1. family and parenting
2. motherhood
3. pregnancy

Use of the Life Course Perspective
to Improve Maternal & Child Health Outcomes
Michael C. Lu, MD, MPH
Associate Professor
Department of Obstetrics & Gynecology
David Geffen School of Medicine at UCLA
Department of Community Health Sciences
UCLA School of Public Health
Tulsa, Oklahoma
October 11, 2011
“If you want 1 year of prosperity, grow grain. If you want
10 years of prosperity, grow trees. If you want 100 years
of prosperity, grow people.”
Chinese Proverb
“If you want to grow healthy people, you start by
improving MCH.”
Not a Chinese proverb
Life-Course Perspective
 A way of looking at life not as disconnected
stages, but as an integrated continuum
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
Matern Child Health J. 2003;7:13-30.
Life Course Perspective
 Early programming
 Cumulative pathways
 Use of the life course perspective to
improve MCH outcomes
Early Programming
Barker Hypothesis
Birth Weight and Coronary Heart Disease
1.5
Age Adjusted Relative Risk
1.25
1
0.75
0.5
0.25
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
8.6-10.0
>10.0
Birthweight (lbs)
Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk
of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.
Barker Hypothesis
165
160
155
Systolic Pressure (mmHg)
170
Birth Weight and Hypertension
<=5.5
5.6-6.5
6.6-7.5
7.6-8.5
>8.5
Birthweight (lbs)
Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in
utero and its amplification throughout life. Br Med J 1993;306:24-27.
Barker Hypothesis
Birth Weight and Insulin Resistance Syndrome
18
Odds ratio adjusted for BMI
16
14
12
10
8
6
4
2
0
<5.5
5.6-6.5
6.6-7.5
7.6-8.5
8.6-9.5
>9.5
Birthweight (lbs)
Barker DJP, Hales CN, Fall CHD, Osmond C, Phipps K, Clark PMS. Type 2 (non-insulin-dependent) diabetes mellitus,
hypertension and hyperlipidaemia (Syndrome X): Relation to reduced fetal growth. Diabetologia 1993;36:62-67.
Maternal Stress & Fetal Programming
Prenatal Stress &
Programming of the Brain
 Prenatal stress (animal model)

Hippocampus
 Site of learning & memory formation
 Stress down-regulates glucocorticoid receptors
 Loss of negative feedback; overactive HPA axis

Amygdala
 Site of anxiety and fear
 Stress up-regulates glucocorticoid receptors
 Accentuated positive feedback; overactive HPA
axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.
J Neuroendocrinol 2001;13:113-28.
Prenatal Programming of the
Hypothalamic-Pituitary-Adrenal Axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.
J Neuroendocrinol 2001;13:113-28.
Epigenetics
Epigenetics
Same Genome, Different Epigenome
R.A. Waterland, R.A. Jirtle, "Transposable elements: targets for early nutritional effects on
epigenetic gene regulation," Mol Cell Biol, 23:5293-300, 2003. Reprinted in the New Scientist 2004
Prenatal Programming of
Childhood Obesity
Epidemic of Childhood Overweight & Obesity
25
Children 6-18 Overweight
Percent
20
15
10
5
0
1976-1980
1988-1994
Black
Hispanic
1999-2002
White
Source: National Center for Health Statistics, National Health and Nutrition Examination Survey
Note: Estimate not available for 1976-1980 for Hispanic; overweight defined as BMI at or above the
95th percentile ofr the CDC BMI-for-age growth charts
Prenatal Programming of
Childhood Overweight & Obesity
Prenatal Programming of Childhood
Obesity
Maternal Diabetes &
Intrauterine Hyperglycemia
Intrauterine Hyperinsulinemia (Fetal
Pancreatic β Cells)
Preadipocyte
Differentiation
Adipocyte
Hyperplasia
Prenatal& Postnatal
Hyperleptinemia
Programmed
Insulin
Resistance
Postnatal
Hyperinsulinemia
Hypothalamic
Leptin Resistance
Pancreatic βCell Leptin
Resistance
Hyperphagia
Hyperinsulinism
Adipogenesis
Cumulative Pathways
Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
Allostasis:
Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Allostastic Load:
Wear and Tear from Chronic Stress
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Stressed vs. Stressed Out
 Stressed
 Stressed Out

Increased cardiac output

Hypertension &
cardiovascular diseases

Increased available
glucose

Glucose intolerance &
insulin resistance

Enhanced immune
functions

Infection & inflammation

Growth of neurons in
hippocampus &
prefrontal cortex

Atrophy & death of
neurons in hippocampus
& prefrontal cortex
Allostasis & Allostatic Load
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
Rethinking Preterm Birth
Preterm Birth
36%
Infant
Mortality
12.3%
50%
Term Births
Neurologic
Disabilities
Preterm Birth
NCHS 2010
Racial & Ethnic Disparities
Preterm Births < 37 weeks
Percent of Live Births
Year 2010 Goal
NCHS 2010
Racial & Ethnic Disparities
Very Preterm Births < 32 Weeks
Percent of Live Singleton Births
Year 2010 Goal
NHS 2010
Racial & Ethnic Disparities
Infant Mortality
Deaths Per 1,000 Live Births
Year 2010 Goal
NCHS 2010
Rethinking Preterm Birth
Vulnerability to preterm delivery may be traced to not only
exposure to stress & infection during pregnancy, but host
response to stress & infection (e.g. stress reactivity &
inflammatory dysregulation) patterned over the life course
(early programming & cumulative allostatic load)
Preterm Birth &
Maternal Ischemic Heart Disease
Smith et al Lancet 2001;357:2002-06
Kaplan-Meier plots of cumulative probability of survival without admission or death
from ischemic heart disease after first pregnancy in relation to preterm birth
Use of the Life Course Perspective
To Improve MCH Outcomes
1. Invest Early
“If you want to grow healthy people, you start by
improving MCH.”
Not a Chinese proverb
Too Much, Too Late?
Public Expenditures Children 0-17,
Sweden, 1995
“If you want to improve MCH, you start by improving
women’s health.”
Not a Chinese proverb
Put the W Back in MCH
Not Only During Pregnancy,
But Before, Between, and Beyond
Pregnancy
PRECONCEPTION &
INTERCONCEPTION
CARE
2. Improve Healthcare
Quality
Prenatal Care 1.0
Receptionist
& Clerks
Medical
Assistant
Nurse Manager
Ultrasound
Tech
Prenatal Care 2.0
High Risk
OB
Primary &
Specialty Care
WIC
Medical
Assistant
Receptionist
Teratogen
Information
Services
Social
Services
Ultrasound
Tech
Nurse Manager
Family
Support
Oral Health
Mental Health
Prenatal Care 3.0
High Risk
OB
OB
Hospitalist
Dietician
& WIC
Primary &
Preventive
Services
Health
Education
Ultrasound
Center
Mental
Health
Family Support
& Social Services
Family
Planning
Oral
Health
Genetic Counseling
& Prenatal Diagnosis
Specialty Clinics
3. Reinvent Public Health
Not just create stop-gap services,
But build integrated systems that work
Assure conditions in which
all Tulsans can be healthy
Harlem
NMPP
MCH LifeCourse
Organization
Housing
Medical
Care
Childcare
Jobs
Healthy
Food
Parks
and
Activities
Alameda
County
Building
Blocks
Collaborative
Economic
Justice
Education
Residents
Clean
Air
Policy
Makers
Safe
Neighbor
-hoods
Preschool
Transporta
tion
Best Babies Zone
Give Every Baby a
Best Chance in Life
Community
Development
Economic
Development
Educational
Development
Best
Babies
Zone
Health
Development
Place-Based
Harlem Children’s Zone
Systems
Approach
Systems Approach
•
•
•
•
Health development
Educational development
Economic development
Community development
Life-Course
Perspective
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
Matern Child Health J. 2003;7:13-30.
Closing the Black-White Gap in Birth Outcomes:
A 12-Point Plan
1. Provide interconception care to women with prior adverse pregnancy outcomes
2. Increase access to preconception care for African American women
3. Improve the quality of prenatal care
4. Expand healthcare access over the life course
5. Strengthen father involvement in African American families
6. Enhance service coordination and systems integration
7. Create reproductive social capital in African American communities
8. Invest in community building and urban renewal
9. Close the education gap
10. Reduce poverty among Black families
11. Support working mothers and families
12. Undo racism
Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes:
A life-course approach. Ethnicity and Disease 2010.
Our Promise
If you live in a BBZ,
your baby will have access to
 Best
 Best
 Best
 Best
healthcare
education
opportunities
community
Best Babies Zones
If you live in a BBZ,
your baby will have the best
chance in life
Best
Healthcare
Best Healthcare
•
“Medical home” for women’s health
•
•
•
•
Preconception & interconception care
Quality improvement in prenatal & intrapartum care
Service coordination & systems integration
Cost-control platform
Triple Aims
• Improve the health of the population;
• Enhance the patient experience of care
(including quality, access, and reliability);
and
• Reduce, or at least control, the per capita
cost of care
The Best Care, for the Whole Population, at the Lowest Cost
Best
Education
Pipeline to Success
Best Education
•
Pipeline to Success
•
•
•
•
•
“Baby college”
Quality early childhood education
Promise academy
Youth development
Health promotion in schools
Best
Opportunities
Change Concepts
• Opportunity Incubator
• Macroeconomic policies
•
•
•
•
•
•
•
•
•
Community Reinvestment Act
Housing development
Empowerment Zones
New Markets Tax Credit
Community Change Initiatives
Microfinance
Business incubator & job training
Financial literacy & asset development for families
High-function safety net programs
Change Concepts
• Opportunity Incubator
•
•
•
•
•
Macroeconomic policies
Microfinance
Business incubator & job training
Financial literacy & asset development for families
High-function safety net programs
Best
Community
Change Concepts
• Healthy Community
• Clean air and water (environmental
justice)
• Healthy foods & physical activities
• Fatherhood & Family
• Social capital
• Racial equity
All this will not be finished in the first 100
days. Nor will it be finished in the first
1,000 days, nor in the life of this
Administration, nor even perhaps in our
lifetime on this planet. But let us begin.
John F Kennedy (1961)