services Service Utilization
Trials of the Program Research 29 Dr. Olds research & development of NFP continues today 1977 Elmira, NY Participants: 400 Population: Low-income whites Studied: Semi-rural area 1988 Memphis, TN Participants: 1,139 Population: Low-income blacks Studied: Urban area 1994 Denver, CO Participants: 735 Population: Large % Hispanics
Research 30
Research 31
Research 32
Monetary Benefits to Society 33 Monetary Savings
Monetary Benefits to Society 34 Nurse-Family Partnership is Cost-Effective The RAND Corporation estimates Nurse-Family Partnership can return up to $5.70 for each $1 spent on the program.* Savings accrue to government from decreased spending on: health care criminal justice child protection mental health education public assistance And increased taxes paid by employed parents Nurse-Family Partnership returns more than $18,000 over and above program costs for each family enrolled.** (Washington State Institute for Public Policy 2008) * RAND Corporation 1998, 2005; return for highest risk families ** Savings related to low birth weight, child injuries and immunizations not included
San Francisco Nurse Family Partnership First 12 clients enrolled 4 teens; youngest is15 6 monolingual in languages other than English Significant issues History of sexual abuse/physical abuse History of drug abuse History of depression 21 pending: 5 teens; 4 monolingual Spanish
San Francisco Black Infant Health Program
Black-White Gap in Birth Outcomes: The Cause The cause is unknown. It is not explained by Black- White differences in: Prenatal care Tobacco, alcohol or drugs Nutrition Current income or education 3
Social Factors The birth outcome patterns suggest that social factors are involved. Prime suspects include: Stress: Especially chronic, e.g., due to racism and/or economic hardships Lack of social support: Social support may directly improve health, affects health behaviors and buffers stress effects Need for empowerment: Self-efficacy plays key role in health behaviors; key to escaping poverty (lack of control at work strongly linked with heart disease) 4
Stress Scientific literature on stress clearly indicates its adverse effects on practically every system in the body. Maternal stress compromises immune, endocrine and vascular functioning during pregnancy resulting in pre-term delivery. P.D. Wadhwa, et al, Stress, Infection and Preterm Birth: A Biobehavioral Perspective, Pediatric Perinatal Epidemiology 10
BIH Focuses on Contributing Factors Chronic stress Social isolation Limited access to services Racial inequities Economic hardship Disempowered communities 10
Group Intervention Group format means women draw strength from each other Skill-building to achieve better physical and mental health Use facilitative learning to access and enhance women s knowledge and skills Weekly personal goal setting culminating in the creation of a Life Plan Focus on empowerment to: Make good choices to have a healthy pregnancy Be a good role model for one s child 14
Prenatal and Postpartum Groups Ten prenatal sessions for pregnant women Ten postpartum sessions for new mothers Individual client plans Personal goal setting and life planning Support from Public Health Nurse and Social Worker Ten prenatal sessions for pregnant women Ten postpartum sessions for new mothers Individual client plans Personal goal setting and life planning Support from Public Health Nurse and Social Worker 15
Program Tenets Designed to encourage and support a healthy pregnancy Builds upon client s strengths to enrich them, their families and their community by empowering them to make healthy decisions Culturally relevant and honors the unique history and traditions of people of African descent Information included is important to African American women Everything is intentional to help close the health gap in Black- White disparities 16
The Black Infant Health Program (BIH) Transforming African American women & their communities to improve health PROGRAM FOCUS BIH addresses the problem of poor birth outcomes and health disparities affecting African American women and their infants. BIH focuses on these contributing factors: Chronic stress Social isolation Limited access to services Racial inequities Economic hardship Disempowered communities PROGRAM MODEL Group intervention plus enhanced case management, designed to: Help women identify their strengths and address their health and social needs and concerns Bolster social support and reduce isolation Provide health education (including stress management techniques) Refer women to appropriate medical, social, economic, & mental health services Partner with and educate community and providers SHORT TERM OBJECTIVES Empower women & build resilience Promote healthy behaviors & relationships Connect women with services Engage communities (awareness, action, change) ULTIMATE GOAL To improve African American infant and maternal health in California and decrease Black:White health disparities and social inequities among women and infants GOVERNING CONCEPTS 1. Cultural competence: Providing culturally relevant information that is important to African American women and honors the unique history and traditions of people of African descent. 2. Client-centered: Placing the client s own needs, values, priorities and goals at the core of every interaction and activity, recognizing that people have an inherent tendency to strive toward growth. 3. Strength-based: Building on each client s strengths to enrich her, her family and her community by empowering her to make healthy decisions. 4. Cognitive skill-building: Encouraging the client to think differently about her behaviors and to act on what she has learned, recognizing that problem solving is a goal-oriented process. 17 [REV. 7/11]
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Selected MCAH Policy Development Nutrition and Physical Activity Lactation accommodations Healthy Mothers Workplace Childcare and preschools Health-promoting physical activities for youth and families in every neighborhood Support to parents Social connection and physical activity by parents with babies and toddlers in Family Resource Centers Public Health Nursing in the home for 0-5 year olds in Children and Family Services Oral health and health care access Young women s health and access to care Sealants in education and care settings
Challenges Funding from Feds poorly supports primary prevention Staffing does not meet demand Wait list for Field PHN NFP projected to reach perhaps half the demand Policy work Data systems to track program interventions uneven
Thank you!