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Effective Review of Natural Infant Deaths 2018 NATIONAL CHILD DEATH REVIEW CONFERENCE Helping Communities Celebrate More Birthdays May 8, 2018
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Effective Review of Natural Infant Deaths
2018 NATIONAL CHILD DEATH REVIEW CONFERENCE
Helping Communities Celebrate More Birthdays May 8, 2018
Caveat!
• We aren’t asking our CDRs to turn into FIMRs!
• How can we build capacity for teams to think strategically and creatively about how CDR can address natural infant deaths in a meaningful way?
Infant mortality
• Definition: The death of any live born infant prior to his/her first birthday.
• “ . . . the most sensitive index we possess of social welfare . . . ”
Sir Arthur Newsholme
Infant mortality in the United States
• 3,978,497 births in 2015– 8.1% were low birth weight (less than 5.5 pounds)– 9.6% preterm, (born less than 37 weeks gestation
• 23,215 infant deaths• Rate of 5.84 deaths per1,000 live births
https://www.cdc.gov/nchs/fastats/infant‐health.htm
US infant mortality trends
6.89 6.86
6.686.75
6.61
6.39
6.14
6.07 5.98
5.965.89
5.2
5.4
5.6
5.8
6
6.2
6.4
6.6
6.8
7
2000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Deaths per 1,000 Live Births
Data Source: https://www.cdc.gov/nchs/nvss/linked‐birth.htm
US Infant Mortality Ranking: 27th
2.32.52.5
2.72.8
3.23.2
3.43.43.4
3.63.63.73.83.83.83.83.9
4.14.2
55.3
5.55.7
6
0 1 2 3 4 5 6 7
Japan
Sweden
Norway
Spain
Germany
Belgium
Israel
Ireland
Switzerland
Australia
Poland
New Zealand
United States
MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: UnitedStates and Europe, 2010. National vital statistics reports; vol 63 no 5. Hyattsville, MD: National Center for Health Statistics. 2014.
Disparities in Infant Mortality Rates
11.11
7.61
5 5.06
4.1
0
2
4
6
8
10
12
Non‐Hispanic Black American Indian orAlaskan Native
Hispanic Non‐Hispanic White Asian, Pacific Islander
Deaths per 1,000 Live births
Data Source: https://www.cdc.gov/nchs/nvss/linked‐birth.htm
23,347 Infant Deaths 3,965 3,965 1‐4
5,4115‐14
10,18615‐19
Impact of Infant Deaths on Overall Child Mortality
• There were 42,909 deaths of youth and children <19 in the US in 2015.
• More than half of those deaths (54%) occurred before the 1st birthday.
Sources: Division of Vital Statistics, 2017; National Center for Health Statistics, 2017; Murphy, S; Xu, J.; Kochanek, K.; Curtin, S.; & Arias, E., November 2017)
First Year of Life Next 18 Years of Life
Preterm related infant mortality
• 36.5% of all infant deaths in the US are preterm related
• Prematurity rate is not going down– Preterm birth rate rose for
the second straight year in 2016, up 2% from 9.63 in 2015 to 9.84 in 2016
• Goals: 8.1% by 2020, 5.5% by 2030
11.6
12.712 11.7 11.5 11.4
9.57 9.63 9.84
0
2
4
6
8
10
12
14
2000 2005 2010 2011 2012 2013 2014 2015 2016
Preterm Birth Rates, US
https://www.marchofdimes.org/mission/prematurity‐reportcard.aspx
Birth Defects
• Accounts for about 20% of IM annually– Affect 1 in every 33 infants (about 3% of all babies) born in the US each year
• Causes– Maternal smoking, drinking, drugs use during pregnancy– Medical conditions such as obesity, infections, diabetes– Teratogens: radiation, chemicals, drugs– Family Hx of birth defects– Older maternal age (over 34)
Birth Defects Prevention
• Most of prevention is aimed at reducing exposures and managing risk factors– Regular prenatal care– Healthy weight – Avoid tobacco, alcohol, drugs– Prevent infections– Manage diabetes and any other chronic medical condition
• 400 micrograms (mcg) of folic acid every day– 4,000 micrograms (4.0 mg) daily if previous neural tube defect
Status of Reviews in the NFR‐CRS
• Of the 205,621 cases reviewed by teams in the NFR‐CRS: – 54% (110,743) are infants under the age of 1
• 31,751 were prematurity/low birth weight • 12,058 were congenital anomalies
The 4 “Rs” of successful review of Natural Infant Deaths
• Identify Risk factors• Get the Right People to the table• Gather the Right information
– Get a clear picture of maternal health history– Past pregnancy outcomes
• Recommendations – best practices and strategies to reduce preterm infant deaths
Risk factors for preterm birth
• Maternal• Fetal• Placental
• Biological• Psychological• Social
Biological risk factors
• Multiple pregnancies• Abnormal uterine or cervical anatomy– Uterine fibroids– Cervical insufficiency
• Infection – UTI, placenta• Placental abnormalities• Alcohol / drugs / cigarettes
Biological risk factors
• Previous preterm birth• Especially young or advanced age• Underweight or overweight• Fetal abnormalities• Short interpregnancy intervals
Biological risk factors
• Poor nutritional status• Chronic maternal health issues
– High blood pressure– Diabetes– Blood clotting disorders
Psychological risk factors
• Stress• Anxiety / depression• Domestic violence or abuse
Social risk factors
• Low socioeconomic status• Late / incomplete prenatal care• Lack of social support• Unmarried• Long work hours / extended standing• Environmental exposures• Exposure to racism
The truth about race . . .
“We need to stop saying and teaching that being Black is a risk factor for illness and death. Instead, we need to start telling the truth: It’s exposure to racism that is the risk factor.”
Joia Crear‐Perry, president and founder of the National Birth Equity Collaborative, (NBEC)
https://rewire.news/article/2018/04/11/maternal‐health‐replace‐race‐with‐racism/
The 4 “Rs” of successful review of Natural Infant Deaths
• Identify Risk factors• Get the Right People to the table• Gather the Right information
– Get a clear picture of maternal health history– Past pregnancy outcomes
• Recommendations – best practices and strategies to reduce preterm infant deaths
Team Composition
• Medical Expertise– Obstetrics– Maternal Fetal Medicine
– Pediatrics– Pathology– Emergency Department
– Family Practice– Psychiatry
Team Composition
• Other Health Care Providers– Nurses– Social Workers– Dietitian– Discharge Planning– Home Care & Home Visiting
Team Composition
• Human Service Providers– Child Welfare Agencies
– Mental Health– Substance Abuse
• Housing Authority• Transportation Authority
Team Composition
• Public Health– Medicaid– Health Plans – WIC– Family Planning– Outreach Workers
Team Composition
• Advocacy Groups– March of Dimes– Healthy Mothers/Healthy Babies
– Family Support Groups
The 4 “Rs” of successful review of Natural Infant Deaths
• Identify Risk factors• Get the Right People to the table• Gather the Right information
– Get a clear picture of maternal health history– Past pregnancy outcomes
• Recommendations – best practices and strategies to reduce preterm infant deaths
Sources of information for Maternal Health History
• Birth and Death certificates• Prenatal records
– OB/GYN history, past pregnancies• Hospital records
– Antepartum– Delivery– Newborn/NICU– ED admissions
Sources of information for Maternal Health History
• Public Health Records– Home Visiting– WIC– Family Planning– Support services (CSHC, Home Visiting, Healthy Start)
• Human Service Records (including CPS histories)• Police reports (domestic violence, other stressors)
The 4 “Rs” of successful review of Natural Infant Deaths
• Identify Risk factors• Get the Right People to the table• Gather the Right information
– Get a clear picture of maternal health history– Past pregnancy outcomes
• Recommendations – best practices and strategies to reduce preterm infant deaths
Recommendations
Improving Health Care Services
Strengthening Families and Communities
Medical Clinical Interventions
Preconception care Father Involvement Hydroxyprogesterone (P‐17)
Improve access and quality of prenatal care
Care coordination and systems integration
Cervical Cerclage
Risk Assessment, screening, treatment, referrals
Implement strategies to reduce implicit bias in Health Care settings
Eliminate early elective deliveries for non‐medical reasons
Post Partum Care Access to evidence based home visiting
https://www.acog.org/Clinical‐Guidance‐and‐Publications/Committee‐Opinions/Committee‐on‐Obstetric‐Practice/Optimizing‐Postpartum‐Care
