Infant mortality is often viewed as a marker of the health

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1 INVITED COMMENTARY North Carolina s Perinatal Health Strategic Plan: Striving to Improve Birth Outcomes for All Families Sarah Verbiest, Belinda Pettiford While North Carolina has made progress in improving perinatal health, much work remains to be done to ensure health for all communities. The state s new perinatal health strategic plan provides an innovative approach that highlights strategies for addressing biomedical, social, and economic inequalities. Infant mortality is often viewed as a marker of the health of women and girls in a society. North Carolina ranks 42nd in the United States for high rates of infant death, and the United States ranks 26th in the world for this measure [1, 2]. Over the past 20 years, North Carolina s infant mortality rate has declined, yet it continues to lag behind other states [3, 4]. Figure 1 depicts the downward trends by race and ethnicity. Most concerning, the gap in infant death between black and white infants has widened, such that the risk of black infants dying before their first birthday is more than 2.5 times the risk for white infants, and the risk for American Indian infants is close behind that of black infants [3]. The majority of infant deaths in North Carolina are due to prematurity/low birth weight, followed by congenital anomalies and then by maternal factors/complications of pregnancy, including those occurring during labor and delivery. Sleep related deaths are also a problem [5]. There are persistent regional disparities in North Carolina, as the northeastern and southeastern regions of the state consistently have the highest infant mortality rates [6]. Looking at statewide data, African American women in North Carolina are more than twice as likely as white women to experience an infant death [6]. Historically, African American women in North Carolina also had a maternal mortality rate that was double the rate of white women in the state [7]. Research in maternal and infant health show that differences in resources throughout the life course including access to health care, education, and employment lead to inequalities in birth outcomes [8]. This is not news in our state. In 2004, the North Carolina Medical Journal published an issue on infant mortality, which called for taking a life course approach to this critical public health challenge. This issue called for greater emphasis on comprehensive women s health and wellness before, during, and after pregnancy. Tobacco use, interpersonal violence, mental health, and drug use were highlighted as areas that must be addressed in order to support better birth outcomes for women [9]. A follow-up issue in 2009 underscored the necessity of expanding from a singular focus on the pregnant woman and fetus to a wider frame that encompasses the adolescent, woman, and mother [10]. The journal highlighted many areas where North Carolina had advanced in serving women by launching innovative projects and serving as a national leader in maternal and child health. Leaders also issued a charge for health care providers and public health officials to offer continuous health care for the whole woman, promote reproductive life planning, align policy and funding, and integrate and collaborate across sectors [10]. While progress has been made in areas such as adolescent pregnancy, tobacco use, access to long-acting reversible contraception, late preterm birth, and access to care, much work remains to ensure that all communities in North Carolina have healthy women and families. In 2011, the UNC Center for Maternal and Infant Health received a small grant from the National Institute of Child Health and Human Development (NICHD) to bring academic and community partners together to develop strategies to close the gap in birth outcomes between African American and white mothers. Focus groups were conducted with 10 community-based infant mortality prevention coalitions, reaching 130 participants across North Carolina. Key informant interviews were conducted with consumers as well as leaders in public health, education, and community and economic development. An equity council was convened to review the data, discuss current research, and learn from experts in health equity and framing. Health care related themes that emerged from these interviews included challenges in accessing services, cost, and competing priorities. For low-income women, lack of transportation, lack of time, and distrust were barriers to care. A further barrier exists for many in the state s private sector workforce, almost half (44.7%) of whom lack paid sick days, as no federal or state law ensures that workers can Electronically published November 16, Address correspondence to Dr. Sarah Verbiest, North Carolina Department of Health and Human Services, 1929 Mail Service Center, Raleigh, NC (sarahv@med.unc.edu). N C Med J. 2016;77(6): by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved /2016/

2 Prestia sidebar earn paid sick days [11]. These interviews also highlighted the need for culturally appropriate health information and the extensive stigma that surrounds mental illness. Strategies for bringing services to communities were suggested, along with strategies for building networks of community activists through health workers. While groups were excited to see new resources coming to their communities (such as walkable green spaces and farmers markets), they noted the importance of ensuring equitable access to these benefits. Significant discussion about faith communities revealed that these organizations are seen as both important partners and as roadblocks to supporting young adults. There was a great deal of discussion about the importance of engaging young men and fathers, including through mentorship. Participants also spoke about the importance of breaking the cycle of poverty, a task that is challenging in light of the fatalism that some communities may feel and perpetuate. These interviews underscored the importance of engaging schools, businesses, and policy makers in solutions [12]. In 2012, North Carolina joined with 12 other states to implement the Collaborative Improvement and Innovation Network (CoIIN) to reduce rates of infant mortality. Focusing on the low-hanging fruit, North Carolina con- 411

3 Prestia sidebar continued tinued its focus on reducing tobacco use during pregnancy, promoting safe sleep, and reducing early elective delivery, while also strengthening its focus on perinatal regionalization/risk appropriate care and interconception care. With these goals providing some direction, 11 lead agencies and more than 125 partners came together in 2014 to create North Carolina s new Perinatal Health Strategic Plan. One of the most innovative in the country, North Carolina s plan is constructed on the 12-point life course framework proposed by Lu and colleagues, which covers 3 major domains: improving health care for women and men, strengthening families and communities, and addressing social and economic inequities [11]. Within these domains, the plan calls for actions in 12 specific areas (see Table 1) [8]. North Carolina partners developed dozens of action steps to advance work in each of these areas. In the domain of health care improvement, for example, the plan calls for increased access to long-acting reversible contraception; implementation of evidence-based obstetric and maternity services; culturally appropriate health education; comprehensive breastfeeding support; affordable health insurance; quality case management; and care continuity from ado- 412

4 figure 1. North Carolina Resident Infant Mortality Rates, Note. Af. Am., African American; Am. Ind., American Indian; NH, non-hispanic. Source: Data derived from North Carolina State Center for Health Statistics website. lescence to preconception, postpartum, and beyond. The Perinatal Health Strategic Plan also calls for full implementation of North Carolina s Preconception Health Strategic Plan. In the area of strengthening families and communities, action steps include promoting evidence-based strategies to promote healthy family relationships, partnering with men s organizations to support fathers, fostering reproductive life planning, decreasing fragmentation in the service delivery system, preventing violence, improving transportation systems, providing tobacco-free housing, installing free wireless Internet in public housing, expanding civic participation, and fully engaging women and communities in the design and delivery of services. The third domain of the Perinatal Health Strategic Plan involves addressing social and economic inequities; this domain was the most challenging to develop and yet also the most critical to implement. New studies such as that by Komro and colleagues, which found that raising the minimum wage by as little as $1.00 above the federal level might lead to fewer infant deaths and cases of low birth weight infants, demonstrate that social determinants of health cannot be ignored [13]. As such, the Perinatal Health Strategic Plan highlights the importance of paid parental and sick leave, enrollment of youth in foster care settings in post-secondary education, livable wages, and equity in compensation. The plan also highlights the necessity of increasing high school and post high school graduation rates, promoting access to early childhood education and affordable quality child care, collaborating with agencies that focus on poverty reduction, and creating safe work places and incarceration environments for women. The most critical and perhaps most challenging component of the plan calls for promoting community and systems dialogue on racism, infusing equity into the provision of health care services, and promoting quality training about institutional and structural racism and its impact on poor communities and communities of color. As recent events have demonstrated, racism is embedded in American society, including in our health care system. To address this problem, much needs to be learned at the micro (individual) level as well as at the macro (policy) level. Partners underscored the necessity of recognizing the diversity of North Carolina families, which include grandparents raising their grandchildren, same-sex couples, stayat-home fathers, and single parents. Women and men also have different needs, perspectives, experiences, and opinions. Services and messages thus need to be inclusive and nonjudgmental. Further, while Lu and colleagues include racism as a single point in their plan, the partners of the Perinatal Health Strategic Plan underscored the importance of considering the impact of racism (and other isms ) on each point of the plan and stressed that equity must be infused across this work. Of note, the proposed directions 413

5 and action steps are part of a living document that will be reviewed and updated annually. Many partners from across the state have offered support and leadership related to different action steps. The full plan can be viewed at and all are welcome to join the team. As Lu and colleagues suggest, however, more is needed for change than just a good plan. They call for research that addresses several disconnects: between the perinatal period and the rest of the life course, between individuals and their environment, across disciplines, and between academic and community researchers [8]. The authors also note the importance of creating political will to command resources for implementation of the plan, which starts with building a compelling case for the cost-benefit of this work. One of us (S.V.) echoed similar calls to action in North Carolina in 2009, underscoring the importance of partnerships, leadership, and public discourse on health disparities and social justice [10]. As S.V. and other coauthors wrote, a key goal of preconception health and the life course approach is to build agency for all women and men to make decisions that will ensure good reproductive health. This goal can best be accomplished by creating neighborhood conditions that support good reproductive decisions, resulting in healthy children who will become healthy adults and populate healthy communities [14]. North Carolina s Perinatal Health Strategic Plan provides a comprehensive road map to address infant mortality, maternal health, maternal morbidity, and the health of men and women of childbearing age. Through collaboration among leaders and communities across the state, this 12-point plan can serve as a tool for designing and implementing initiatives that will impact the health and well-being of North Carolinians. This strategic plan highlights current initiatives that are moving the state in the right direction, and it also reveals gaps in North Carolina s current systems and policies. To realize the strategic plan s 3 goals, our state will need to consider new ways of understanding health and employ new functions to address health. The action steps table 1. Life-Course Approach for Reducing Infant Mortality 1. Provide interconception care to women with prior adverse pregnancy outcomes 2. Increase access to preconception care 3. Improve the quality of prenatal care 4. Expand health care access over the life course 5. Strengthen fathers involvement in families 6. Enhance coordination and integration of family support services 7. Create reproductive social capital in communities 8. Invest in community building 9. Close the education gap 10. Reduce poverty among families 11. Support working mothers and families 12. Undo racism Source: Lu MC, et al [8]. demonstrate the holistic approach required to truly impact infant mortality rates and perinatal health outcomes. City, county, state, and community agencies and organizations are encouraged to review the 12 points and consider how they can engage in the plan. Further, agencies, groups, and businesses with expertise outside of perinatal health are also invited to offer action steps and join the effort. Although the strategic plan provides an in-depth range of strategies to address perinatal health, there remains a need for agencies and organizations to listen to and engage with the men, women, and families they serve to better understand how to implement the 12-point plan. The 2011 focus groups that convened to discuss reducing inequities in birth outcomes in North Carolina revealed a wealth of ideas regarding program needs, design, and implementation efforts specific to different communities [12]. Unless we listen to the women, men, and families we aim to serve, we run the risk of offering misguided services that will not achieve the intended results. We also risk perpetuating inequities. To reduce the infant mortality rate and close the gap in birth outcomes between African Americans and whites, we must answer an important question: Do we have the drive to invest what is necessary to ensure that all babies in North Carolina are born healthy? The direction is set. The work is clear. Do we have what it takes at this moment to create the change our mothers and babies so desperately need? The choice is ours. Sarah Verbiest, DrPH, MSW, MPH clinical associate professor, School of Social Work, University of North Carolina at Chapel Hill; executive director, Center for Maternal and Infant Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Belinda Pettiford, MPH branch head, Women s Health Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina. Acknowledgments The authors would like to acknowledge Kendall Gurske, MPH, MSW, whose graduate master s thesis summarized the community focus group results. The authors also acknowledge the members of the initial Perinatal Health Strategic Planning Committee for their work; committee members included Sarah Ahmad, Angela Aina, Sydney Atkinson, Vienna Barger, Laila Bell, Kate Berrien, Rebecca Sink, Sheila Bunch, Tonya Daniel, Janice Freedman, Kimberly Harper, Elizabeth Hudgins, Kathleen Jones-Vessey, Carol Koeble, Kathy Lamb, Alvina Long Valentin, Erin McClain, Sarah McCracken Cobb, Kweli Rashied-Henry, Judy Ruffin, Royland Smith, and Shelby Weeks. Finally, thanks to Megan Canady, MSW, MSPH, for assisting with this manuscript. Financial support. This work was funded in part by grant R13 HD from the National Institute of Child Health and Development and by grant number H18MC00037 from the Health Resources and Services Administration, Maternal and Child Health Bureau. Potential conflicts of interest. S.V. and B.P. have no relevant conflicts of interest. References 1. United Health Foundation. Infant mortality rate in the United States as of 2015, by state. us-infant-mortality-rate-by-ethnicity-2011/. Published December Accessed July 11, MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, Natl Vital Stat Rep. 2014;63(5): North Carolina State Center for Health Statistics. North Carolina 414

6 Infant Mortality Report: Infant Death Rates (per 1,000 Live Births) by Race/Ethnicity and Year. Raleigh, NC: Department of Health and Human Services; ims/2014/table3.html. Accessed July 11, Mathews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. Natl Vital Stat Rep. 2015;64(9): North Carolina State Center for Health Statistics. Infant Mortality Statistics for North Carolina Neonatal Deaths by Cause of Death. Raleigh, NC: Department of Health and Human Services; Accessed July 11, North Carolina State Center for Health Statistics. Infant Mortality Statistics for North Carolina Infant Mortality Report, Final Infant Death Rates (per 1,000 Live Births). Raleigh, NC: Department of Health and Human Services; data/vital/ims/2014/2014rpt.html. Accessed July 11, North Carolina State Center for Health Statistics. North Carolina Infant Mortality Report: Non-Hispanic White and Non-Hispanic African American Pregnancy-related Mortality Rates by Year, North Carolina Residents Raleigh, NC: Department of Health and Human Services; Figure4_MaternalMortality2013.pdf. Accessed July 11, Lu MC, Kotelchuck M, Hogan V, Jones L, Wright K, Halfon N. Closing the Black-White gap in birth outcomes: a life course approach. Ethn Dis. 2010;20(1 Suppl 2):S DeClerque JL, Freedman JA, Verbiest S, Bondurant S. North Carolina s infant mortality problems persist: time for a paradigm shift. N C Med J. 2004;65(3): Verbiest S, Holliday J. Issues brief: preconception care: building the foundation for healthy women, babies, and communities. N C Med J. 2009;70(5): Institute for Women s Policy Research and National Partnership for Women and Families. Workers Access to Paid Sick Days in the States. Table library/work-family/psd/workers-access-to-paid-sick-days-in-the -states.pdf. Accessed July 14, Gurske KB. North Carolina Equity in Birth Outcomes Council: Reducing Inequities in Birth Outcomes in North Carolina: Developing an Actionable Strategic Plan Community Stakeholder Focus Group Research Report. [master s thesis]. Chapel Hill, NC: University of North Carolina; ablecontent/uuid:3be6fc e-a795-4e7495b3cdcb. Accessed September 27, Komro KA, Livingston MD, Markowitz S, Wagenaar AC. The effect of an increased minimum wage on infant mortality and birth weight. Am J Public Health. 2016;106(8): Verbiest S, Malin CK, Drummonds M, Kotelchuck M. Catalyzing a reproductive health and social justice movement. Matern Child Health J. 2016;20(4):