Addressing socio-economic factors to improve birth outcomes in Connecticut
Promoting a “whole person, whole family, whole-community systems approach”7 to improving birth outcomes, Coalition members recommend expanding efforts from traditional healthcare-centric approaches to multi-level cross-sector interventions and policies that aim to prevent health inequities by acting in the very community settings in which daily life occurs (i.e. schools, day care centers, workplaces, WIC offices, parks and recreational facilities, churches, dining facilities, detention centers, courthouses, housing units, etc.) By addressing socio-economic conditions such as poverty, racism, education, housing, isolation, fractured families, food security, trauma and violence; legislators, providers, leaders, and community members can build upon protective factors and mitigate risk factors affecting the life course of women, children, and their families, positively impacting birth outcomes and the health trajectory of generations to come.5,8
Recommendation 1A: Raise awareness among legislators, leaders, and administrators about social determinants of perinatal health and the life course perspective.
The Life Course Perspective offers an opportunity to view health as an integrated continuum across a person’s life course, rather than a series of disconnected stages unrelated to each other. This perspective, supported by the most current research, highlights the complex interactions of environmental, biological, social, psychological, and behavioral factors contributing to a person’s health across his/her life and, through resulting genetic modifications, the health outcomes of the offspring.7
The Life Course Perspective, therefore, encourages an intergenerational and multi-sectoral approach to improving the health and wellbeing of our communities. To this aim, non-traditional holistic approaches to improving perinatal health disparities are essential, as is the need to successfully integrate policies, systems, funding streams, and organizational partners from diverse sectors serving families in all aspects of their lives.
Tier 1 Recommendations: Addressing Socio-Economic Factors
A. Raise awareness among legislators, leaders, and administrators about social determinants of perinatal health (intended holistically to include oral and mental health9), and the Life Course perspective
B. Invest in preventing and mediating early life trauma and violence
C. Identify opportunities to reduce stressors affecting families in the inter-conception period
The state of Connecticut has a number of organizations and agencies that have been working tirelessly to improve the health and wellbeing of families across our territory. Yet, too many times, efforts and successes have been “siloed”, at times duplicated, and often challenged by limited resources. Coalition members, supported by current research, believe that for birth outcomes to improve in our state, we must act on interventions and policies that require much greater systems integration.
Effective systems integration calls for nontraditional partners from a number of sectors, public and private, to engage in a common agenda, with shared measurement systems, integrated funding streams, clear ongoing communications, mutually reinforcing activities, and clearly identifiable lead organizations that can mobilize financial resources and political will, coordinate community outreach and cross-agency communications, champion an overall strategic direction, and manage data collection and analysis.10
Since the early stages of implementation of the Patient Protection and Affordable Care Act (PPACA), Connecticut has been at the forefront of redesigning a statewide integrated healthcare system with the aim of improving the delivery, efficiency, and efficacy of health care services. Maternal and Child Health (MCH) practitioners and advocates in Connecticut have the opportunity to engage with legislators, leaders, and administrators in the conversation about systems integration (vertical, horizontal, and longitudinal)8,10 to go beyond the traditional health care services, minimizing isolated impact, and capitalizing on evidence supporting the Life Course Perspective and the role that social determinants play in shaping health inequities and preventing growing health care costs.
Recommendation 1A: Emerging and promising examples
A New Way to Talk about Social Determinants
When planning to advocate for policies impacting social determinants of health, Connecticut practitioners may consider the work completed by the Robert Wood Johnson Foundation. This organization has shared research-based resources on effective message framing on social determinants that resonate across the political spectrum.
Measuring Life Course Indicators
As more strategies to improve perinatal health outcomes become guided by the Life Course Perspective, national agencies have found it necessary to define effective ways to measure success. After a lengthy multi-state collaborative project, the Association of Maternal and Child Health Programs (AMCHP) has now become the official repository for the materials produced under the umbrella of the Life Course Metrics Project. Connecticut legislators, leaders, and administrators may appreciate learning about the growing prominence of data tied to early childhood and early life services, family and community wellbeing, economic experiences, discrimination and segregation, and their association with birth and lifelong health outcomes across generations. Another similar effort at the national level is the Child Opportunity Index hosted by diversitydatakids.org and mapping diverse levels of opportunities for child wellbeing across major metropolitan centers in the United States (US), including the greater Hartford, New Haven, and Bridgeport metropolitan areas. There have also been valuable efforts made to increase the usability and access of publicly available data in State of Connecticut. An example is DataHaven.org, a member organization of the Connecticut Data Collaborative, which seeks to compile and share data in visually compelling ways to inform decision- making and policy initiatives. Another effort aimed at linking health outcomes data, including perinatal health outcomes specifically, with social determinants such as housing, environmental quality, employment, community safety, education, economic security, and civic involvement at the community level, is the Health Equity Index. Efforts should be made to sustain this Connecticut- focused and Connecticut-made tool, which was the first of its kind in the nation, and which allows users to visually identify, through GIS mapping, the geographic communities most impacted by social determinants of health.
Using Health Information Technology (IT) to Go Beyond Electronic Medical Records
Well before becoming the current Maternal and Child Health Bureau (MCHB) Associate Administrator, Dr. Michael Lu was the lead author on an article titled “Innovative Strategies to Reduce Disparities in the Quality of Prenatal Care in Underresourced Settings.” where he advocated for, among other strategies, the use of health IT to improve continuity of patient medical records, promote spatial mapping of access gaps, enhance health education, and facilitate service integration.
One promising example of health IT solution that may facilitate service integration and promote a “whole person, whole family, whole community” throughout the life course approach is the WellFamily System developed by Go Beyond. By securely sharing one standard system of input, accountability and flow, social service agencies, schools, court systems, medical providers, and other partners providing services to individuals and families across the life course, can seamlessly ensure a greater level of integration of wrap-around services, avoiding costly duplication and time delays, and potentially improving outcomes.
Recommendation 1B: Invest in preventing and mediating early life trauma and violence.
The effort of addressing socio-economic factors impacting the health and wellbeing of the state’s population would not be complete without making a concerted effort to prevent and mediate early life trauma, violence, and discrimination that are particularly prevalent in some communities. Cumulative traumatic events, such as witnessing or being a victim of violence or abuse, can lead to alterations of the central neurobiological system and has been associated with higher chances of developing mental health disorders in childhood, as well as long after entering adulthood.11–13 Substance abuse, alcoholism, family dysfunction, sexual risk-taking behaviors, depression, and anxiety are but some of the lifelong consequences of early life exposure to adverse experiences and cumulative traumatic stress. Additionally, research has demonstrated links between early life trauma and inflammatory responses giving rise to autoimmune diseases, as well as higher propensity to suffer from obesity, heart disease, cancer, and other illnesses. Cumulative stress experienced from the early stages of life and throughout a woman’s lifetime has been increasingly linked to poor birth outcomes, through a biological mechanism known in the Maternal and Child Health (MCH) community as “weathering.” 8,14–22
While the Adverse Childhood Experiences Survey (ACES) has been a powerful tool used to build a strong body of research surrounding the importance of preventing and mediating early life trauma, critics of ACES argue its potential shortcomings where issues such as experiencing chronic or episodic poverty, food and housing insecurity, are not included in the list of adverse experiences but should.23 Coalition members are cognizant of the powerful data provided by ACES, yet are also focused on elevating and contributing to the defeat of poverty affecting children and their families, as they understand the intricate connection and vicious cycle permeating the daily reality of poverty interlaced with and often fueled by mental illness, violence, trauma, and poor physical, emotional, behavioral, and social wellbeing.
In a state that ranks as one of the wealthiest in our country, nearly a third of its children are living at or below 200% of the federal poverty level, with as much as half of urban core children experiencing poverty and family economic insecurity.8 Members of the Coalition to Improve Birth Outcomes feel strongly about the need to scale up evidence-based efforts to reduce poverty and economic inequality, increase housing stability, and reduce exposure to other critical sources of early life trauma such as domestic violence, family dysfunction, emotional, sexual, and physical abuse, child neglect, discrimination, and neighborhood violence.
Recommendation 1B: Emerging and promising examples
Roca Intervention Model
Based out of Massachusetts, this evidence-based intervention model seeks to interrupt the vicious cycles affecting youth at high risk for incarceration and recidivism. Through cognitive-restructuring and skills development during an initial two year program, participants then benefit from a subsequent two year period of supportive follow-up. This model provides services to at-risk young males, as well as to at-risk young mothers. Roca’s model is based on the theory that “when young people are re-engaged through positive and intensive relationships they can gain competencies in life skills, education and employment that keep them out of prison and move them toward living out of harm’s way and toward economic independence.” The program outcomes are promising in terms of program engagement, reduced incarceration, and continued employment and self-sufficiency.25
Nurturing Families Network (NFN)
The Nurturing Families Network (NFN) is a free, voluntary resource for first time parents offered through three options: 1) home visits for new parents who are at risk for abusing/neglecting their child; 2) parenting support groups designed to identify and address challenges and celebrate the successes of parenting; and 3) Nurturing Connections that match new parents with over the phone support and assistance.
Connecticut Home Visiting Plan
Families in Connecticut with young children often struggle to overcome challenges. The state helps provide supports to many of these families in their homes through funding, program support and oversight, and coordination or delivery of services. Legislation in Public Act 13-178 required the OEC, through the Early Childhood Education Cabinet, to provide recommendations for implementing the coordination of home visiting programs within the early childhood system by December 1, 2014. To view the report, click here.
Recommendation 1C: Identify opportunities to reduce stressors affecting families in the inter-conception period.
The early postpartum period, as well as the time between pregnancies (a.k.a. interconceptional period) have been documented as being critical periods for children, their parents, and the family unit as a whole. Stressors are not uncommon, and in fact can be heightened during this period, especially when parents of young children are not embedded in a strong social support network, and when they do not have access to comprehensive family-supportive policies and programs such as paid parental leave, affordable and high quality childcare, breastfeeding-friendly workplaces/schools, and safe communities ripe with opportunities for families to positively impact and support each other.
Despite the dramatic changes in workforce composition in our country, with many more dual income families and single parents working outside the home, very few changes have occurred at the societal level to align workers’ needs with organizational and workplace policies. For example, typical school days still end hours before parents return from work and summer breaks continue to be longer than most workers’ yearly paid time off.26
Situations are further aggravated when parents need to entertain more than one low-paying job, in order to make ends meet. Role strain and work-related stress continue to be a documented factor impacting marital relationships, child development, and household stability, as well as a contributor to the development of chronic stress affecting physiologic and emotional health, including preconception and interconception health.26,27
At the current moment, some working families in Connecticut are able to take advantage of the federal Family and Medical Leave Act (FMLA), which became effective in 1993, and allows eligible employees to take up
Whenever the employer required the workers to work overtime, the group of women [factory workers] had their babysitters drop their children off at their workplace. When the security guards saw the children, they were dumbfounded, and when the women were confronted by their managers, they said, “I would be put in prison and my children would be taken away from me if I leave them home alone — I cannot do that. You told me to stay, so they’re going to come here.”
to 12 weeks of annual job-protected unpaid leave to bond with a new child.28 Unfortunately, the loss of income has been cited as a common reason for not taking advantage of this important benefit.29 Additionally, strict FMLA eligibility criteria have limited its reach to approximately 50% of workers in the US, often leaving a large proportion of working poor without coverage, in fact, as documented by the Commission on Family and Medical Leave, “employees who fare best in covering lost income during leave-taking are employees with high family incomes, salaried employees, union members, highly educated employees and white employees.”30
Not having adequate and equitable access to family-supportive policies can place working families at a substantial disadvantage when it comes to maintaining a balance between keeping a steady job and paying the bills, and establishing important foundations for healthy family dynamics throughout the life course.30 This inevitably sets the stage for a broad range of preventable socio-economic and health inequities. Family Medical Leave Insurance, currently being considered in the state of Connecticut, has the potential to significantly reduce the number of families who fall into poverty shortly after the birth of a child, while also facilitating conditions for the initiation and establishment of optimal breastfeeding, and parent-infant bonding.28,31
Coalition members, supported by current research, believe that for birth outcomes to improve in the state, we must expand access to family-supportive policies and programs that reduce stressors in the interconceptional period, allowing new parents to continue being productive members of their communities, while also enhancing and not sacrificing their own health and wellbeing, and that of their young children.
Recommendation 1C: Emerging and promising examples
Time-flexible Work Policies
Data from a large national representative sample of employees from a variety of different types of employment, show that employers offering the most time-flexible work policies registered the highest proportions of employees with greater levels of job satisfaction and loyalty, as well as fewer unplanned absences, missed deadlines, and tardiness, along with fewer reported symptoms of stress.26 Flexible work policies come in a variety of configurations, and include among others: flexible start and end times, compressed workweeks, job sharing, part-year work, telecommuting, predictable schedules, and alternative worksites.32,33
Leveraging Smart Phone Technology and Social Networking to Increase Social Capital
Aimed at facilitating the mother-infant bond, along with increasing social connectedness amongst local New Haven mothers, MoMba is a modern and creative social networking-based solution developed by the New Haven MOMS Partnership.
Building Community Connectedness and Reducing Parental Isolation
Connecticut has a track record of establishing dynamic community-based resource centers serving families across the state. These Family Resource Centers, usually located in public schools, offer parents and caregivers of young children opportunities for social interaction, education on child development, resource and referral services, family literacy programs, playgroups, and childcare. The Brighter Futures Family Centers located in six Hartford neighborhoods, offer similar services to families even during weekend and evenings hours, thus expanding access to much needed resources and support.
Choosing to intervene even earlier in a family’s lifespan, the Developing Families Center located in Washington D.C., provides access to group prenatal care, midwifery services, and a stand-alone birth center, in addition to more traditional family resource center services, thus helping women and their families to establish social ties and reduce isolation even before their children are born.
Taking a different spin on traditional family resource centers typically located in neighborhood schools or community centers, the Moms HUBS in New Haven will be located in local businesses (i.e. grocery stores), and will be branded as a “one-stop solution center” where mothers can consult with Community Mental Health Ambassadors; be connected to employment and job training resources; receive diapers and other basic need items.
Paid Parental Leave
Actively supported by the Connecticut Association for Human Services (CAHS), Connecticut Women’s Education and Legal Fund (CWEALF), the Connecticut Commission on Women, Children and Seniors, among others, the 2013 Legislative Session ended with the establishment of a Task Force charged with studying the feasibility of offering short-term paid benefits to working individuals and families under the Connecticut Family and Medical Leave Insurance (FMLI) program. The implementation of FMLI would allow Connecticut to join the ranks of other progressive family-supportive states such as California, New Jersey, and Rhode Island. The Task Force voted to provide recommendations that include:
Expanding the reach of FMLI to all employers (not just those with 50 or more employees)
Expanding access to more employees by making an employee eligible for the leave once they have earned $9,300 in a 12-month period – even if some of the earnings were from a different employer
Providing employees out on leave 66% of their base weekly salary
Allowing up to six weeks of paid leave per year
These recommendations are expected to become a top issue in the 2015 legislative session, with businesses and organized labor advocates becoming very engaged on the topic. Coalition members may want to consider how involved they intend and are able to be, as they strive to improve birth outcomes by, among other means, relieving financial stressors, enhancing parent-infant bonding opportunities, and facilitating optimal breastfeeding conditions for families in the early postpartum period.
Refer to Appendix A for additional Tier 1 strategies supported by Coalition members.