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Reducing Infant Mortality in Maryland
Donald Shell, M.D., MACenter for Health Promotion
Family Health AdministrationDepartment of Health and
Mental Hygiene
2
Infant and Child Deaths
Percentage of Child Deaths By Age, Maryland, 2009
<1 year68.1%
1-4 years 8.4%
5-9 years 4.8%
10-14 years 7.8%
15-17 years10.8%
Data Source: MD DHMH, Vital Statistics Administration
3
Infant Mortality in Maryland & U.S.
Infant Mortality Rate, Maryland and U.S., 1984-2009
6
7
8
9
10
11
12
13
Year
Rate
per
1,0
00 l
ive b
irth
s
Mary land 11.7 11.9 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2
United States 10.8 10.6 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Source: MD DHMH:Vital Statistics Administration, CDC:NCHS* U.S. data for 2008, 2009 are not available
4
Leading Causes of Infant Mortality Maryland National Rankings
Infant Mortality - 07 42nd
Preterm Birth - 07 37th
Low Birth Weight - 08 41st
VLBW – 08 47th
5
Leading Causes of Infant Mortality
Causes of Infant Death, Maryland, 2009
Preterm/Low Birth Weight, 25.0%
Congenital Abnormalities, 15.9%
SIDS, 11.3%Maternal Complications,
7.6%
All Other Causes, 26.6%
Respiratory Distress, 2.4%
Sepsis, 3.0%
Necrotizing Enterocolitis, 3.1%
Complications of Placenta/Cord, 5.2%
Data Source: MD DHMH, Vital Statistics Administrationn = 541 deaths
6
Timing of Infant Deaths
Percent of Total Infant Deaths by Age at Death, Maryland, 2009
Postneonatal Mortality
29%
Neonatal Mortality
71%Data Source: MD Vital Statistics Administration
7
Percent of MD Births by Birth Weight 2009 Births
1.6%7.1%
91.3%
0%
20%
40%
60%
80%
100%
<1500 gm 1500-2500 gm >2500 gm
Birth Weight
Note: Includes only births to MD mothers in MD hospitalsData Source: MD Health Services Cost Review Commission
8
Birth Weight and Neonatal Deaths
Percent of Total Neonatal Deaths by Birth Weight, Maryland, 2007
≥2500 g9%
1500-2499 g9%
<1500 g82%
Data Source: MD Vital Statistics Administration
9
Racial Disparity in Infant Mortality
Infant Mortality Rates, Maryland, 2000-2009
0
5
10
15
20
Year
Rat
e p
er 1
,000
live
bir
ths
All Races 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2
White 4.7 5.5 5.4 5.4 5.6 4.7 5.7 4.6 5.2 4.1
Black 13.0 13.6 12.7 14.7 14.9 12.7 12.7 14.0 13.4 13.6
Hispanic 5.1 6.2 5.3 6.0 5.3 4.6 3.0 3.8 3.2 3.1
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Source: MD DHMH, Vital Statistics Administration
10
Racial Disparity in Preterm Births
Percentage of Births that are Preterm (<37 weeks gestation), Maryland, 2000-2009
6.0
8.0
10.0
12.0
14.0
16.0
Calendar Year
% P
rete
rm B
irths
All Races 10.8 10.8 10.9 11.0 11.3 11.3 11.4 10.9 11.0 10.4
White Non-Hisp 9.1 9.5 9.6 9.7 10.0 10.0 10.4 9.6 9.6 9.0
Black 14.5 13.9 14.2 14.3 14.3 14.3 14.1 13.9 13.9 13.9
Hispanic 8.6 9.1 8.8 9.1 9.4 9.7 9.3 8.9 9.4 8.6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Source: MD DHMH, Vital Statistics Administration* Gestational age computed via clinical estimate of gestationStarting in 2007, MD data include births of unknow n gestational age in the denominator
11
Racial Disparity in Low Birth Weight
Percentage of Low Birth Weight (<2500g) Infants, Maryland, 2000-2009
4
6
8
10
12
14
16
Pe
rce
nt
All Races 8.7 9.0 9.0 9.1 9.4 9.2 9.4 9.1 9.3 9.2
White 6.4 7.0 7.0 7.1 7.4 7.1 7.4 7.1 7.2 7.0
Black 12.9 13.0 13.3 13.1 13.2 13.2 13.4 12.9 13.2 13.0
Hispanic 6.5 6.9 6.9 7.0 7.3 7.2 6.8 7.3 7.1 6.6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Sources: MD DHMH, Vital Statistics Administration
12
Racial Disparity in VLBW Births
Percentage of Very Low Birth Weight (<1500g) Infants, Maryland, 2000-2009
0
2
4
6
8
Pe
rce
nt
All Races 1.9 2.0 1.9 1.9 2.1 1.9 1.9 1.9 1.9 1.8
White non-Hisp 1.2 1.4 1.3 1.3 1.3 1.3 1.3 1.2 1.2 1.1
Black 3.3 3.3 3.3 3.4 3.6 3.3 3.1 3.2 3.2 3.2
Hispanic 1.1 1.4 1.1 1.3 1.5 1.2 1.2 1.3 1.4 1.3
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Sources: MD DHMH, Vital Statistics Administration
13
Racial Disparities in Birth Outcomes
In Maryland, a Black infant ….
is 1 ½ times as likely to be born prematurely,
almost 2 times as likely to be born at low birth weight,
3 times as likely to be VLBW
and 2 ½ to 3 times as likely to die in the first year of life as a white infant.
14
BaltimoreCity
AnneArundel
Howard
Caroline
QueenAnne’s
PrinceGeorge’s
St. Mary's
Charles
Kent
Wicomico
Dorchester
Worcester
Montgomery
Talbot
Calvert
Somerset
Geographic Disparity in MarylandAverage Infant Mortality Rate, By Jurisdiction, 2005-09
BaltimoreCity
AnneArundel
Howard
Baltimore
Caroline
QueenAnne’s
PrinceGeorge’s
St. Mary's
Charles
AlleganyCarroll Harford
Cecil
Kent
Wicomico
Dorchester
Worcester
WashingtonGarrett
Frederick
Montgomery
Talbot
Calvert
Somerset
Geographic Disparity in MarylandAverage Infant Mortality Rate, By Jurisdiction, 2005-09
Legend
Rate per 1000 live births
2.7 – 5.0
5.1 – 9.0
9.1 -16.5
Data Source: MD Vital Statistics Administration
15
Behavioral Risks: Unintended Pregnancy Associated with Increased Neonatal Mortality *
* Bustan et al, AJPH, March 1994
Distribution of Mothers by Pregnancy Intention, Maryland, 2009
Didn't w ant to be pregnant then or later
12%
Wanted to be pregnant then
37%
Wanted to be pregnant sooner
18%
Wanted to be pregnant later
33%
Intendedpregnancies55%
Unintendedpregnancies45%
Data Source: Maryland PRAMS, 2009
16
Behavioral Risks: Teen Births Associated with Increased Infant Mortality
Birth Rate Among Adolescents (15-19 years), Maryland, 2000-2009
0
20
40
60
80
100
120
Rat
e p
er 1
,000
po
pu
lati
on
All Races 41.2 37.8 35.4 33.3 32.3 31.8 33.6 34.4 32.7 31.2
White 29.2 26.4 24.5 22.7 23.7 24.2 26.0 26.7 24.3 23.0
Black 67.5 61.0 57.6 53.0 49.9 48.0 49.6 50.8 49.7 47.4
Hispanic 63.9 72.6 74.1 81.0 77.5 87.2 91.6 95.5 84.0 66.4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Source: MD DHMH, Vital Statistics Administration
17
Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality
Percent of Births to Women Receiving 1st Trimester Prenatal Care, Maryland and U.S., 1998-2009
78
81
84
87
90
% o
f Bir
ths
MD 87.9 87.0 86.4 83.7 84.1 83.7 82.3 81.3 80.4 79.5 80.2 80.2
U.S.* 82.8 83.2 83.2 83.4 83.7 84.1 84.2 83.9 83.2
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Sources: MD: DHMH, Vital Statistics Administration, US: National Center for Health Statistics* US data for 2003-2006 represents 32 states using 1989 birth certif icate, US Data for 2007, 2008, 2009 for states using the 1989 birth certif icate w as not available
18
Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality
Percentage of Births to Women Receiving Late or No Prenatal Care, Maryland, 2000-2009
2
4
6
Per
cen
t
Maryland 3.1 3.7 3.6 3.8 3.9 4.3 4.3 4.7 4.2 4.7
U.S. 3.9 3.8 3.6 3.5 3.6 3.5 3.6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Sources: MD DHMH, Vital Statistics Administration, NCHS, National Vital Statistics Reports, U.S. data for 2007,2008, 2009 not available
19
Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality
Infant Mortality Rate by +/- Receipt of Prenatal Care and Race/Ethnicity, Maryland 2004-2008
0
10
20
30
40
50
Ra
te p
er
1,0
00
bir
ths
(i
n P
NC
su
bc
ate
go
ry)
1st, 2nd, 3rd Trim PNC 6.5 5.9 9.4 3.4
No PNC 35.9 31.6 43.1 22.9
All Races White Non-Hisp Black Non-Hisp Hispanic
Data Source: MD DHMH, Vital Statistics Administration
20
Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors
0
20
Pre
term
Bir
th R
ate
(Per
cent)
Maternal Race-Ethnicity
< Grade 8 Grades 8-12 Grades 13-15 > Grade 15
< Grade 8 19.6 11.0 10.7 11.5
Grades 8-12 16.8 9.9 10.4 10.5
Grades 13-15 14.5 8.3 9.3 9.1
> Grade 15 12.8 7.0 8.4 7.5
Black White Hispanic Asian
From NCHS 1998-2000 data, Preterm Birth, IOM, 2007
21
Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors
0
20
Pre
term
Bir
th R
ate
(Per
cent)
Maternal Race-Ethnicity
< Grade 8 Grades 8-12 Grades 13-15 > Grade 15
< Grade 8 19.6 11.0 10.7 11.5
Grades 8-12 16.8 9.9 10.4 10.5
Grades 13-15 14.5 8.3 9.3 9.1
> Grade 15 12.8 7.0 8.4 7.5
Black White Hispanic Asian
From NCHS 1998-2000 data, Preterm Birth, IOM, 2007
22
Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors
0
5
10
15
20
Maternal Race-Ethnicity
Infa
nt
Mo
rtali
ty R
ate
(death
s p
er
1,0
00
liv
e b
irth
s)
<12 yrs 12 yrs 13-15 yrs 16+ yrs
<12 yrs 8.3 14.1 8.0 2.6
12 yrs 9.9 14.7 6.7 4.6
13-15 yrs 7.0 11.1 4.5 2.6
16+ yrs 4.8 9.5 3.2 2.2
All Race/Ethnic Black White non-Hisp Hispanic
Data Sources: MD DHMH, Vital Statistics Administration
Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009
23
Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors
0
5
10
15
20
Maternal Race-Ethnicity
Infa
nt
Mo
rtali
ty R
ate
(death
s p
er
1,0
00
liv
e b
irth
s)
<12 yrs 12 yrs 13-15 yrs 16+ yrs
<12 yrs 8.3 14.1 8.0 2.6
12 yrs 9.9 14.7 6.7 4.6
13-15 yrs 7.0 11.1 4.5 2.6
16+ yrs 4.8 9.5 3.2 2.2
All Race/Ethnic Black White non-Hisp Hispanic
Data Sources: MD DHMH, Vital Statistics Administration
Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009
24
Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors
Infant Mortality Rates by Maternal Education and Race/Ethnicity, Maryland, 2005-2009
8.06.7
4.53.2
14.1 14.7
11.19.5
0
5
10
15
20
<12 yrs 12 yrs 13-15 yrs 16+ yrs
Years of Education Completed
Rat
e p
er 1
,000
live
bir
ths
0
1
2
3
4
Rat
io
White non-Hisp Black Black/White Ratio
Data Source: MD DHMH Vital Statistics Administration* Note - There w ere 95 infant deaths and 2,315 births among w omen in these race/ethnicity categories for w hom education level w as not stated.
25
Maryland’s Challenges
Racial disparities/System barriers Fiscal resources to address health Uninsured Safety net providers difficulties OB/GYN malpractice premiums Few providers for prenatal care Providers to see high risk patients
26
Governor’s Strategic Goal
Reduce infant mortality in Maryland
by 10% by 2012
*************************
2007 Baseline – 622 deaths, rate of 8.0/1,000 births
2012 Goal – 60 fewer deaths, rate of 7.2/1,000 births
27
Babies Born Healthy Initiative
Perinatal Collaborative
High-risk OB consultation outreach through the two academic medical centers
Updated standards for perinatal care
Real time access to data Birth records, death records, Pregnancy Risk Assessment
forms (PRAMS), hospital and practice specific outcomes, sleep-related deaths, FIMR, Child Fatality Review, MCO’s
28
What Works…Maryland Plan Built on Evidence Based Practices
Reducing unintended pregnancy
Promoting the health of women
Improving access to prenatal and postpartum care
Improving the safety and quality of obstetric
and neonatal care
29
Maryland Infant Mortality PlanBroad and Substantive Input
Maryland Infant Mortality Epidemiology Work Group – 2011 “Findings from Data Analysis and Overall Recommendations” Summarize research/recommendations
Gov. Forum on Children and Health 2011 - Infant Mortality Breakout
“The Role of Community Pediatricians in Preventing Infant Mortality” – Meeting
Web-based survey 339 Marylanders
30
Infant Mortality Epi Work Group 2011 Findings/Data Analysis/Recommendations
Chronic conditions before/during pregnancy Htn disorders during & preconception GDM, pre-preg DM, Ht Dz, IPV, asthma Depression, obesity, ETOH, tobacco use
Fertility treatment Infant sleep position, co-sleeping Maternal postpartum tobacco use
31
Infant Mortality Epi Work Group 2011 Findings/Data Analysis/Recommendations
Timing and effectiveness of risk-targeted prenatal care
Maternal age teens (Hispanic), > age 35
Prior pre-term birth Birth hospital level of care for VLBW Early term deliveries (37-38 weeks)
32
Partners include
Office of Minority Health and Health Disparities
Maryland Medicaid – coordinate MCO’s, birth outcome data
Behavioral Health referrals to and from Mental Hygiene Administration Alcohol and Drug Abuse Administration
Local Health Departments
DHMH coordination/data - WIC, Chronic Dz, Tobacco…
Department of Human Resources (DSS) Medical Assistance
Governor’s Office for Children – Home Visitation Program
Community Health Resources Commission - $ and data sharing
33
Partners include
MD Institute for Emergency Medical Services Systems (MIEMSS) with MD Perinatal Standards – Level III
MD Patient Safety Center – hosp d/c MSDE home visiting program & data Birthing Hospitals prohibit elective
deliveries <39 weeks, VLBW, breast feeding and tobacco cessation
FQHC case mgt, care coordination, community referrals, provider training
34
Partners include
MD Chapter AAP expertise and resources infant and child health
MD Chapter ACOG expertise and resources maternal health/birth out
Maryland Breast Feeding Coalition CareFirst BC/BS home visitation MCO facilitate early PNC entry Community Peds coordination and
communication with OB/GYN providers Cert. Nurse Midwives high risk @ PNC UMD and JHU Med & SPH expertise and
support
35
Intervention Across the Lifespan
PRECONCEPTION (Before
pregnancy)
Healthier women at time of
conception, planned
pregnancies
Earlier entry into prenatal
care
Comprehensive, high quality
perinatal and neonatal care
Healthier Children
and Adults
PRENATAL (During
pregnancy)
PERINATAL NEONATAL
(After delivery)
36
Oversight and Evaluation – Governor’s Delivery Unit and State Stat
Performance measurement system Developed by DMHM, GDU, State Stat Monthly Program and Health Outcomes Collection/Reporting target jurisdiction Annual Assessments State and Jurisdictional
Vital Statistics Medicaid Title X PRAMS
37
Strategy 1 – Before Pregnancy Expand access to women’s comprehensive health and
wellness services
• Transition family planning sites into Comprehensive Women’s Health Programs.
• Include screening/referral for Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, smoking cessation, weight management services.
•FQHC integration of reproductive & primary care, Title X FP Primary Provider training
• Culturally-competent outreach and education efforts in the community, Perinatal Navigators
38
Oversight and Evaluation – Strategy # 1 Governor’s Delivery Unit and State Stat
#comprehensive women’s health #referred to/from STD clinics #referred to/from behavioral health #FQHC Primary trained thru Title X #new Medicaid FP enrollees #enrollees utilizing Medicaid FP #visits to Title X FP clinics % unintended pregnancies
39
Strategy 2 – During Pregnancy Increase the # of women accessing early prenatal care
•LHD maternity sites implementation of Quick Start prenatal care program.
•12/1/09 Accelerated Certification of Eligibility (ACE) for pregnant women seeking Medicaid coverage, LHD, DSS
• Screening/referral - Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, and smoking cessation.
•PGCHD/UMD OBGYN Midwife Perinatology “Tapestry Program”
•2011 PGC FQHC initiation prenatal care
40
Oversight and Evaluation – Strategy # 2 Governor’s Delivery Unit and State Stat
#Medicaid “ACE” processed 10 days #total applications #weeks pregnant at application #women receiving Quick Start Ser. #Perinatal navigator pt encounters #pregnant women home visits
41
Strategy 3 – During & After Delivery Expand access to more comprehensive, high quality
perinatal and neonatal care•Develop a standardized hospital postpartum discharge process that ensures risk appropriate follow-up care for mother and infant.
•Breast feeding support, MH/SA services, DV support, smoking cessation, FP, Safe sleep instruction: Distributed thousands of B’more “Safe Sleep. Alone. Back. Crib” DVD
•4/1/2011 implemented standardized d/c referral form for high risk mothers to CBO’s
•Monitoring level I and II (MMQRC), level III (MIEMSS) birthing hospital compliance with Perinatal Standards VLBW deliveries
42
Oversight and Evaluation – Strategy # 3 Governor’s Delivery Unit and State Stat
# comprehensive women’s health #LHD postpartum referrals received # level I/II site visits conducted # Safe Sleep DVD’s distributed % VLBW deliveries @ level III hosp #postpartum home visits conducted
43
Summary of the Plan
APPROACH
• Assessing the Data & Targeting Disparities
• Building on Strengths & Partnerships
• Comprehensive Systems Approach
GOALS
• Healthier Women/ Planned Pregnancies
• Earlier Entry into Prenatal Care
• Improve Quality of Perinatal and Post-
Delivery Care
STRATEGIES
• Comprehensive Women’s Health Centers
• Expediting Medicaid eligibility / Quick Start
Prenatal Care
• Standardized hospital discharge protocols
44
Infant Mortality in Maryland & U.S.
Infant Mortality Rate, Maryland and U.S., 1984-2009
6
7
8
9
10
11
12
13
Year
Rat
e p
er 1
,000
liv
e b
irth
s
Mary land 11.7 11.9 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2
United States 10.8 10.6 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Data Source: MD DHMH:Vital Statistics Administration, CDC:NCHS* U.S. data for 2008, 2009 are not available
45
Governor’s Strategic Goal
Goal Re-Set in October 2010: Reduce both total and Black infant mortality
in Maryland by 10% by 2012*************************
2007 Total baseline – 622 deaths, Rate of 8.0/1,000 Black infant baseline – 369 deaths, Rate of 14.0/1,000
births
2009 Status – 541 deaths, Rate of 7.2/1,000 Black infant status – 343 deaths, Rate of 13.6/1,000 births
2012 Goal –Total rate ≤ 7.2/1,000 Black infant goal – 319 deaths, Black rate ≤ 12.6/1,000
births
46
2010 Infant Mortality in Maryland
Infant Mortality Rate, Maryland and U.S., 1986-2010
6
7
8
9
10
11
12
Rate
per
1,0
00 li
ve b
irths
Maryland 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2 6.7
United States 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8 6.6 6.4
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20072008
*2009
*2010
*
Data Source: MD Vital Statistics Administration, National Vital Statistics System* U.S. data for 2008, 2009 are preliminary. Data for 2010 are not available.
47
2010 Infant Mortality in Maryland
Infant Mortality Rates by Race, Maryland, 2001-2010
0
2
4
6
8
10
12
14
16
Rat
e p
er 1
,000
live
bir
ths
All Races 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2 6.7
White 5.5 5.4 5.4 5.6 4.7 5.7 4.6 5.2 4.1 4.1
Black 13.6 12.7 14.7 14.9 12.7 12.7 14.0 13.4 13.6 11.8
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Data Source: MD Vital Statistics Administration
48
What’s Next?
January 1, 2012 Expanded Maryland Medical Assistance
program eligibility for family planning to include all women at or below 200% of the federal poverty level
Developing standardized 34 hospital postpartum discharge process DHMH, MD Pt Safety Center Perinatal
and Neonatal Learning Network, MD Perinatal System Standards, MIEMSS
49
What’s Next?
Development of an integrated statewide Fetal Infant Mortality Review (FIMR) and State Child Fatality Review (SCFR) database DHMH, MD Medical Chirurgical Society,
LHD’s, FIMR, SCFR Define at-risk groups/factors ID’ed by
Infant Mortality Epidemiology Work Grp Targeted interventions