D.C. Director of Health's New Plan to Champion Maternal and Child Health

May 24, 2018|11:52 a.m.| ASTHO Staff

LaQuandra Nesbitt, MD, MPHOn April 18, the District of Columbia Department of Health (DC Health) released the “Perinatal Health and Infant Mortality Report,” a comprehensive plan to improve the health and well-being of mothers and babies in Washington, D.C. Earlier this month, as part of National Women’s Health Week, ASTHO spoke with LaQuandra Nesbitt, MD, MPH, director of DC Health, about the District’s approach to perinatal health, collaboration with community health centers, and opportunities to address disparities in maternal and child health outcomes.

In 2015, DC Health adopted a new approach to addressing perinatal health and infant mortality disparities, emphasizing a lifespan perspective and the social determinants of health. Since then, what have been some of the most noticeable changes or shifts in thinking across the agency?

The DC Department of Health’s work on perinatal health has played a key role in improving the health of the District’s moms and babies over the past decade. 

As our city has grown and numerous citywide indicators of health have improved, we know that some of our residents have been left behind. We developed a common framework with a clear vision that is rooted in our local data which show that maternal complications of pregnancy and prematurity are the leading causes of infant mortality. Based on this, we expanded our approach to infant mortality to a broader perinatal health approach.

Our framework to improve perinatal health outcomes is based on the overarching goal to ensure every community understands its health risks and role in improving perinatal health outcomes. It includes seven core priorities:

  • Every teenage girl and woman in D.C. is in control of her reproductive health.
  • Every pregnant woman receives patient-centered, high quality prenatal care beginning in the first trimester.
  • Every healthcare provider has the tools and resources they need to provide quality care and manage complex social needs of women and infants.
  • Every healthcare facility providing maternal and infant care has the tools and resources to practice evidence-based healthcare and to document quality improvement and quality assurance activities.
  • Every newborn receives high-quality neonatal care in the hospital and outpatient setting.
  • Every parent has the life skills and resources needed to nurture and provide for their family.
  • Every infant, mom, and dad has a safe and healthy environment to thrive and receive the support they need to promote early childhood development and learning. 

Since we launched this framework, it has informed our programs and our funding, and has been at the forefront of our communications strategy on perinatal health. Our staff now understand their work in the context of this framework and they have made new connections internally and externally. In our role as a convener and as the chief health strategist for the District, the framework creates a structure for policy and funding discussions.

Another key change is that the framework has allowed us to highlight gaps in perinatal health in the District. To that end, Mayor Muriel Bowser has devoted $1.6 million to the B.A.B.I.E.S bill (Better Access for Babies to Integrated Equitable Services Act of 2018) in her FY19 budget which includes four key provisions to reinforce the goal of providing high-quality services for pregnant women, mothers and newborns.

To help women achieve their optimal health before pregnancy, one of the strategies underway at DC Health involves integrating the One Key Question tool into electronic health record systems at community health centers. What outcomes are you hoping this strategy will generate?

I see this as a critical strategy for the District to reduce unintended pregnancies, and improve birth outcomes overall. District women who smoked during pregnancy, who were overweight or obese, or who had diabetes prior to pregnancy were far more likely to experience poorer perinatal health outcomes such as prematurity, low birth weight and infant mortality. One Key Question (OKQ) encourages all women’s health providers to routinely ask: “Would you like to become pregnant in the next year?” From there, providers can support women who choose to become pregnant to achieve their optimal health through smoking cessation support, weight management and control of chronic disease. For women who respond negatively, providers can help them choose the most effective method of contraception that meets their needs and preferences.

Leveraging decision supports and clinical information systems has been shown to increase the use of evidence-based clinical interventions. DC Health will work closely with providers to support the routine use of OKQ in practice.

Tell us about DC Health’s role in championing place-based initiatives throughout the District.

In recent years, DC Health has developed specific initiatives aimed at establishing safe and healthy environments that will allow District babies to thrive.  Through feedback from families and communities, we’ve recognized a need in the District to offer more than one type of family support program in order to meet the unique needs of all our families. Evidence-based home visitation is a critical tool in our toolbox, but not all families choose or prefer a home visit. Alternative methods of family supports, such as enhanced case management through medical homes and place-based initiatives, are promising ways to meet the diverse needs of District families.

Through place-based initiatives, DC Health strives to create neighborhoods that are places where children and families can succeed and grow. Place-based initiatives are also an innovative way to reach and serve multiple generations within families. DC Health has recently provided funding and partnership for place-based initiatives in five District communities. These initiatives intend to achieve improved health, education and economic outcomes through effective and sustainable neighborhood transformation. Current projects include:

  • Smart From The Start (Smart) is a family support and community engagement organization promoting the healthy development of children located in the Woodland Terrace community (Ward 8). Smart engages, educates, and empowers parents to step confidently into their role as their child's first teacher and to achieve goals to increase their self-sufficiency. Smart's multi-disciplinary team works with families to create home and community environments conducive to healthy child development while addressing the social determinants of health that impact the overall wellness of families and communities. Woodland Terrace families participate in individual and group programming that addresses trauma and stress, financial literacy classes, job training programs, and mental health counseling while also learning to address their children's health and development.
  • The Early Childhood Innovation Network (ECIN) Place-Based project provides a holistic health strategy in Historic Anacostia, Barry Farm, Sheridan, and the Buena Vista communities (Ward 8) through the development and implementation of a Neighborhood Family Champions model. ECIN partners with Far Southeast Family Strengthening Collaborative, Parent Watch, Total Family Care Coalition and Health Alliance Network to recruit and train a Neighborhood Family Champion (NFC) from each neighborhood to reach families where they live. NFCs from each community serve as social capital builders, making important contact and connecting with families with children ages zero through five. The NFCs will utilize the ECIN mobile app to connect families to physical and mental health supports that reduce the duration and severity of maternal depression, food insecurity, and other family stressors that perpetuate poor health outcomes.

During 2015-2016, 52 percent of non-Hispanic black mothers entered prenatal care in the first trimester—compared to 86 percent of non-Hispanic white mothers and 64 percent of Hispanic mothers. What do you see as some of the most immediate opportunities to address this disparity?

There is a common misperception in the District that some women don’t enter prenatal care because there is a lack of prenatal care capacity or healthcare access points are spread unevenly in the city. Neither of these are accurate. The District has ample prenatal care capacity and it’s available throughout the city. 

This wasn’t always the case. About ten years ago, the District invested around $60 million to upgrade existing health facilities and build new ones. In particular, the city focused on underserved areas. Today, there are new and well-resourced health facilities in some of the city’s historically underserved neighborhoods and they all provide prenatal care. Yet we still see women failing to access prenatal care in a timely manner. It’s important to note that this underutilization of health services isn’t just limited to prenatal care. Other forms of care—primary care, oral health, etc.—are not utilized by District residents who have the third-highest rate of insurance and the most generous Medicaid program in the nation.

There is still much to learn about why insured women of color with physical access to prenatal care don’t access it at the same rates as white women in D.C. Perceptions of brand, quality and convenience may also drive our residents’ decisions about where to seek care. There is also some evidence to suggest that health literacy may also play a significant role. Mayor Bowser is pursuing a 3-year health literacy campaign that aims to address this issue. We’re still in the development phase but the campaign is likely to feature social media outreach aimed at promoting the need for health services like prenatal care, and giving people clear information about how and where to access such services.  The campaign will also address provider aspects of cultural competency in healthcare.