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Disclosure  of  Relevant    Financial  Relationships   2ND  PERINATAL  HOSPITAL  LEADERSHIP  SUMMIT  MAY  6,  2014 It  is  the  policy  of  North  Memorial  Health  Care  accordance  with  the  Accreditation  Council  for  Continuing  Medical  Education  (ACCME),  to  ensure  balance,  independence,  objectivity,  and  scientific  rigor  in  all  CME  activities.      

As  planners  and  speakers  of  the  2nd  Perinatal  Hospital  Leadership  Summit,  the  following  physicians  and  their  spouse/partner  disclose  that  they  do  not  have  any  relevant  personal  financial  relationship  with  a  commercial  interest  producing  health  care  goods  or  services  about  this  educational  activity:                    

 

•  Dr.  Dana  Barr  •  Linda  Dech,  MPH,  IBCLC    •  Dr.  Edward  Ehlinger  •  Pam  Galle,  IBCLC  •  Dr.  Pam  Heggie,  FAPP,  

IBCLC  •  Mary  B.  Johnson  

•  Evelyn  Lindholm,  BSN,  RNC,  IBCLC  •  Marcia  McCoy,  IBCLC  •  Dr.  Raylene  Phillips  •  Dr.  Philip  Rauk  •  Dr.  Eleanor  Schwartz  •  Juliann  Van  Liew  

CREATING HEALTH FOR ALL MINNESOTANS A CALL TO ACTION

FOR BEST PRACTICES IN MOTHER-BABY CARE

Perinatal Hospital Leadership Summit Crowne Plaza Minneapolis West

May 6, 2014

Edward P. Ehlinger, MD, MSPH Commissioner of Health

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Rabindranath Tagore born on May 6, 1861

• Bengali poet, novelist, composer. Nobel Prize for literature in 1913.

• “The sparrow is sorry for the peacock at the burden of his tail.”

Minnesota Is a Healthy State

Source: United Health Foundation

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1

2

3

4

5

6

7

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Minnesota’s State Health Ranking

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Infant Mortality Rate in MN is 5th Best

Overall Infant Mortality

6.49

7.72 7.65 7.41 6.97

6.44

5.36

7.09

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

All Other OH MI IN IL WI MN Total

Dea

ths

per 1

,000

Region V

Regions Region V

Ashley Schempf Hirai, PhD, MCHB

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Racial/Ethnic Components of Excess Deaths*

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

OH MI IN IL WI MN Total

Exce

ss D

eath

s pe

r 1,0

00

due to racial/ethnic composition

due to higher NH Black IMR

due to higher NH White IMR

due to higher Hispanic IMR

due to higher NH Other Race IMR

* Compared to All Other Regions Ashley Schempf Hirai, PhD, MCHB

Rabindranath Tagore born on May 6, 1861

• “The sparrow is sorry for the peacock at the burden of his tail.”

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Less than 1000 grams 1000 to 1499 1500 to 1999 2000 to 2499 2500 to 2999 3000 to 3499 3500 to 3999 4000 to 4499 Greater than

4499 1989 50.9 7.5 3.9 0.8 0.2 0.1 0.1 0.1 0.1 2008 35.9 5.0 1.8 0.6 0.2 0.0 0.1 0.1 0.1 2011 31.3 3.2 2.4 0.8 0.1 0.1 0.0 0.1 0.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Perc

ent

Birthweight

Neonatal Infant Deaths as a Percent of Births by Birthweight, Minnesota 1989, 2008 and 2011 (Birth Year)

1989

2008

2011

Source: MDH, Center for Health Statistics, Linked Birth/Infant Death Files

Birthweight-specific neonatal mortality — United States, 1950, 1985, and 2008

Morbidity and Mortality Weekly Report (MMWR) - August 9, 2013 / 62(31);625-628

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Excess Black Deaths* by Gestational Age

26% 16% 18% 63%

88% 137%

38% 17%

26% 47%

33%

20%

58%

58%

35%

43%

74% 42%

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

2.50

OH MI IN IL WI MN^ Total Exce

ss D

eath

s pe

r 1,0

00 due to gestational age

distribution

due to higher mortality among preterm infants

due to higher mortality among term infants

* Compared to All Other Regions ^ US-born Black mothers Ashley Schempf Hirai, PhD, MCHB

John F. Kennedy

• May 6, 1957 – awarded the Pulitzer Prize for Biography.

• Quoting Luke 12:48, he said, “To those whom much is given, much is expected.”

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Advancing Health Equity Report February 1, 2014

• “…the opportunity to be healthy is not equally available everywhere or for everyone in the state.”

0

2

4

6

8

10

12

14

16

Rat

e pe

r 1,0

00 b

irths

Black/ African-American NH American Indian NH Asian NH

Hispanic*

White NH

Total

Infant Mortality Rates by Race Minnesota Center for Health Statistics

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Infant Mortality Black-White Disparity in MN is one of the highest in the US

7.14 8.24

8.94 8.01 8.14 8.71

9.45

8.28

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

10.00

All Other OH MI IN IL WI MN* Total

Dea

ths

per 1

,000

Regions Region V

Rate Ratio 2.32 2.31 2.51 2.24 2.48 2.63 3.05 2.43 Population Attributable Fraction 16% 18% 22% 13% 20% 14% 11% 18% *US-born Black mothers

Congenital hearing loss

120

66 0

50

100

150

Baby of black mother

Baby of white mother

Days to Diagnosis

37

64

0

20

40

60

80

Baby of black mother

Baby of white mother

Percent Diagnosed within 3 months

71 61

51

0 20 40 60 80

Child of black mother

Child of Asian mother

Child of white mother

Median days to hearing aid fitting

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Rabindranath Tagore born on May 6, 1861

• Bengali poet, novelist, composer. Nobel Prize for literature in 1913.

• “You can't cross the sea merely by standing and staring at the water. Don't let yourself indulge in vain wishes.”

ADVANCING HEALTH EQUITY IN MINNESOTA

Report to the Legislature February 2014

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Healthy Minnesota 2020

All people in Minnesota enjoy healthy lives and healthy communities.

Minnesota’s vision for health

Change the narrative about what creates health

• Disparities are not just because of lack of access to health care or to poor individual choices.

Social and Economic Factors

40%

Health Behaviors 30%

Clinical Care 10%

Physical Environment

10%

Genes and Biology 10%

Factors determining health

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Determinants of Health • Necessary conditions

for health (WHO) " Peace " Shelter " Education " Food " Income " Stable eco-system " Sustainable resources " Social justice and

equity

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

Healthcare is a Social Determinant • “Social determinants usually identified as influencing health and health equity include those such as housing, employment and education. Growing evidence shows that health systems are themselves social determinants. …health systems have ‘upstream’ influence as well, extending even to impacts on the broader socio-political environment.”

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Healthcare is a Social Determinant • “…when appropriately designed and managed, health systems can address health equity…when they specifically address the circumstances of socially disadvantaged and marginalized populations, including women, the poor and other groups excluded through stigma and discrimination…and they may be influential in building societal and political support for health equity.”

•  The World Health Organization’s Commission on the Social Determinants of Health

How to capitalize on the opportunities for infants? 24

Improve Birth Outcomes •  Reduce premature births •  Reduce early elective inductions

Improve breastfeeding rates •  Address barriers

• Knowledge • Support • Employment & Child Care • Hospital Maternity Care practices

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CoIIN Collaborative Improvement & Innovation Network

Healthy Babies are Worth the Wait http://www.health.state.mn.us/divs/cfh/program/prematurity/

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Infant Mortality State Plan

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Breastfeeding as a Public Health issue

“Breastfeeding is a public health issue not just a lifestyle choice” AAP recommends…exclusive breastfeeding for 6 months & continued breastfeeding after introduction of baby foods for 1 year or longer …

AAP 2012 Breastfeeding Policy Statement PEDIATRICS Volume 129, Number 3, March 2012 e827

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Benefits of Breastfeeding • Improves health outcomes in babies – short and long-term

• Improves health outcomes in mothers

• Saves money

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Risks of Not Breastfeeding

100

178

257

6732

6423 18

56

138

427

0

50

100

150

200

250

300

Excess  Risk  Associated  with  Not  Breastfeeding  (%)

Adapted from Surgeon General’s Call to Action. http://www.surgeongeneral.gov/topics/breastfeeding/

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Breastfeeding… saves money Reduces cost of care in baby’s 1st year of life

• 25% fewer ear infections • 60% less diarrhea • 200% fewer admissions for pneumonia • Formula cost for 1 year $1,800

Reduces cost of care for lifetime – Mother/Child • Less cancer, obesity and heart disease in mothers • Less SIDS, infection, obesity , diabetes, asthma in children •  If 90% of mothers exclusively breastfed at 6 months

• Save $13 billion/year in the US • Prevent 911 deaths

Bartick M, and A Reinhold. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010 May;125(5):e1048-56. Epub 2010 Apr 5.

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Breastfeeding Rates - 2013

0

10

20

30

40

50

60

70

80

90

Ever BF 6 mo 12 mo Excl BF 3 mo Excl BF 6 mo

77

49

27

38

16

74

49

23

47

24

82

61

34

46

26

US

MN

Healthy People 2020 Goals

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http://www.cdc.gov/breastfeeding/pdf/2013BreastfeedingReportCard.pdf

41.6

45.8

30.4

14.9

30.9

30.2

32.6

52.1

56.4

47.0

23.3

47.2

37.1

42.3

0 10 20 30 40 50 60 70 80 90 100

Overall

White

African American

Foreign born Black

American Indian

Other Race

Hispanic

Percent

Exclusively Breastfed* at 4 & 8 Weeks, Statewide by Race/Ethnicity:

MN PRAMS 2009-10

4 Weeks Breastfeed Only

8 Weeks Breastfeed Only

#

^

^

* Includes mother who ever breastfed ^ p< 0.05 African American vs Foreign born Black <30 respondents were Asian; data not reported.

^

^

Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health This data was made possible by grant number IU01DP003117 from the Centers for Disease Control and Prevention

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Breastfeeding Initiation by Race/Ethnicity in Minnesota WIC

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

American  Indian  NH

Asian  NH

Black/  African-­‐American  NH

White  NH

Multiple  Races  NH

Hispanic

Healthy  People  2010

Healthy  People  2020

http://www.health.state.mn.us/divs/fh/wic/statistics/bffactsheet0312.pdf

MN WIC has 75% Initiation Rate

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What Is the Baby-Friendly Hospital Initiative?

•  International hospital designation in Maternity Care •  Implies clinical excellence in hospital care similar to a Trauma Center or Magnet status

• Developed by UNICEF and WHO in 1991 to reduce worldwide infant mortality

• Recognizes hospitals for best-practice maternity care and lactation support

• Promotes evidence-based practices known to improve breastfeeding rates “Ten Steps to Successful Breastfeeding”

• Ten Steps endorsed by AAP in 2009

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The Ten Steps to Successful Breastfeeding

1. Written Breastfeeding

Policy 2. Train all

Healthcare Staff

3. Inform all Pregnant Women of Benefits

4. Help Mothers Initiate BF within

One Hour

5. Show Mothers How to BF and Maintain

Lactation

6. Give Newborn Infants Only Breastmilk

7. Practice Rooming In

8. Encourage BF on Demand

9. Give No Pacifiers or

Artificial Nipples to Breastfeeding

Infants

10. Foster the Establishment of

BF Support Groups

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Baby Friendly Hospital Initiative: Increases exclusive breastfeeding rates

41

77

0 10 20 30 40 50 60 70 80 90

100

Britain

% E

xclu

sivi

ty

Before After

5

33.5

0 10 20 30 40 50 60 70 80 90

100

Boston Medical Center

% E

xclu

sivi

ty

Before After

Cattaneo A, Buzzetti R. BMJ 2001, 323:1358-1362

Philip et al. PEDIATRICS 2001, 108:677-681

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Exclusive Breastfeeding Rates at MN Hospitals after Ten Steps 37

Before  BFHI  

A6er  BFHI  

0  

10  

20  

30  

40  

50  

60  

70  

80  

90  

100  

2009   2011  

%  Exclusive  BF  

U  of  M  Amplatz    

41  

71  

18  

45  

0  

5  

10  

15  

20  

25  

30  

35  

40  

45  

50  

2012   2013  

%  Exclusive  BF  

HCMC  

Before  BFHI  

 

A6er  BFHI  

Formula Introduction in the Hospital Decreases Breastfeeding Duration in MN WIC Infants

•  50% of Minnesota WIC infants received formula while in the hospital.

•  Infants fed formula in the hospital were 144% more likely to have stopped breastfeeding by three months than those with no formula in the hospital.

Minnesota WIC Summary Statistics Supplemental Report-Breastfeeding: July 2009 – June 2010. Additional analysis by Karl Fernstrom, MPH candidate UofM SPH.

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Baby Friendly: Global and Local •  20,000 hospitals in 150 countries are

designated Baby- Friendly (9/2013)

•  7% of US birth hospitals certified Baby-Friendly •  167 / 2420 birth hospitals in the U.S (9/2013)

•  In Minnesota 2/97 birth hospitals are Baby-Friendly certified •  Mayo-Austin Medical Center Jan 2011

•  U of MN Amplatz Children’s Hospital Feb 2012

•  Soon to be others •  16 hospitals engaged in Baby-Friendly program

with letter of intent signed by CEO

•  HCMC & Regions have CDC grant

Racial Disparity in Breastfeeding Rates Reduced at Baby-Friendly Hospitals • Disparities in breastfeeding rates in low income and women of color – many years

• Biased view that there is a “cultural” reason •  “that’s their culture, they always supplement” •  “they don’t breastfeed”

• The Research says otherwise…. • Babies born in Baby-Friendly Hospitals have higher BF

rates across all income and ethnicities **

**Merewood, et al J Hum Lact 2007 May; 23(2) and Merewood, et al Pediatrics 2005 Sep;116(3)

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Baby-Friendly Reduces Racial Disparities

http://www.calwic.org/storage/documents/factsheets2013/statefactsheet2013FINALrevised.pdf

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Sigmund Freud born May 6, 1856

• Austrian psychoanalyst. Developed the concept of the subconscious mind; founded psychoanalysis.

• “Thought is action in rehearsal.”

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Minnesota Mother-Baby 10 S.T.E.P.S. Program Striving Towards Excellence in Perinatal Services

What: §  Call to Action by MDH §  Maternity Center quality improvement program

Goals:

1.  Reduce statewide infant mortality 2.  Increase statewide breastfeeding rates 3.  Reduce mother-baby health disparities in Minnesota

How:

§  Implementation of WHO best practice mother-baby care §  Ten Steps to Successful Breastfeeding in all MN maternity centers §  Voluntary participation in Baby-Friendly Hospital Initiative OR adoption of

10 steps in hospitals & birth centers across Minnesota §  Assistance from MDH and MN Breastfeeding Coalition

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“Public health is what we, as a society, do collectively to assure the conditions in

which (all) people can be healthy.” -Institute of Medicine (1988), Future of Public Health

Edward P. Ehlinger, MD, MSPH Commissioner, MDH P.O. Box 64975 St. Paul, MN 55164-0975 Ed.ehlinger@state.mn.us

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MDH-Supported Initiatives to Reduce Health Disparities

•  Back to Sleep Campaign à Safe to Sleep Campaign •  Abinouji Leech Lake Tribal Health Infant Mortality Conference

(2010) •  African American Infant Mortality Summit (2013) •  Infant Mortality Reduction Plan Stakeholders’ Meetings (2013) •  Eliminating Health Disparities grants

• Perinatal Hospital Leadership Summit (2013 & 2014)

•  MN Medicaid Family Planning Waiver •  Child Care Back to Sleep law (2013) •  Healthy Babies are Worth the Wait campaign •  MN Prematurity Coalition •  And more…

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