Transcript Slide 1

March of Dimes
Models of Policy
& Advocacy
Promoting Healthy
Birth Outcomes
October 27, 2009
Amy Mullenix, MSPH, MSW
Acknowledgments
Thank you to…
Anna Bess Brown, MPH
Director of Program Services and Public Affairs
March of Dimes, North Carolina Chapter
Robert Meyer, PhD
Director
North Carolina Birth Defects Monitoring Program
Objectives
1. Identify factors that contribute to birth defects
2. Identify factors that contribute to a reduction in birth
defects
3. Understand the importance of full-term pregnancies
4. Learn skills needed to advocate for healthy women and
positive birth outcomes
5. Identify collaborative ways to integrate services to
promote preconception health
6. Identify important components of a collaborative
community action plan to improve birth outcomes
Why it matters
• 1,066 babies died in 2008 in North Carolina
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Prematurity & other birth-related conditions (528)
Birth Defects (232)
Sudden Infant Death Syndrome (136) 39% increase
Unintentional Injuries: motor vehicle, drowning,
suffocation, Shaken Baby, falls, poisoning, others
– Intentional Injuries: abandonment, homicide
• Infant mortality accounts for 67% of child fatality in
NC
Background & overview
• Reducing birth defects and prematurity are
central to the missions of March of Dimes
and the North Carolina Folic Acid Council
• Advocacy efforts and policies have played an
important role in impacting health outcomes
in these areas
• Will give overview of these topics, then
discuss advocacy’s role
Birth defects
• Definition: a structural, functional or chemical
abnormality that is present at birth
• Second leading cause of infant death and childhood
disability
• 1 in 33 babies is born with serious birth defects (3%)
• In NC, each year more than 3,500 infants are born with
major birth defects
– Cardiovascular defects are most common (36% of all
birth defects) – 1 in 70 infants affected
– Central nervous system defects – 1 in 280 affected
North Carolina Birth Defects Monitoring Program, 2003
Causes of birth defects
• The causes of most birth defects are unknown
• Some linked to: genetic factors, maternal illnesses,
certain medications, environmental influences
• Some are entirely preventable: fetal alcohol
syndrome, congenital rubella syndrome
• Some are preventable in certain cases: neural tube
defects
Neural tube defects
• Conclusive evidence demonstrates that if
taken daily before pregnancy, folic acid can
prevent up to 70% of NTD cases from
occurring
• The neural tube is fully formed by the 28th
day of pregnancy, before most women know
that they are pregnant
Neural tube defects
• 50% of all
pregnancies are
unplanned
• US Public Health
Service recommends
that every woman
of childbearing age
consume 400 mcg of
folic acid daily
Congenital heart defects
• Most common type of birth defect
• Studies have found that use of MV containing folic acid is
associated with a 60% reduction in risk for congenital heart
defects (Hungarian study) and a 25% reduction (Atlanta study)
– Czeizel, AE., Eur J Obstet Gynecol Reprod Biol, Vol. 78, 1998.
– Botto, LD et al., Am J Epidemiol, Vol. 151, 2000.
– Scanlon, KS et al., Epidemiology, Vol. 9, 1998.
• American Heart Association recommends that “...[those] that
wish to become pregnant should take a multivitamin with folic
acid daily.”
– Recommendation is endorsed by the American Academy of
Pediatrics
– Jenkins, KJ et al., Circulation, Vol. 115, 2007.
Cleft lip with or without cleft palate
• Folic acid deficiency is known to result in facial
clefts in rodents; association in humans is
unclear and research findings have been
inconsistent
• Recent Norwegian study found that folic acid
intake of > 400mcg/day around conception and
during early pregnancy resulted in a 33%
reduction in cleft lip with or without cleft
palate in humans
– Wilcox, AJ et al., British Medical Journal, Vol. 334, 2007.
Pre-eclampsia
• 1,835 pregnant women who took a daily MV at least
once per week prior to conception through 1st
trimester
– 45% reduction in risk of preeclampsia among MV users, after
controlling for confounding factors
– If BMI < 25, prepregnancy MV use was associated with a 71%
decreased risk of preeclampsia after controlling for confounding
factors
– No relation between MV use and preeclampsia in overweight
women thus suggesting no protective effect
• “If our findings are confirmed by others, they
highlight a modifiable risk factor for preeclampsia
for which there is a relatively inexpensive, safe, and
straightforward intervention available.”
– Bodnar, LM et al., Am J Epidemiol, 164(5), 2006.
Preterm birth
• Recent study published in PLoS Medicine (5/09)
– Observational study
– 38,033 participants in an NIH trial
– Singleton pregnancies w/ no complications
• Findings:
– Folate supplementation for at least one year prior to
conception was linked to a 70% decrease in very early
preterm deliveries (20 to 28 weeks gestation) and as much
as a 50% reduction in early preterm deliveries (28 to 32
weeks)
– No effect was found for pregnancy duration of more than
32 weeks or for supplementation lasting less than 1 year
prior to conception
– Effect was found for patients with and without a history of
preterm birth
Preterm birth overview
• Almost 13% of all
births in North
Carolina were
premature in 2008
• North Carolina ranks
in bottom 10 in U.S.
• Significant racial
disparity
Risk factors for preterm birth
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Maternal age
Multiples – 5 times more likely to have early birth
Previous preterm birth
Genitourinary infections
Smoking, drug use
Obesity, diabetes, hypertension
Uterine/cervical abnormalities
Stress
Maternal race/ethnicity and preterm birth
• Mothers who are African American are 2.5 times
more likely to have an early birth than other women
• Preterm birth/low birthweight is the leading cause
of death for African American infants
• 18.7% of infants born to non-Hispanic black mothers
in 2005 were preterm (versus 12.1% to non-Hispanic
white mothers and 12.1% Hispanic)
2004-2006 data, March of Dimes, Peristats
Maternal race/ethnicity and preterm birth
• Mothers who are African American are 2.5 times
more likely to have an early birth than other women
• Preterm birth/low birthweight is the leading cause
of death for African American infants
• 18.7% of infants born to non-Hispanic black mothers
in 2005 were preterm (versus 12.1% to non-Hispanic
white mothers and 12.1% Hispanic)
2004-2006 data, March of Dimes, Peristats
Preterm birth: No easy answers
• Complex problem with multiple causes and
interactions at play
• A syndrome in which different disorders contribute
to the initiation and progression of labor
• Interactions among biological, genomic and social
factors have not been well evaluated
• There will be no silver bullet
• The most effective interventions may well be
BEFORE a woman becomes pregnant
UNC Center for Maternal & Infant Health, 2009
Prevention of preterm birth
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Folic acid supplementation
Smoking cessation
Alcohol/drug use cessation
Weight management
Progesterone therapy
Early and adequate prenatal care
Cost of healthy birth = $3,640
Medicaid data, North Carolina
Infant Condition
Number of
Infants
Average
Cost
Total Cost
Late Preterm
4,546
$ 8,032
$ 36,515,327
Preterm
6,686
$19,781
$132,255,522
Very Preterm
1,332
$59,320
$ 79,013,727
Very Low
Birthweight
1,217
$63,877
$ 77,738,693
Birth Defect
1,622
$34,713
$ 56,304,736
Infant Death
485
$35,327
$17,133,818
Neonatal Death
(< 28 days of life)
263
$16,581
$
3,523
$36,976
$130,268,583
At Risk Birth
4,360,854
Division of Medical Assistance, 2009
Policy & advocacy
• What does policy have to do with
health?
• What does advocacy have to do with
policy?
• How can they be used promote healthy
birth outcomes?
Role of policy
Policy 101
• Policy-making is not a rational process.
• Policy-making is not always based on data.
• If policy-making were rational, we would not need
advocacy …lawmakers would objectively survey
needs of citizens and act accordingly.
• Example: legislative funding for Folic Acid Campaign
Advocacy
Advocate: a person who speaks or writes in support or
defense of a person, cause, etc. (usually followed
by of): an advocate of peace.
Advocates attempt to change or influence policy by:
• Protest and demonstration
• Letters and phone calls
• Lobbying
• Personal relationships
Advocacy
• What is needed to
advocate for healthy
birth outcomes?
– Information,
including financial
cost data
– Articulate
expression
– Coordinated efforts
– Active voters
Advocacy strategies
Be Informed & thoroughly prepared
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Most legislators respond to the power of informed
opinion, particularly when the opinion is shared by a
significant number of his/her constituents
Study the issue and its history – pros and cons
Know your legislator's views and voting record on the
issue or similar issues, if possible
Know how it will affect the legislator's district if such
information is possible to discern
Know the status of your legislation or issue
Advocacy strategies
Express your views
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Be positive
Be sympathetic to their position or opinion
Remember, public officials are elected to represent
the interest of all the public
Use meetings, phone calls, and written
correspondence
Meetings
• Arrange a meeting in advance, if possible
• During the meeting, be specific, concise and polite.
Always thank the legislator for his or her time
• Follow up your visit with a thank you note
• Invite legislators to visit your program; get them on
the agenda as speakers for special events and ask
them to give you a legislative update
Phone calls
• Make a list of the points you wish to convey and tell
the legislative assistant why you are calling
• When talking with the legislator, be specific,
concise and polite
• Always thank the legislator for his or her time
Written correspondence
• Discuss one issue per letter or e-message. Avoid
form letters
• State your position on the bill by reasons and facts
• Request the legislator’s position on the issue
• Again, be specific, concise and polite
• If referring to a specific bill, use the bill number
and the short title in your letter or e-message
• Always thank the individual for his/her
consideration
• Be judicious in the use of e-mail messages
Coordinated efforts
• No elected official can afford to ignore the weight
of public opinion; there is power in numbers
• Get others in your community who share your views
to contact the public official as well
• Join with other advocacy organizations to determine
strategies, common language & priorities
• Develop clear advocacy agenda for each
year/session so that all partners are on the same
page
Examples of advocacy
Examples of advocacy
Examples of advocacy in NC
• March of Dimes has ongoing advocacy efforts
through Public Affairs Advocacy Network (please
join!) and an Advocacy Day held each year in the
spring
• Partners:
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Action for Children-North Carolina
North Carolina Alliance for Health
North Carolina Justice Center
Covenant with North Carolina’s Children
March of Dimes advocacy
2007
• Increase funding for NC Birth Defects Monitoring
Program by $200,000
• Make state buildings smoke-free
2008
• Add cystic fibrosis to newborn screening panel
• Make state vehicles & perimeter of state buildings
smoke-free
• Continue funding statewide folic acid campaign
March of Dimes advocacy
2009
• Study a Medicaid waiver to cover interconception
care for high-risk women
• Fund multivitamin distribution program
• Prohibit smoking in public and workplaces
• Passed Healthy Youth Act to provide comprehensive
sexuality education in public schools
Results of advocacy
• Multivitamin distribution program
– Used data about what worked in western North Carolina
– Used advocacy network to make visits, calls, letters
– Coordinated effort with broad support and a champion
• Resulted in statewide program to start November 1
• Program is example of a collaborative way to
integrate services to promote preconception health
– All health departments and safety net clinics eligible; can
use any clinical setting to distribute free multivitamins to
women of childbearing age
Community Action Plans
• Don’t re-invent the wheel
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Local Infant Mortality coalitions
Healthy Carolinians
NC Preconception health strategic plan
Local health departments
Community organizations
• Work with existing partners
Community Action Plans
• Use data to drive decisions
– NC State Center for Health Statistics – PRAMS, BRFSS
– NC Birth Defects Monitoring Program
• Develop a strategic plan and timeline
Thanks!
Questions…
Thoughts…
Ideas…
Amy Mullenix
[email protected]
919-424-2158