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CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of California, San Francisco
Why we need a vastly expanded version of maternity care
June 19, 2014Maternity Care Symposium, Sacramento CA Department of Health Care Services and the Institute for Population
Health Improvement, UC Davis Health Systems
Paula Braveman, MD, MPHProfessor of Family & Community MedicineDirector, Center on Social Disparities in HealthUniversity of California, San Franciscowww.ucsf.edu/csdh
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Why we need a vastly expanded version of maternity care
Many pregnant women in California have serious economic/social problems Women on Medi-Cal and Low-income privately insured women
These problems put their health and birth outcomes at risk Health care systems, payers, and providers – working with
other sectors-- need to address these problems
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Maternal and Infant Health Assessment (MIHA)
• Annual statewide-representative mail/telephone survey of postpartum women
• Collaborative effort of California Department of Public Health, Maternal, Child, & Adolescent Health Branch (MCAH) with the Center on Social Disparities in Health, Department of Family and Community Medicine, UCSF
• Acknowledgements: • Michael Curtis, PhD, Acting Chief, MCAH Division of Epidemiology,
Assessment, and Program Development• Kristen Marchi, MPH, MIHA Project Director at UCSF• Monisha Shah, MPH, UCSF & other collaborators at MCAH and
UCSF
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
14.9
43.4
Low-Income Private
1.8
Insurance coverage for prenatal care, CA MIHA 2011-201250 47.5
45
40
35
30
25
20
15
10
5
0
Perc
ent o
f wom
en
Medi-Cal UninsuredPrivate
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
12.2 Medi-CalPrivate
12.3
6.0 5.7
3.4 2.2
Low-Income Private
Relationship stress, CA MIHA 2011-2012
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0Separation or divorce during
pregnancyIntimate Partner Violence
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Medi-Cal 20.8 17.7 Private
Low-Income Private
9.8 10.0
8.3
4.6
Need for counseling/assessment, CA MIHA 2011-2012
25.0
20.0
15.0
10.0
5.0
0.0
Per
ecnt
o fw
omn
in e
ae
ch in
sur
uporg nc
ea
Unwanted pregnancy Depressive symptoms duringpregnancy
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
65.5 Medi-CalPrivateLow-Income Private41.6
17.3 17.2 13.0 11.3 8.5
6.9 3.7
Lack of social/economic support, CA MIHA 2011-2012
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
Not married No practicalsupport
No emotionalsupport
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
1.5 2.3
0.1 0.2
11.2
Medi-CalPrivateLow-Income Private
5.0
6.2
3.2
0.6
Housing problems, CA MIHA 2011-2012
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0Moved bc could notpay rent/mortgage
No regular place tosleep
Homeless
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Private29.2
22.0
6.8
Medi-Cal
Low-Income Private
Food insecurity, CA MIHA 2011-2012
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0Food insecure
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Involuntary job loss and financial strain, CA MIHA 2011-2012
55.9
7.3 3.9
Medi-Cal
Private
Low-Income Private
60.0
24.7
17.1 12.8 10.2
6.2
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
Partner Lost Job R Lost Job Hard to live on income
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
78.9
66.0
46.3
34.0
16.1 15.0 14.317.9
2.2 0.4 0.6
8.3
0-100%101-200%201-300%301-400%> 400%
Poverty/ Near Poverty, CA MIHA 2011-2012
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0Low-Income PrivatePrivateMedi-Cal
s
Parents’ income shapes the next generation’s:• Education• Work• Income
How could income affect health? By shaping options for:
Housing Neighborhood conditionDietExerciseServices (e.g., childcare, transportation, repairs, medical care…) Alleviating stressChronic stress can erode family stability
•••••
••
Income shapes neighborhood options. How could a neighborhood affect health?
Safe places to exercise Access to healthy food Ads for harmful substances Social networks & support Norms, role models, peer
pressure Fear, anxiety, despair, stress Quality of schools Racial segregation tracks
lacks & Latinos into poorer eighborhoods than Whites
Bn
Image: http://www.seattlemet.com/news-and-profiles/publicola/articles/some-rich-architects-mansion.
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
The stress-health link: biologically plausible?
• Advances in neuroscience help elucidate how social factors “get into the body”
• HPA axis, sympathetic nervous system, and immune/inflammatory mechanisms have been demonstrated as responses to stress– Mediators include cortisol, other stress hormones,
cytokines, telomerase
• Chronic stress is a plausible and likely major contributor to both socioeconomic and racial/ethnic inequalities in health
How could stress affect health? One example
HypothalamusCRH
Pituitary GlandACTH
Adrenal GlandsCORTISOL
AFFECTS MULTIPLE ORGANS & SYSTEMS, INCLUDING
IMMUNE SYSTEM
STRESSOR
Center on Social Disparities in Health, University of CA, San Francisco
Behaviors Medical Care
Interactions between genes and experiences
HEALTH
Improving maternal health by addressing the role of social factors across the life course
Economic & Social Opportunities and Resources
Living & Working Conditionsin Homes and Communities
Adapted from Braveman et al., for the Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
We need an expanded version of maternity care
• Both Medi-Cal and low-income privately insured women experience many stressors during pregnancy that cannot be addressed by traditional prenatal care
• Non-low-income privately insured women face fewer challenges and have more resources, but still experience important stressors during pregnancy
• Pregnant & postpartum women require services and supports in multiple sectors
• The health sector must reach out to other sectors and develop new models of maternity care
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
Extra slide on racial/ethnic distribution, if needed
CENTER ON SOCIAL DISPARITIES IN HEALTHUniversity of Cali fornia, San Francisco
6.8
21.7
70.1
58.860.0
50.0
40.0
30.0
43.4
30.2
22.3
10.914.7
0.3 1.43.8
6.4 8.0
0.7
Latina
Racial/ethnic group, CA MIHA 2011-2012
Perc
ent o
f wom
en in
eac
h in
sura
nce
grou
p
American Indian/AlaskanNativeAsian/Pacific Islander
Black
White
80.0
70.0
20.0
10.0
0.0Low-Income PrivatePrivateMedi-Cal
