What Can We Do To Improve Infant Health : An Epidemiological Look at Infant Mortality In Missouri

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What Can We Do To Improve Infant Health? An
Epidemiological Look at Infant Mortality In
Missouri

• Pamela K. Xaverius, PhD, MA
• Public Health Epidemiologist
• Missouri Department of Health and Senior Services

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Outline

• Fetal and Infant Mortality An Epidemiological
  Perspective
• Stage 1 Hypotheses
• Reporting
• Cause and Timing at Death
• Maturity Specific Mortality
• Stage 2 Hypotheses
• Maternal Attributes
• Social and Physical Environment
• Health Services (e.g., ob care, ART)
• Barriers to Change
• Strategies for Lowering Infant Mortality/Morbidity

 
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Infant Mortality Rate MO vs. U.S., 1990-2002
MO
US
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Infant Mortality Rate, by Race U.S., 1990-2000
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Age at Death Fetal Neonatal PostNeonatal
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Fetal Deaths

• The fetal deaths recorded in Missouri since 1911.
• Fetal death is defined by statute (MRS-193) as
• Non-induced death, in utero
• No evidence of life (e.g., beating heart,
  pulsating umbilical cord, voluntary muscle
  movement)

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Reporting requirementsfor fetal deaths

• Model Law recommends 350 grams/20 wks
• All products of conception 7 States
• 16 weeks 1
  State
• 20 weeks or more/350 grams 39 States
• 500 grams or more 3
  States
• District of Columbia 20 wks or 500 grams

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Fetal mortality rates MO 1994-2003
FORMULA Fetal mortality rate fetal deaths with
stated or presumed gestational age of 20 weeks
per 1,000 live births plus fetal deaths. SOURCE
MO Vital Records- Linked birth / death files
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Neonatal Post-Neonatal Mortality in MO
1994-2004
FORMULA Neonatal mortality rate neonatal
deaths (less than 28 days old) per 1,000 live
births. SOURCE MO MICA- Linked birth-death
files
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Disparity Fetal Neonatal PostNeonatal
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Fetal mortality rates By Race 1994-2004
FORMULA Early fetal mortality rate fetal
deaths with stated or presumed gestational age of
20 weeks per 1,000 live births plus fetal
deaths. SOURCE MO MICA
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Infant Mortality Racial Disparity
SOURCE MO MICA
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Neonatal and Post Neonatal Mortality Racial
Disparity
SOURCE MO MICA
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Multiples Fetal Neonatal PostNeonatal
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Twin and triplet birth rates United States,
1980-2002
Twin
Triplet
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Multiples Fetal Mortality Rates
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Singleton versus MultiplesInfant Mortality Rates
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Multiples Neonatal and Post Neonatal Mortality
Rates
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Primary Hypotheses as to Why the Rates Fluctuate
REPORTING CAUSE TIMING OF DEATH MATURITY AT
BIRTH MATURITY SPECIFIC MORTALITY
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Reporting issues which may affect changes in
infant mortality rates

• Changes in reporting of deliveries at
  borderline of viability i.e., increased
  tendency to report delivery as live birth rather
  than fetal death
• Improved reporting of deaths of very small
  infants.
• Accuracy of LMP

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Re-engineered vital statistics systems

• More immediate, more thorough analysis
• More timely, higher quality data
• Data released within months of event
• Electronic death reporting - Births/infant deaths
  automatically linked data available
  simultaneously (2009)
• New, improved items (2006)
• Pregnancy risk factors - Infertility therapies,
  Infections
• Method of delivery - attempted trial of labor

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Causes and Timing of Death
Changes in specific causes of death (e.g.,
increase in injuries) Changes in the
classification of causes of death (e.g., medical
trauma, asphyxia, SIDS, etc) Changes in timing
of death, e.g., increase in hebdomodal
deaths Changes in causes and timing of death
within specific birth weight and/or gestational
age categories
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Five Leading Causes
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Infant Deaths Due to Birth Defects Missouri
1990-2002 Rate per 100,000
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Sudden Infant Death Syndrome in MO Rate per
100,000 (1990-2002)
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Maturity at Birth Maturity Specific Mortality

• Changes in proportion of high risk birth weight
  or gestational age infants
• Changes in proportion of small-for-gestational
  age infants
• Changes in birth weight or gestational
  age-specific survival, e.g., no temporal
  improvement in survival for lt1000 gram or lt24
  week infants
• Changes in survival of small-for-gestational age
  infants.

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Infant mortality rates by birthweight U.S., 2001
grams
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Birthweight-Specific Neonatal Mortality, by Race
U.S., 1995-97
Data source CDC/NCHS
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Birthweight-Specific Postneonatal Mortality, by
Race, U.S., 2001
Data source CDC/NCHS
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Secondary Hypotheses Regarding Disparity in the
Population
MATERNAL ATTRIBUTES ENVIRONMENTAL
ATTRIBUTES HEALTH SERVICES
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Maternal Attributes

•   Maternal demographic risks
• Age
• Race
• Marital Status
• Education, Income, Employment and SES
• Nativity and Immigrant Status
• Insurance.
• Pregnancy-related risks
• Maternal complications and infections
• Parity/ gravidity/ interval/ spacing
• Prior pregnancy outcomes and abortion use
• Prior health status (chronic disease, mental
  health, etc.)

•  Behavioral risks
• Tobacco, alcohol and drug/substance use
• Exercise/work
• Nutrition
• Genetic (including paternal) and
  intergenerational risks
• Beliefs and attitudes
• Intendedness.

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Maternal Race/ Ethnicity 1990 - 2002
.
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Smoking During Pregnancy in Missouri
(Rate per 100)
1990-2002
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Inadequate Prenatal Care in Missouri
1990-2003
(Rate per 100)
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Overall
White
Black
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15-17
18-19
20-24
25-29
30-34
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Environmental Attributes

•  Social Environment
• Family
• Community and Social Support Networks
• Poverty and Neighbor violence
• Physical Environment
• Toxins/pollutants/contaminants
• Infections
• Environmental Hazards
• Disasters

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Health Services

• Types of Systems/Services
• Preconception care and family planning
• Prenatal / OB care
• Perinatal Care (hospital levels
• Pediatric Care
• Public health
• ART, C-section and other medical procedures
• Attributes of Systems/Services
• Quality
• Content
• Organization and functioning
• Access and Availability
• Work force training
• Utilization of systems/services

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Rates of induction of labor bylength of
gestation U.S., 1990-2002
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Rates of cesarean delivery Missouri, 1994-2003
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Trends in ART use and births, 19962001
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Summary Thus Far

• Babies die at high rates in the USA, even higher
  in MO.
• The African American (AA) IMR is 20 years behind.
• AA babies die at a higher rate at all stages of
  life.
• Multiples pregnancies are on the rise, and at
  great risk.
• Vital records will be expanding data collected.
• The majority of infant deaths are caused by
  congenital anomolies, perterm birth/low birth
  weight, SIDS and maternal complications.
• We need to better understand birth weight
  distributions and maturity as they related to
  mortality
• We need to better understand the role of health
  services in serving pregnancies

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Strategies in Missouri
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Current Infant Mortality Initiatives

• Home Visiting Programs
• Toll Free Resources (Tel-Link/ MOTIS)
• Fetal and Infant Mortality Review (FIMR)
• Prenatal Case Management
• Maternal and Child Health (MCH) Program
• Healthy Start Programs
• Folic Acid Campaigns (Baby Your Baby)
• Reduction in HIV Transmission (Mother to Baby)
• Maternal-Child Health Coalitions
• Reaching Out to Women Who Smoke

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Proposed Projects For Further Investigating The
Infant Mortality Problem

• Perinatal Periods of Risk Analysis
• Epidemiologic Evaluation of Missouris
  Nurse-Family Partnership Program
• Sexually Transmitted Diseases During Pregnancy 
• Evaluating Responsible Reproductive Behavior
  Messages  
• Creating an MCFH Research Agenda

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Other Proposed Investigations for the Infant
Mortality Problem

• Evaluate interventions designed to increase
  proper infant sleep position, especially among
  the minority populations
• Identify strategies to prevent infant deaths due
  to injury
• Identify opportunities for improving infant care
  in minority populations
• Analyze sleep position and infant death
  connection through analysis of linked child death
  review and death certificate data
• Identifying states that have successfully
  decreased SIDS rates
• Conduct focus groups with African Americans to
  identify the key variables that influence infant
  care.

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Target Areas

• Increase understanding of culturally based
  barriers
• In-depth analytical evaluations (e.g., Fetal and
  Infant Mortality Review FIMR Perinatal Periods
  of Risk- PPOR St. Charles County investigations
  child death review)
• Infant and Child Health (e.g., focus groups in IM
  concentrated areas, healthy start programs
  maternal-child health programs and coalitions)
• Maternal Health (e.g., STD studies Evaluate how
  MO providers are trained)
• Maternal Care (e.g., home visiting programs
  prenatal case management smoking cessation)
• Identification of evidence-based practices
  regarding infant health (e.g., infant sleep
  position, infant injury prevention infant care
  in minority populations SIDS)

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In an age of unprecedented health prosperity, the
persistently high infant mortality and associated
racial disparities are both unacceptable and
under active evaluation in the state of Missouri.