improving infant mortality in ohio - Maternal and Child Health ...

IMPROVING INFANT MORTALITY IN OHIOThe following document is a combination of many of our thoughts over the past fewmonths about how to improve infant mortality in Ohio. I would like for you to imaginethat we are declaring WAR against Infant Mortality. To wage this war, we have tosimultaneously fight on several different Battlefields. In this document, these“battlefields” are represented by different categories like premature birth, congenitalanomalies, etc.Some would suggest that we “pick a few battles”, limit our interventions or just try toimprove one or two of these issues, and not take on the entire bunch. I am suggestingthat we figure out how to win EVERY battle. Each area of interest represents amechanism by which newborns do not survive until their first birthday. The recognizedareas not only acknowledge clinical/medical concerns that identify biological causes ofinfant mortality, but also attempt to identify up-stream contributors to why babies die.None of them are easy to solve; all require intense, sustained, committed efforts fromALL of us to have an opportunity to win this war.I am certain my list is not comprehensive, that there are “other” battles we need to wagethat are not considered in this document. Please help me to include other areas requiringour attention.Please also help to provide descriptions/explanations about how each “battlefield”contributes to our challenges to improve infant mortality.Help me to delineate how we best fight each battle…what we need to consider doing towin each battle. What “weapons” we need to employ to give us the best opportunity tobe successful?Can each of these battlefields be assigned to a current OCPIM work-group or do we needto develop additional work-groups? For example, which of our current work-groupsworks to decrease the incidence of congenital anomalies? I do not think this is an issuewe address thru OCPIM…and I think it should be.Likewise, I think we need additional recruits to join our OCPIM army; representativesfrom Family Planning, legislators, business, government, more grass-root representation,etc.How does this list apply to local communities?If we continue consideration for sponsoring an Ohio Infant Mortality Summit inNovember, might we consider our sub-theme the official Ohio declaration of war againstInfant Mortality?

1. Premature Birth:a. Progesterone Project 34.3% of infant deaths are ultimately due to preterm birth. 95% of infant deaths occurred in infants born before 32 weeks andbelow 1,500 grams birth weight. Women at risk of preterm birth from previous preterm birth orshort cervix can be identified early in their pregnancies with avariety of screening technics. Once identified, treating these women with 17P, a form ofprogesterone, can significantly extend the weeks of theirpregnancy, resulting in larger, better-developed babies with agreater chance of survival. Partners in the Ohio Collaborative to Prevent Infant Mortality aredeveloping a statewide project to implement this screening andtreatment approach to improved birth outcomes. For more information, contact Jay Iams, MD at the OSU MedicalCenter: Jay.Iams@OSUMC.edu or phone 614-293-8736.b. Scheduled Birth Initiative: OPQC (Ohio Perinatal QualityCollaborative: Ohio Perinatal Quality Collaborative (OPQC) is a networkof Ohio perinatal clinicians, hospitals, state agencies (Ohio Department ofHealth, Ohio Medicaid), and policy makers founded in 2007. The missionof OPQC is: “through collaborative use of improvement science methods,reduce preterm births and improve outcomes of preterm newborns in Ohioas quickly as possible.” OPQC improvement efforts target the populationof all Ohio pregnancies and all families with women of childbearing age.The first OPQC NICU project aimed to reduce hospital-associatedinfections (HAI) among preterm infants. Among Ohio’s 24 participatingNICUs, infections have been reduced by 20% from 18% to 14%. Insertionand maintenance bundle development and use at sites contributed to thisreduction.) The first OPQC OB project aimed to reduce unnecessary, planned,late preterm and near term deliveries at 36 to 38 weeks gestationalage. Since initiating this OPQC project, more than 18,000 birthshave moved from occurring prior to the due date to full term (39 to41 weeks). Approximately 500 NICU admissions and some infantdeaths have been avoided. Compared to the baseline period beforethis project, this work, by 20 large Ohio maternity hospitals andtheir staffs represents a major, positive transformation ofobstetrical care in Ohio and at least approximately $10 million inannual Ohio health care cost savings. Next steps for OPQC include:1. Disseminating successful practices from scheduled deliveryproject to the additional 96 hospitals across the state;2. Implementing the next OB improvement project: to ensurethat all pregnant women at risk receive appropriateAntenatal Corticosteroids;

3. Continuing efforts to decrease rate of bloodstreaminfections by 1) increasing the reliability of catheter caremaintenance bundle use; and 2) implementing a bundle toimprove the rate and volume of human milk feeding inpremature infants; and4. Improving birth certificate data entry quality and use ofvital stats as population health outcome measurec. Assisted Reproductive Technology: (I am not certain what the situation islike in Ohio…if there is a limit to the number of eggs used, what thecircumstance is re: selective termination, how we regulate these issues inOhio).d. Cervical Length Measurement: as a predictor of individuals at increasedrisk of PTB. If done routinely,1. When should it be done?2. On whom?3. Who pays?2. Congenital Anomalies:a. Obesity Control Pilot Project Obese women are at higher risk for having babies born withserious birth defects such as neural tube defects; heart problemsand oomphalocele. Congenital anomalies are a leading cause ofinfant mortality in Ohio. OSU School of Public Health intern implemented pilot project intwo Ohio counties with the highest rate of female obesity. Pilot testing a brief intervention model (5A’s) in ODH-fundedWomen and Reproductive Health Clinics. Project currently in implementation (May 2012) Future plans include evaluating staff knowledge and skills, andevaluating efficacy of this model for weight control in women ofreproductive health age.b. Interconception health card for WIC Projects Ohio Partners for Birth Defects Prevention are developing a healtheducation card to be used at WIC postpartum visits.c. Metabolic Formula Program ODH removes barriers for pregnant women with inborn errors ofmetabolism such as PKU to receive metabolic formula, which isexpensive and not well covered by health insurances. Pregnantwomen with untreated PKU are more likely to have babies withcongenital anomalies.d. Newborn Screening for Critical Congenital Heart Disease (CCHD) Congenital anomalies account for approximately 20% of theinfants who die before their first birthday. Of those infants whodie from congenital anomalies, greater than 20% die from CCHD.

USHHS Secretary Sebelius added newborn screening for CCHD tothe national uniform panel of disorders for state newborn screeningprograms in 2011. Newborn screening for CCHD is done by pulse oximetry, a pointof care test completed and read at the newborn nursery level. ODH is currently exploring the issues, barriers, etc. of addingnewborn screening for CCHD to Ohio’s newborn screening panel.1. Is this budgetary process the time to request funding to beable to do this?3. Sudden Unexplained Infant Deaths:a. Sleep-related Deaths and Sudden Unexplained Infant Death (SUID) Fifteen percent of all infant deaths are sleep-related. Of the deaths between 29 days and 1 year of age, 42 percent weresleep-related. After the first month, sleep-related death is the biggest threat to ababy’s life the rest of the first year. More than three Ohio infant deaths each week are sleep-related. We can reduce the incidence of this cause of infant mortality byimplementing the American Academy of Pediatrics (AAP) Safe SleepGuidelines published in October, 2011 and available at:http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2285)The Ohio Injury Prevention Partnership/Child Injury Action Group has identifiedinfant sleep-related deaths as a priority issue. An action plan has been developedthat includes: Creating a statewide subcommittee; Collaborating with other organizations to conduct a statewide safesleep campaign; Promoting legislative mandates for safe sleep policies and parenteducation policies in birthing hospitals;o Encourage all providers of prenatal care teach all pregnantwomen about safe sleep.o Just like we currently will not discharge a baby from thehospital if her/his parents do not have a car seat for the ridehome, it is time to “mandate” that hospitals DO NOTdischarge any baby from the hospital without proof thatthe parents have been taught about safe-sleep during thepostpartum period of time!• Let us appeal to the CIAG (Child Injury Action Group)and the OCPIM Policy work-group to design and lobbyfor adoption of such a policy.• Encourage that “reinforcement education” about safesleepbe a part of newborn evaluations (for the first yearof life).

• Adopt a “uniform” safe sleep message based on10/2011 AAP guidelines.• REQUIRE that safe sleep be a part of the teaching of allprenatal providers. Begin teaching by 24 weeks, before familiesbegin buying cribs, clothes, etc., for baby. Document that such teaching occurred.• REQUIRE every hospital, nursery, day care center,health care facility to develop a safe sleep policy (oradopt the ODH policy)In each location REQUIRE that safe sleep beutilized and therefore modeled within theorganization.• REQUIRE each hospital to have a safe sleep check-listwhich they use to document safe sleep teaching to eachmother prior to being discharged from the hospital.Maternal signature should be required.• Arrange for a home visit for each postpartum motherwithin 1-2 weeks of discharge from the hospital.Although there might be a number of issues tobe addressed at the time of this visit (BP, postpartum depression, breastfeeding, etc), one ofhem would be to visually verify the sleepenvironment of the baby and to review the cafésleep check list AGAIN (signed again bymother/parents/caregivers)• Well Baby visit: enforce safe sleep message• Postpartum visit: enforce safe sleep message• Death scene investigation for any sids or sleep relatedinfant death.Partnering with retailers to promote safe sleep to customers; andEnsuring that prenatal care providers and pediatric health careproviders are promoting and distributing safe sleep messages. The subcommittee includes professionals from many state agenciesand local health department as well as parent representatives. Thegroup is currently working with the Ohio chapter of the AmericanAcademy of Pediatrics on plans for a social marketing campaign.4. Drug use during pregnancy:a. Prescription Medication Importance of preconception care, to optimally “control” chronicillnesses with non-teratogenic medications. To wean off Rx. drugs being taken by someone other that who theyare prescribed for.b. Illegal Drugs

5. Breastfeeding:a. AAP recommends exclusive breastfeeding for about 6 months, followedby continued breastfeeding as complementary foods are introduced, withcontinuation of breastfeeding for 1 year or longer as mutually desired bymother and infant.b. Breastfeeding is linked to decreased risk of SIDS, necrotizing enterocolitis(NEC), ear infections, GI infections, celiac disease, inflammatory boweldisease, obesity, diabetes, childhood leukemia and lymphoma, and betterneurodevelopmental outcomes. Therefore, feeding artificial baby formulais linked to increased risk of SIDS, necrotizing enterocolitis (NEC), earinfections, GI infections, necrotizing enterocolitis (NEC), SIDS, celiacdisease, inflammatory bowel disease, obesity, diabetes, childhoodleukemia and lymphoma, and better neurodevelopmental outcomes.i. If 90% of families exclusively breastfeed for 6 months, nearly1,000 deaths among infants could be prevented.ii. Prematurity largest single cause of infant death. NEC is the mostcommon gastrointestinal emergency in premature infants. Byfeeding preterm infants human milk, there is a 58% reduction inthe incidence of NEC.iii. SIDS is the fourth single cause of infant death. The rate of SIDS is60% lower among infants who had any breastfeeding versus thosewithout breastfeeding. The rate of SIDS is 70% lower inexclusively breastfed infants (no formula) for any period of time.c. Ohio breastfeeding rates have been slowly increasing over the past 6years.i. In 2010, 67% of Ohio mothers initiated breastfeeding, but thatfalls short of the Healthy People 2010 goal of 75%.ii. Ohio has also made progress in the number of infants who arebreastfed at 6 months of age, almost 40%. However, this also trailsbehind the US rate of 44% and the HP2010 objective of 50%.iii. HP 2020 goals: 81.9% to initiate breastfeeding and 60.6% for anybreastfeeding at 6 months of age.d. Rates within racial and ethnic subgroups are increasing as well; however,disparities persist. Improving breastfeeding initiation and duration ratesamong all demographic groups can help to reduce health disparities.According to the Centers for Disease Control (CDC), 64.7% of Ohiowhite, non-Hispanic mothers initiate breastfeeding while only 54.1% ofblack, non-Hispanic mothers initiate breastfeeding. By six months postpartum,only 33.4% of Ohio white, non-Hispanic mothers arebreastfeeding and only 23.4% of black, non-Hispanic mothers arebreastfeeding. By 12 months, less than 15% of white, non-Hispanicmothers are breastfeeding and less than 10% of black, non-Hispanicmothers are breastfeeding. Many barriers have been identified and the2011 US Surgeon General’s Call to Action to Support Breastfeedingprovides actions and implementation strategies.

http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdfe. Increasing the percentage of mothers electing to breastfeed by educatingclinicians, women, and hospitals using the AAP recently releasedguidelines on breastfeeding (3/2012). According to these guidelines, if90% of women breastfed, we could reduce the infant mortality rate by30%.http://pediatrics.aappublications.org/content/129/3/e827.full#contentblockf. Breastfed infants have immunological and nutritional benefits that infantswho are not breastfed do not. Benefits of breastfeeding include improveddevelopmental and psychosocial outcomes, increased mother/infantbonding, reduced risks to the mother, reduced health care costs, lessenvironmental waste and reduced infant mortality (American Academy ofPediatrics, 2005). Breastfeeding is linked to decreased risk of SuddenInfant Death Syndrome (SIDS), necrotizing enterocolitis (NEC), earinfections, GI infections, necrotizing enterocolitis (NEC), SIDS, celiacdisease, inflammatory bowel disease, obesity, diabetes, childhoodleukemia and lymphoma, and better neurodevelopmental outcomes.Therefore, feeding artificial baby formula is linked to increased risk ofSIDS, necrotizing enterocolitis (NEC), ear infections, GI infections,necrotizing enterocolitis (NEC), SIDS, celiac disease, inflammatory boweldisease, obesity, diabetes, childhood leukemia and lymphoma, and betterneurodevelopmental outcomes.6. Smoking Cessation: In 2010, one in three women in Ohio smoked three months beforepregnancy (30.9 percent, PRAMS) In 2009, the percent of women who smoked during pregnancy in Ohio(19.2) is more than double that of those who smoked during pregnancy inthe United States (9.3)(2009, ODH Vital Statistics) 21.8 percent of women in Ohio continue or start smoking 2-6 months afterpregnancy (2010, PRAMS) Forty-eight percent (48.1%) of women on Medicaid in Ohio smokedbefore and during pregnancy compared to 18.5 percent of non-Medicaidwomen (2009-2010, PRAMS). In 2006, The Prenatal Smoking Cessation Program (PSCP) launched theOhio Partners for Smoke-Free Families (OH-SFF) initiative to ensureconsistent smoking cessation messages and interventions are delivered topregnant and postpartum women. Ohio Partners for Smoke-Free Families works with public healthpractitioners implement the 5 A’s USPHS Treating Tobacco Use andDependence clinical practice guidelines. The5A’s evidenced-based smoking cessation intervention has beenimplemented into 14 Child and Family Health Services (CFHS) perinatal

2. The Ohio Connections for Children with Special Needs(OCCSN) birth defects information system promotespreconception/interconception health by developing anddistributing educational materials, and promoting BirthDefects Prevention Awareness Month statewide. Expand “Pathways” for Maternal and Child Health. RichlandCounty achieved a 30 percent reduction in low-weight births intargeted populations by using a Community Pathways Model toimprove care coordination for women in difficult-to-serve areas.1The model, which was developed by the Community HealthAccess Project in Richland County, coordinates care for womenand children within targeted medical “pathways.” One pathway(pregnancy and postpartum) employs community health workers toidentify pregnant women early in their pregnancies and then uses asimple, standard protocol—or checklist—to identify the barriers toa woman delivering a full-birth-weight infant. The model pays forperformance by providing financial incentives that are tied toeliminating barriers to achieving normal-weight births, andeliminates duplication among health and human services agencies.The model has demonstrated success in Richland County (13years), Toledo (four years) and Cincinnati (three years).1. The Kasich administration’s Office of HealthTransformation is investing $350,000 and partnering withIntegrated Professionals for Appalachian Children (IPAC)and the Nationwide Children’s Hospital’s Partners for Kids(PFK) network to replicate the Community PathwaysModel in southeast Ohio. The impact of this program isprofound for mothers and babies, and for taxpayers.Nationally, every low-weight or preterm birth costs statesbetween $28,000 and $40,000 in medical care and otherrelated costs.2 In Ohio, low-weight births represent onlyabout 10 percent of all Medicaid births but account for over50 percent of all Medicaid birth expenditures. The RichlandCounty Community Pathways Model saved $3 for every $1invested in the first year of the program and an additional$6 for every $1 invested over the next three years. For moreinformation see: 2/2/2012 Press Releasec. Quality of care:d. Cost of care:e. Care Coordination: Gov. Kasich administration is taking action to improve carecoordination for at-risk mothers and children &reduce number ofLBW babies. Examples:1. Healthy Mothers/Healthy Babies: can we delineate whereprograms are, how long they have been in existence, how

many they each serve annually, how their infant mortalityrates compare with general community’s?2. Managed Care by Cincinnati Health Department (? Is thisan OIMRI program?).3. OIMRI (Ohio Infant Mortality Reduction Initiative)a. OIMRI (Ohio Infant Mortality ReductionInitiative): Although I am still learning about thisprogram, each time I hear about it the infantmortality data sounds pretty impressive. Are we ata point that we can look at each of the 14 OhioCounties that have OIMRI programs and compareat least 5 year IMR’s for OIMRI participants withtheir local cohorts?4. The participant counties include: Allen (Lima), Butler(Middletown), Clark (Springfield), Cuyahoga (Cleveland),franklin (Columbus), Hamilton (Cincinnati), Lorain(Elyria), Lucas (Toledo), Mahoning (Youngstown),Montgomery (Dayton), Richland (Mansfield), stark(Canton), summit (Akron), Trumbull (Warren) (Have weidentifiesd all of the programs, how long they have been inexistence, how many they each serve annually, how theirinfant mortality rates compare with general community’s?)a. How were these locations chosen?b. Seems that each of these programs is based on CaseManagement, including home visitation…is thiscorrect?c. If we have enough data to suggest that theseprograms work, then how do we spread them towider areas of the counties the programs alreadyexist in?d. Can Medicaid Managed Care adopt these models?f. Different models of care: Group Prenatal Care1. Centering Pregnancy: Can we review the impact ofCentering in Ohio? What is the IMR in Centeringprograms compared to other local programs serving asimilar cohort that is not Centering? Summarize the models of care in the Strong Smart application. Can we begin to investigate how strongly tying women’s care intothe Medical Care Home initiative might look. How all of this tiesinto however the Affordable Care Act is going to look in Ohio?Importantly, we want to ensure that women have access tohealthcare even when they are not pregnant, includingpreconception and interconception care without copay, whichwill provide an extraordinary opportunity to improve women’s

health not only during pregnancy, but before, between, andbeyond pregnancy and across their life course.8. Family Planning:a. Decrease unwanted/un-intended pregnancies, prolong inter-pregnancyintervalb. Medicaid Family Planning Expansion /State Planning Admendment A healthy pregnancy is a planned pregnancy and one that does notoccur too close to a previous birth (space at least 18-24 monthsapart). As of January 2012 Ohio became the (? 29, 30 th , or 31 st )State to offer a family planning waiver, known in Ohio as the StatePlanning Amendment (SPA). Ohio Medicaid’s recent expansionof eligibility for family planning services for men and women upto 200% of the FPL (federal poverty level) enables a whole newgroup of Ohioans to gain access to family planning services thatwill help plan pregnancies, which will result in healthier babies.To apply for Medicaid family planning services, apply online athttp://jfs.ohio.gov/OHP/consumers/Application.stm or contact yourlocal county department of job and family services:http://jfs.ohio.gov/County/County_Directory.pdf. Can we work with Medicaid and Managed Care Organizations tohelp ensure that women have seamless postpartum transition ontothis SPA w/o a hard stop between the postpartum end of theMedicaid coverage for their pregnancy and coverage forpostpartum SAP coverage of contraceptive services? Since womenwith private insurance do not have to re-apply to continue theirbenefits after delivering a baby, is there a way for us not to requirewomen paying for their births by Medicaid to have to re-applybefore they can take advantage of this benefit? How does the SPA influence the ACA coverage? How do we assure that ALL mothers who deliver babies haveaccess to family planning services, including those who deliver atCatholic Healthcare Centers where family planning services arenot as available? My interest is not to undermine CatholicDirectives or to interfere with the Catholic Church, but to becertain that the option of family planning services are available toeveryone whishing to access such services.1. I am not looking for any type of mandate here, but“community-level partnerships” that provide contraceptiveservices seamlessly/conveniently to women interested inreceiving them and to do so in a manner that respects theCatholic church.9. Policy:a. Should we look to legislatively “mandate” FIMR as a part of CFR Rationale: infant mortality accounts for 66% of all Childhooddeath in Ohio, so we should have a process that conducts more in-

depth investigation of each infant (and perhaps fetal) death. (Ithink the State of Florida conducts FIMR State-wide, so perhapsthey might be a model for us to study).b. Mandate Safe-Sleep education prior to discharge from the hospital.10. Marketing: (We have to end the relative silence that exists in Ohio about theimportance of infant mortality. On April 4, 2012 the Ohio chapter of the Marchof Dimes released the Ohio 2010 infant mortality rates to 825 media outletsthroughout the State. Only one radio station in Cleveland responded! While thereare no doubt many reasons for such a lack of interest in these numbers (whichwere substantially worse than the preliminary USA 2010 infant mortality rates.One has to go back to 1995 to find National infant mortality rates comparable toOhio’s 2010 infant mortality rates). ONE out of 825 media outlets was interestedin this story. Our silence on this issue makes it impossible to create the“community will” we need to improve these rates.)a. September is Infant Mortality Month. What are we doing?b. Begin a media campaign in conjunction with all of the workgroups to havea major Statewide article to distribute about some element of infantmortality. With 5 workgroups, this would mean each workgroup would beresponsible for an article every fifth month.c. Challenge ODH to consider the development and annual release of a muchmore comprehensive annual document that provides more details aboutinfant mortality in our State.11. Decreasing Teen Birth Rate:In Ohio in 2010, 2.7 percent of all resident live births were to females between 15and 17 years of age. This is slightly lower than in previous years (teenagers aged15-17 made up 3.0 percent of live births in 2009 and 3.2 percent of births in2008). Nationally the birth rate for teenagers ages 15-17 decreased from 19.6 per1,000 in 2009 to 17.3 per 1,000 in 2010, according to the National Vital StatisticsSystem. Ohio has also experienced a decline in the teenage birth rate from 2009to 2010, with rates for teenagers aged 15-17 lower than national figures (18.7 per1000 in 2009 and 15.6 per 1000 in 2010). Racial disparities among 15-17 yearolds giving birth are apparent. The birth rate for white teenagers aged 15-17 inOhio in 2010 was 11.4 per 1,000. This compared to 31.5 per 1,000 blackteenagers and 29.7 per 1,000 Hispanic teenagers aged 15-17 in the same year.The decline in teen births in Ohio suggests that programs to prevent teenpregnancy have had a positive effect. But data from the national Youth RiskBehavior Survey (YRBS) do not indicate a significant decline in the percentage ofstudents who have ever had sexual intercourse from 1999 (49.9, 95% CI 46.1-53.7) to 2011 (47.8, 95% CI 45.1-50.6). The percentage of students havingintercourse in the past three months who also used birth control pills to preventpregnancy before the last sexual intercourse did not change between 1993 and

2011 (22.8 percent in 2011). On the other hand, among students havingintercourse in the past three months, the percentage that used either birth controlpills or Depo-Provera increased over the period, from 22.0 percent in 1999 to 31.8percent in 2011.Ohio’s State Health Improvement Plan (SHIP) has identified decreasing birthrates among adolescents as a key strategy of the Infant Mortality/Preterm BirthPriority. Using the Ohio Adolescent Health Partnership Plan as a guide, thefollowing objectives are included in the SHIP: Increase the number of schools with comprehensive health educationincluding reproductive health. Improve the knowledge, skills and behavior of health care providers toprovide reproductive health services to adolescents and their families. Increase the use of effective and appropriate contraception amongadolescents.12. Elimination of Racial Disparity in Birth Outcomes, establish “Parity” as theOhio goal for infant mortality.a. Life Courseb. Social Determinants of Healthc. Much more investment from public health and clinical health has to bemade.d. Consider establishment of REACH teams in Ohio REACH: Racial and Ethnic Approaches to Community Health, is aCDC sponsored approach to assisting local community efforts toimprove infant mortality. At this time there is not a REACHproject in the State of Ohio.1. Might we consider developing a REACH project inFranklin County as a next step to the Action LearningCollaborative of CPH?2. An example of a REACH project occurs in GeneseeCounty, Michigan where In 2010 Genesee County recordedits lowest infant mortality rate in the last 25 years with anoverall IMR of 5.7/1,000 live births (compared to 9.4 in2009), white IMR of 4.8 (compared to 5.2 in 2009), andblack IMR of 7.9 (compared to 20.3 in 2009).3. The Genesee County REACH (Racial and EthnicApproaches to Community Health) 2010 initiative,conducted between 2000 and 2007, focused on reducinginfant mortality, particularly the disparity in rates amongAfrican Americans and European Americans, in GeneseeCounty, Michigan. The Community Action Plan (CAP)was derived from a community-based participatory

esearch approach and based on a socioecological model.The plan derived both from "bench” science and “trench”study with community residents. Its theoretical foundationswere grounded in a philosophy of public health as socialjustice and based on the understanding that culture can beboth protective and harmful. No single intervention willeliminate racial health disparities. Interventions aimed atreducing infant mortality must precede, include, and followthe period of pregnancy. Core themes for the work of thisinitiative included fostering community awareness andmobilization, enhancing the “baby care” (medical care andsocial services) system, and reducing racism. The overarchinggoal of the REACH project was to effectcommunity and systems change sufficient to improve thelocal infant mortality problem. At the start of the project,African American infants in Genesee County were dying ata rate greater than three times that of European Americaninfants. Major outcome objectives in the project’s logicmodel included: (1) reducing racism; and (2) reduction ininfant mortality rates and the disparity ratio from 1999-2000 baseline data. Project interventions within thissuccessful model’s three interconnected spheres of activityincluded: community dialogue sessions; undoing racismworkshops; university cultural competency in health carecurriculum; African Culture Education DevelopmentCenter; maternal/infant health advocates; PRIDE(Programs to Reduce Infant Deaths Effectively) medicalservices committee; community media campaign; healthyeating curriculum; and Harambee celebrations. Throughthis multifaceted array of successful practice-basedinterventions, the REACH Community Action Plancontributed significantly to the decline in the infantmortality disparity ratio and a historic low rate of AfricanAmerican and overall infant deaths in Genesee County.4. The REACH planning process examined racial disparitiesin infant mortality from both “bench” (science) and“trench” (community) perspectives. Racial disparities ininfant mortality in Genesee County have persisted despiteat least two decades of applied contributions from theclinical, scientific laboratory, and legislative “benches” toreduce these gaps. Although many explanations have beenproposed for the failure of standard interventions to reduceracial disparities, two of the most compelling explanationshave been central to the REACH project: 1. No singleintervention is likely to eliminate racial disparities in infanthealth. Racial disparities arise from multiple factors: poor

outreach to and coordination of public health and medicalservices for high-risk patients; informal access barriers toneeded services; cultural barriers that hinder access andpatient adherence to beneficial health behaviors; structuralinequalities that promote poverty and communitydislocation; and internalized racism that fosters desperationand spiritual exhaustion in those communities at greatestrisk. 2. The period of pregnancy is simply too short toaddress effectively many risk factors important to infanthealth. A life-course perspective that focuses on improvedmaternal health is essential to improve birth outcomes inthe African American population. From this perspective,effective infant mortality prevention requires variedinterventions that go beyond prenatal or postpartum clinicalcare, to include primary prevention well before firstpregnancies; preconceptional care for planned pregnancies;postnatal intervention to prevent adverse outcomes amongnewborns and older infants and also to provide primaryprevention for future pregnancies and to increase intervalsbetween pregnancies. Given the multifaceted nature of thispublic health problem, multifaceted solutions are required.The Genesee County REACH initiative set in motion acomprehensive and sustainable process to improvematernal and infant health rather than provide for a specifichigh-profile intervention in the hope of dramatic short-termgains.5. With a vision of "Better Life Through Better Health" and amission to protect and promote the community's health, theGenesee County Health Department (GCHD) was asked byits community partners to serve as the Central CoordinatingOrganization (CCO) because of its experience andrecognized success in facilitative, coordinating roles and itsleadership in community-based public health work. TheGCHD has broad experience as a coordinator of andparticipant in community-based work and as a catalyst forplanning and implementing change in public healthpractice, academic training, and community-based work.The membership of the Genesee County REACH Coalitionhas been composed of 10 core partners over the past sevenyears: (1) the Genesee County Health Department; (2)University of Michigan-School of Public Health-AnnArbor, (3) University of Michigan-Flint; (4) Faith Accessto Community Economic Development; (5) the GreaterFlint Health Coalition; (6) Genesee County CommunityAction Resource Department; (7) PRIDE (Programs toReduce Infant Deaths Effectively) Medical Services

Committee; (8) Flint Odyssey House Health AwarenessCenter; (9) Priority Children; and (10) Flint Family Road.The coalition adheres to the principles of community-basedresearch developed by the University of Michigan Schoolof Public Health and adopted by the Prevention ResearchCenter of Michigan. RESPECTFUL represents theapproach that steers community-based participatoryresearch in Genesee County: Respect each other’scontributions; Encourage change and promote knowledgein ways that benefit communities; Share credit andresponsibility for results; Promote an emphasis on locallyrelevant health issues; Examine the social, economic, andcultural influences on health; Collaborate on all majorphases of the research process; Treat research participantsethically; Furnish results to the community in a usefulmanner; Utilize community strengths and expertise; andLink research to action to enhance community capacity. Inits role as the CCO, the GCHD had responsibility formanagement and oversight of the REACH CAP.Community-based partners have been responsible forguiding the "trench" work, which explained during theplanning phase why the disparity continued to exist despitetwo decades of contributions from the "bench". Reasonsincluded problems of language, communication, trust,culture and racism. Partners helped to link “bench” and“trench” by building shared language and trust to promoteimproved understanding and communication, while at thesame time addressing structural problems in institutionsand systems to accomplish the goal of reducing AfricanAmerican infant mortality and racial disparity.6. During the first year of implementation, the GeneseeCounty REACH project was funded at $988,968, including$37,631 in in-kind contributions. In subsequent years (2-7),the funding was reduced to $912,062 including $28,595 inin-kind contributions.7. The REACH planning process examined racial disparitiesin infant mortality from both “bench” (science) and“trench” (community) perspectives. Racial disparities ininfant mortality in Genesee County have persisted despiteat least two decades of applied contributions from theclinical, scientific laboratory, and legislative “benches” toreduce these gaps. Although many explanations have beenproposed for the failure of standard interventions to reduceracial disparities, two of the most compelling explanationshave been central to the REACH project: 1. No singleintervention is likely to eliminate racial disparities in infant

health. Racial disparities arise from multiple factors: pooroutreach to and coordination of public health and medicalservices for high-risk patients; informal access barriers toneeded services; cultural barriers that hinder access andpatient adherence to beneficial health behaviors; structuralinequalities that promote poverty and communitydislocation; and internalized racism that fosters desperationand spiritual exhaustion in those communities at greatestrisk. 2. The period of pregnancy is simply too short toaddress effectively many risk factors important to infanthealth. A life-course perspective that focuses on improvedmaternal health is essential to improve birth outcomes inthe African American population. From this perspective,effective infant mortality prevention requires variedinterventions that go beyond prenatal or postpartum clinicalcare, to include primary prevention well before firstpregnancies; preconceptional care for planned pregnancies;postnatal intervention to prevent adverse outcomes amongnewborns and older infants and also to provide primaryprevention for future pregnancies and to increase intervalsbetween pregnancies. Given the multifaceted nature of thispublic health problem, multifaceted solutions are required.The Genesee County REACH initiative set in motion acomprehensive and sustainable process to improvematernal and infant health rather than provide for a specifichigh-profile intervention in the hope of dramatic short-termgains.8. Eight years prior to the REACH initiative, in 1992, theGCHD was the coordinating organization of a partnershipwith the University of Michigan School of Public Health,University of Michigan-Flint, and six predominatelyAfrican-American-led community-based organizations whotogether worked and identified themselves as the BroomeTeam. The Broome Team was part of a four-year initiativeto change public health professional education and practice.This was accomplished by linking practitioners andacademia in partnerships with community-basedorganizations, thereby enhancing the ability of publichealth systems to address societal health issues, particularlyin multicultural communities. Funded in 1992 as part of theW.K. Kellogg (WKK) Foundation's Community-BasedPublic Health (CBPH) Initiative, this project has led toimproved social and preventive health services throughinnovative programs and approaches incorporatingcommunity residents as equal partners in efforts to designand improve the public's health. An Institute of Medicine

eport featured the Broome Team in a section aboutcommunity collaboration: "Over the four years of theCBPH partnership, wide gaps in culture, race, trust,orientation, and history have been bridged among teammembers whose experience working jointly now forms thefoundation for work with an expanded network ofcommunity residents and organizations." In the evaluator'sreport back to WKK, the Broome team was described as "abeacon of hope for others who believe that healthycommunities can be created within a common visionthrough respectful, effective partnerships." When the WKKfunding ended in 1996, the partners continued to meetregularly and work on projects at their own expense inorder to sustain the commitment and relationshipsdeveloped. It was upon this foundation that the GeneseeCounty REACH initiative was built. As testament to thesustainability of the REACH infant mortality and healthdisparity work, the project was just refunded for anotherfive years, through 2012, and designated as a Center ofExcellence in the Elimination of Health Disparities underthe CDC’s REACH US program. Some REACH 2010interventions have become “institutionalized” within theregular programming and operating budgets of partneragencies. Some are now being supported by philanthropicgrant resources. Opportunities to leverage furthercommunity and financial commitments continue to bepursued.13. Education:a. FIMR Teams: Fetal and Infant Mortality Review Teams Currently two Counties in Ohio with FIMR teams (Cuyahoga andHamilton). Dr. Cynthia Shellhaas (OSU/ODH), Lisa Holloway (MoD), ArthurJames (OSU/NCH/ODH) interested in developing this concept forOhio. Consider making a subset of CFR Processb. Education Work-group: Find best Statewide models for us to consider emulating…1. California, NY, Florida, Minnesota, others.c. Monthly discussion with LDH’s about relevant infant mortality topics.d. “Health Alerts”14. Best Baby Zones:

(The following explanation was taken from a planning grant submitted to Kelloggfoundation by Dr. Michael Lu (Mario Drummond, Magda Peck, Cheri Pies,Milton Kotelchuck) on 5/12/2010 for consideration of establishing BBZ). Thisconcept hosted it’s inaugural meeting in New Orleans, Louisiana during the weekof 7/16/2012 and is launching in four cities (Cincinnati, Ohio; Milwaukee,Wisconsin; New Orleans, Louisiana; and a city in northern California)a. Goal: To eliminate disparities in child and family healthb. Objective: Establish (10) Kellogg Best Babies Zones (BBZs), with the firstand primary objective of closing the infant mortality gap in participatingcommunities in 10 years.c. Background: Despite advancements in clinical medicine and public health,racial-ethnic and socioeconomic disparities in child and family health persist.A new, bold, transformative approach is needed. Our system of care is fragmented at best; we spend more in the U.S.but achieve less The racial-ethnic and socio-economic inequities in health are mirroredin the inequities in the conditions and environments in which peoplelive We must take health promotion beyond clinical care While the first and primary objective of the BBZ is to close the infantmortality gap in 10 years, BBZ is also designed to close the gaps inchild obesity, asthma, developmental delays, etc. because the sameinequities that create the infant mortality gap also contribute todisparities in child and family health. The health gap in MCH is an underappreciated contributor to theachievement gap in schools that is a cause of poor productivity, higherrate of poverty and other national and social ills; closing the health gapin MCH is an important prerequisite to closing the achievement gapd. Approach: Multi-level, multi-sectoral, and life-course Multi-level: not only individual, but family, community, systems, andpolicy Multi-sectoral: not only health development, but educational,economic, and community development Life-course: not only disease prevention, but health promotion andoptimization over the life course, with strategic investments insensitive periods. We are creating “pipelines” to health.e. Conceptual Frameworks Ecological model and social determinants Health Equity Life-course health development

f. Design Systems approach in a defined geographical areas Prototypes in Michigan, Mississippi, New Mexico, Louisiana, NewYork, and California Zones defined by census tracts and/or school districts with1. Large health gap in maternal and child health2. high level of community readiness3. potential to succeed Place-based Community-driven Local Resource Center/Network approach Nations that have successfully achieved similar goals have anchoredcommunity interventions to a “Sure Start” center, or neighborhoodnetwork Collaborative Innovation Network (COIN)1. Sites serve as prototype in their local communities and ascenters of innovation2. Sites linked into a collaborative learning and innovationnetwork to support cross-site learning, innovation andimprovement strategies Common outcomes framework with local customizationg. Interventions Focus on 4 developmental strategies1. Health development2. Educational development3. Economic development4. Community developmenth. Health Development Goal: To eliminate disparities in child and family health Objective: To close the infant mortality gap in BBZs in 10 years Major Outcomes1. 90% of births in BBZ are intended at conception2. 90% of pregnant women in BBZ received preconception care3. 90% of pregnant women in BBZ received quality prenatal andintrapartum care4. 90% of pregnant/postpartum women in BBZ identified with aproblem (e.g. depression) receive care/support5. 90% of women in BBZ have a medical home before, between,and beyond pregnancy6. 90% of women in BBZ asked about their reproductive life planby a healthcare provider in the past year

7. 90% of women of childbearing age in BBZ engage in healthpromotingbehaviors daily (e.g. diet, exercise, intake ofmultivitamin containing folic acid)8. 90% of mothers in BBZ initiate breastfeed, 50% breastfeed in 6months, 25% breastfeed in 12 months9. 80% of women of childbearing age in BBZ are normal weight10. 90% of parents in BBZ are asked if they have concerns at thewell-child visit11. 90% of children in BBZ assessed with structural screeningtools by pediatrician12. 90% reduction in healthcare costs in BBZ related to healthdisparities for child and family13. 90% of youths in BBZ engage in health-promoting behaviorsdaily (e.g. diet, exercise) and avoid risky health behaviors (e.g.smoking, alcohol or drug use, unsafe sex).14. 80% of youths in BBZ are normal weight Change Concepts1. Preconception and interconception care2. Quality improvement in prenatal and intrapartum care (e.g.Breakthrough series)3. Systems integration (e.g. Patient-Centered Medical Home,Family Resource Center) and service redesign (e.g. Centering)and coordination (e.g. Nurse Family Partnership; promotora)4. “Pipeline to health”: Pipeline for health promotion andoptimization with multiple entry points (middle and highschools, preconception, pregnancy, interconception/earlychildhood)5. Cost control platform: Need to demonstrate that redesign willreduce or control healthcare costs Educational Development1. Goal: To eliminate disparities in child and family health2. Objective: To close the educational achievement gap in BBZsin 10 years3. Major Outcomesa. 90% of new parents in BBZ attended parentingeducation classesb. 90% of new parents in BBZ are ready to parentc. 90% of children in BBZ read to dailyd. 90% of children/families in BBZ receive enrichmentsupport from appropriate community resources (e.g.libraries, family resource centers, play groups)e. 90% of children in BBZ are in a quality early childhoodeducation setting with emphasis on resilience-buildingand problem-solving

f. 90% of children referred to specialized agenciescomplete the initial intake processg. 90% of children in BBZ have shared management plansacross agenciesh. 90% of youths in BBZ are in quality youthdevelopment programsi. 90% of youths in BBZ complete high school and go onto college Change Concepts1. “Baby college”: parenting education starting before birth2. Quality early child education: with greater emphasis onresilience building and problem-solving (e.g. Ypsilantipreschool program);3. System integration and service redesign/coordination: (e.g.integrating Early Head Start/Head Start with Healthy Start orother perinatal home visiting programs)4. “Pipeline to success”: akin to Harlem Children’s Zone withmultiple entry points (e.g. baby college, early childhoodeducation, “Promise Academy”, youth development, etc.), butstarts earlier and supports youth development with after-school,summer-school, and other pipeline programs);5. Health promotion: integrated throughout educational curriculaand through full-service school health clinici. Economic development Goal: To eliminate disparities in child and family health Objective: To reduce poverty rate by 50% in BBZ in 10 years bycreating pipeline from poverty to prosperity Major Outcomes1. 95% of middle and high school students in BBZ participate inclasses focused on teaching skills for achieving andmaintaining financial stability and security2. 95% of parents in BBZ participate in classes to increase theirskills for achieving and maintaining financial stability andsecurity, and have a financial plan (e.g. money management,savings) for their family3. 95% of middle and high school students in BBZ engaged inpipeline to success or pipeline to prosperity programs4. 90% of children/families in BBZ requiring safety net servicesreceive high quality, well-coordinated services5. 95% of workforce in BBZ employed in stable employment thatpays a living wage6. 50% reduction in the percentage of children in BBZ living inpoor households

7. 90% of families in BBZ move up by one income quintile in adecade Change concepts1. Financial stability and job readiness: promoting financialstability and security and job readiness with multiple entrypoints along the “pipeline to prosperity”, starting early inmiddle and high schools with financial stability training andpipeline programs.2. Safety net programs: creating a high-functioning, wellcoordinatedsystem of safety net programs (e.g. TANF,housing, food stamps, healthcare, childcare etc).3. Microfinance: providing microloans to support localentrepreneurialship.4. Job creation: stimulating job creation and creating a stable jobbase within BBZs with economic incentives.5. Policy and advocacy: increasing local capacity and collectiveefficacy to engage in policy and advocacy for economicdevelopment.j. Community Development Goal: To eliminate disparities in child and family health Objective: To promote strong families and healthy community in BBZin 10 years Major Outcomes1. 90% of births in BBZ are born to families with high level offather (or partner) involvement2. 90% of children in BBZ grow up in families with high level offather involvement3. 90% of men in BBZ have a medical home4. 90% of men in BBZ asked about their reproductive life plan bya healthcare provider in the past year5. 90% of men in BBZ engage in health-promoting behaviorsdaily6. 90% of fathers received preconception care7. 90% of residents in BBZ aware of the impact of racism on birthoutcomes8. 90% of residents in BBZ exercise at least 150 minutes perweek9. 90% of households in BBZ are food-secure10. 90% reduction in the percentage of pregnant women exposedto environmental toxicants in the workplace11. 90% reduction in the percentage of children in BBZ exposed toenvironmental toxicants at school or at home. Change Concepts

1. Family and fatherhood: multi-level (individual, relational,community, institutional, policy), multi-sectoral (health,education, economic), and life-course (e.g. reproductive lifeplanning beginning in middle and high schools) approach toput the “F” back in MCH2. Racial equity: in alignment with Kellogg’s Racial EquityStrategy, the BBZs will work on healing, repair, andreconciliation while taking on structural racism3. Transforming the “obesogenic environment”: in alignment withKellogg’s Food and Community Program, the BBZs will workon transforming physical and social environments to promotehealthy weight, with emphasis on increasing availability andaccessibility of healthy foods and opportunities for physicalactivities.4. Environmental justice: with emphasis on reducingenvironmental exposures to reproductive and developmentaltoxicants;5. Policy and advocacy: increase local capacity and collectiveefficacy for policy and advocacy for healthy (built and social)environmentk. Systems integration and innovations Systems integration1. Requires transformative leadership and trans-sectoralcollaboration2. Build trans-disciplinary, trans-sectoral leadership team at eachBBZ3. Summer Leadership Institute4. Build integrated data systems Innovations1. Engineer innovations across BBZs through CollaborativeInnovation Network (COIN)2. Use of appropriate incentives tied to performance andachievement of specific goals to support the adoption andspread of innovative change strategiesl. Policy Development Develop and work towards implementation of local, state and nationalpolicies that facilitate the multi-level, multi-sectoral, life-courseKellogg BBZ initiatives Remove the challenges, barriers and constraints that will inhibitgrowth, success, seeding and spread of the Kellogg BBZ initiatives Provide policies that enable, facilitate an enhance local capacity andregional capability to support the spread of Kellogg BBZ prototypes

m. Evaluation Will utilize our BBZ community metrics and data systems to providethe basis for outcome evaluation of the proposed Kellogg BBZInitiative. Planned variations across BBZs, and national/alternative communitybenchmarks, will provide basis for effective evaluation designs Will use a systems improvement approach with rapid cycles of changeto evaluate and optimize process performance at each BBZ Goal is to eliminate disparities in child and family health1. Primary objective is to close infant mortality gap in 10 yearsa. Preterm birthb. Fetal growth restriction/Small-for-gestational agec. Sudden infant death syndrome2. Secondary objective is to eliminate disparities in other childhealth outcomes, includinga. Obesityb. Asthmac. Developmental delays3. Tertiary objective is to eliminate disparities in family andcommunity healtha. maternal and/or paternal depressionb. family violencec. child abuse and neglectd. father absence Approach is not only to change individual developmental trajectories,but to shift entire population health curvea. Thus metrics focus on not only disease outcomes, butpositive health and developmental outcomes in 4 keydomains of development (health, education, economic,and community)b. Measurable outcomesn. Preconditions/Cross Site Support Community readiness1. levels of engagement of residents, institutions, andstakeholders2. amounts of social and venture capital raised3. degree of political will to support transformative change4. presence of transformative leadership5. strength of systems redesign6. capacity for community measurement and mapping7. preparedness for systems improvement and collaborationinnovation Data Systems

1. To measure positive (thriving) and negative (disease, disabilitydysfunction) health and development outcomes at theindividual and community level2. To measure longitudinal health and development trajectories3. To track systems improvement over time Outcomes and Performance Improvement Framework1. Structure site specific goals and measurement strategy2. Used to engage wider community, policy leadership and local,county, and state level stakeholders Collaborative Innovation, Improvement, and Learning Mechanism(COIN)15. Perinatal Regionalization: (look for revised guidelines to be released by theAAP during August of 2012). What is perinatal regionalization and how does it impact infanthealth? Perinatal regionalization is a system of designating where infants areborn or are transferred based on the amount of care that they need at birth. Inregionalized systems very ill or very small infants are born in hospitals that areable to provide the most appropriate care, with high-level technology andspecialized health providers. Regionalized systems define hospitals at riskappropriatelevels; Level III hospitals, for example, provide the most appropriatecare for the sickest infants. Regionalized systems are often designed, designated,and managed by state health departments, but in some states hospital networks ornon-profit groups make these decisions. Infants receiving risk-appropriate careare hypothesized to be more likely to survive when born too little or toosoon. The goal of a regionalized system is to reduce infant deaths. How are the current systems evaluated? There are limited formal evaluations ofthese regionalized systems. There exist multiple measures of regionalizationincluding reporting of the percentage of very low birth weight (VLBW) infantsborn at facilities for high-risk neonates (National Performance Measure #17 [NPM 17], Health Resources and Services Administration/Maternal and ChildHealth Bureau; HRSA/MCHB). Additionally, information reported on theCertificate of Live Birth (BC) (2003 revised version) may be used to estimate thenumber of VLBW infants who receive appropriate care, specifically, in aNeonatal Intensive Care Unit (NICU). What are leading agencies and institutions doing to help public healthprofessionals better understand the impact of perinatal regionalization oninfant health? In 2009, AMCHP, the Centers for Disease Control’s Division ofReproductive Health (CDC/DRH) and HRSA/MCHB sponsored a meeting on theimpact of perinatal regionalization and infant health. Attendees included selectedstate maternal and child health (Title V) directors, perinatal health researchers,and representatives from the American Academy of Pediatrics, American Collegeof Obstetricians and Gynecologists, and National March of Dimes. Specifically,the meeting focused on assessing the similarities and differences of theseregionalized systems in different states across the US. Additional topics includeddiscussion of the national indicators used to measure risk-appropriate care,

particularly NPM 17 (HRSA/MCHB). Meeting attendees described their state’sregionalized system and provided the most recent information on VLBW infantsborn at risk-appropriate facilities. Work from this meeting culminated inattendees recommending further development of guidelines for standardizingregionalized systems.This meeting was triggered by preliminary results of a CDC review of all currentliterature examining the impact of risk-appropriate care on infantsurvival. Researchers from CDC/DRH, the Rollins School of Public Health,Emory University, and the University of Maryland, School of Medicineconducted a meta-analysis of published research on risk-appropriate care in theUS. The major finding from this work indicates that VLBW and very preterminfants born outside of a level III hospital are at an increased likelihood ofneonatal death or death prior to discharge from the hospital. This work waspublished this month, National Infant Mortality Awareness Month, in the Journalof the American Medical Association (Lasswell SM, Barfield WD, Rochat RR,Blackmon LR. Perinatal Regionalization for Very Low-Birth-Weight and VeryPreterm Infants—A Meta-analysis, JAMA 2010; 304.9: 992-1000).Additionally, the CDC has also conducted analyses of the percentage of VLBWinfants admitted to the NICU following delivery. This research was conductedusing information obtained from the National Center for Health Statistics reportedby the 19 states that have implemented the revised 2003 BC which containsinformation on NICU admission. Findings from this research suggest that 77% ofVLBW infants were admitted to a NICU in 2006. This percentage is lowconsidering the high mortality rate of these infants. As noted by CDC/DRHDirector and neonatologist, Wanda Barfield, MD, MPH “these recent scientificfindings indicate that more work must be done to better understand the impact ofrisk-appropriate care on babies born too little or too soon. Our regionalizedsystems must be systematically evaluated to determine effective care of neonatesand prevent infant death”. AMCHP, CDC, HRSA/MCHB, and states willcontinue to partner on this important maternal and child health topic. For moreinformation, visit here.