Winning the Fight against Infant Mortality in Regions IV & VI

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Winning the Fight against Infant Mortality in
Regions IV VI
Michael C. Lu, MD, MPH Chair Secretarys
Advisory Committee on Infant Mortality Regions
IV VI Infant Mortality Summit New Orleans,
LA January 12-13
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• E Pluribus Unum

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Infant mortality rates, selected countries, 2005
Source Health, United States, 2008
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Infant mortality rates, United States, 2007
An infant death occurs within the first year of
life. Source National Center for Health
Statistics, final mortality data, 1990-1994 and
period linked birth/infant death data,
1995-present. Retrieved January 10, 2012, from
www.marchofdimes.com/peristats.
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Infant mortality rates, United States, 2007
Source CDC/NCHS linked birth/infant death data
set, 2007.
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Racial Gap in Infant Mortality1980-2007
Data Source NCHS
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• We Can Do Better

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Richmond-Kotelchuck Model
Knowledge Base
Political Will
Social Strategy
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Richmond-Kotelchuck Model
Knowledge Base
Political Will
Social Strategy
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Major Pathways to Spontaneous Preterm Birth

• Premature Activation of Maternal-Fetal HPA Axis
  (Stress)
• Infection/Inflammation
• Uteroplacental ischemia or thromboses
• Uterine overdistension

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Components of preterm birth
Spontaneous preterm labor 40-45
Source Goldenberg et al. Lancet, 2008.
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Spiral Arteries (non-pregnant)
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Spiral Artery (pregnant)
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Spiral Artery (Preterm)
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• Life Course
• Perspective

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Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in
birth outcomes a life-course perspective.Matern
Child Health J. 2003713-30.
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Richmond-Kotelchuck Model
Knowledge Base
Political Will
Social Strategy
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• SACIM
• Priorities

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SACIM Members

• Mark Bartel, M. Div, BCC
• Sharon M. Chesna, M.P.A.
• Robert Mande Corwin, M.D., FAAP
• Raymond L. Cox, Jr., M.D., M.B.A.
• Phyllis Armelle Dennery, M.D.
• Tyan A. Parker Dominguez, Ph.D., M.P.H., M.S.W.
• Carolyn L. Gegor, C.N.M., M.S., F.A.C.N.M.
• Arden Handler, Dr. P.H., M.P.H.
• Fleda Mask Jackson, Ph.D., M.S.
• Kay A. Johnson, M.P.H., Ed. M., B.A.
• Miriam Harriet Labbok, M.D., M.P.H.

• Michael C. Lu, M.D., M.S., M.P.H.
• Joanne B. Martin, Dr.P.H., R.N., FAAN
• Monica Mayer, M.D.
• Joann R. Petrini, Ph.D., M.P.H.
• Virginia Morriss Pressler, M.D., M.B.A., FACS
• Melinda Dolan Sanders, M.S.N., R.N.
• Ruth Ann Shepherd, M.D., FAAP
• Susan E. Sheridan, M.I.M., M.B.A.
• Sara G. Shields, M.D., M.S.
• Adewale Troutman, M.D., M.P.H., M.A., CPH
• David S. de la Cruz, Ph.D., M.P.H. (staff)

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• 1.
• Quality
• Safety

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Quality and Safety

• Support improvement in the quality and safety of
  maternity, newborn infant care
• Elective delivery at lt 39 weeks
• 17P (17 alpha-hydroxyprogesterone caproate)
• Smoking cessation
• Assisted Reproductive Technologies

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Intermountain Healthcare
Oshiro BT, Henry E, Wilson J, Branch DW, Varner
MW Women and Newborn Clinical Integration
Program. Decreasing elective deliveries before
39 weeks of gestation in an integrated health
care system. Obstet Gynecol. 2009
Apr113(4)804-11..
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Ohio Perinatal Quality Collaborative
Donovan EF, Lannon C, Bailit J, Rose B, Iams JD,
Byczkowski T Ohio Perinatal Quality
Collaborative Writing Committee. A statewide
initiative to reduce inappropriate scheduled
births at 36(0/7)-38(6/7) weeks' gestation.Am J
Obstet Gynecol. 2010 Mar202(3)243.e1-8.
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Perinatal Regionalization
Figure 4. Meta-analysis Results of Adequate- and
High-Quality Publications on Extremely
Low-Birth-Weight Infants
Figure 5. Meta-analysis Results of Adequate- and
High-Quality Publications on Very Preterm Infants
Lasswell SM, Barfield WD, Rochat RW, Blackmon L.
Perinatal regionalization for very
low-birth-weight and very preterm infants a
meta-analysis. JAMA. 2010 Sep 1304(9)992-1000.
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• 2.
• Preconception
• Interconception Care

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• CDC/ATSDR Select Panels Recommendations to
  Improve Preconception Health and Health Care in
  the U.S.
• Recommendation 1. Individual responsibility
  across the life span. Each woman, man and couple
  should be encouraged to have a reproductive life
  plan.
• Recommendation 2. Consumer awareness. Increase
  public awareness of the importance of
  preconception health behaviors and preconception
  care services by using information and tools
  appropriate across various ages literacy,
  including health literacy and cultural/linguistic
  contexts.
• Recommendation 3. Preventive visits. As a part of
  primary care visits, provide risk assessment and
  educational and health promotion counseling to
  all women of childbearing age to reduce
  reproductive risks and improve pregnancy
  outcomes.
• Recommendation 4. Interventions for identified
  risks. Increase the proportion of women who
  receive interventions as follow-up to
  preconception risk screening, focusing on high
  priority interventions (i.e. those with evidence
  of effectiveness and greatest potential impact).
• Recommendation 5. Interconception care. Use the
  interconception period to provide additional
  intensive interventions to women who have had a
  previous pregnancy that ended in an adverse
  outcome (i.e., infant death, fetal loss, birth
  defects, low birthweight, or preterm birth).
• Recommendation 6. Prepregnancy checkup. Offer, as
  a component of maternity care, one prepregnancy
  visit for couples and persons planning pregnancy.
• Recommendation 7. Health insurance coverage for
  women with low incomes. Increase public and
  private health insurance coverage for women with
  low incomes to improve access to preventive
  womens health and preconception and
  interconception care.
• Recommendation 8. Public health programs and
  strategies. Integrate components of preconception
  health into existing local public health and
  related programs, including emphasis on
  interconception interventions for women with
  previous adverse outcomes.
• Recommendation 9. Research. Increase the evidence
  base and promote the use of the evidence to
  improve preconception health.
• Recommendation 10. Monitoring improvements.
  Maximize public health surveillance and related
  research mechanisms to monitor preconception
  health.

Johnson K, Posner SF, Biermann J, Cordero JF,
Atrash HK, Parker CS, Boulet S, Curtis MG
CDC/ATSDR Preconception Care Work Group Select
Panel on Preconception Care. Recommendations to
improve preconception health and health
care--United States. A report of the CDC/ATSDR
Preconception Care Work Group and the Select
Panel on Preconception Care. MMWR Recomm Rep.
2006 Apr 2155(RR-6)1-23.
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Preconception Interconception Care

• IOM Clinical Preventive Services for Women
• Contraceptive services
• Lactation support
• HIV testing
• HPV testing
• STI tesing
• Interpersonal and domestic violence screening
• Gestational diabetes screening
• Well-woman preventive care visit including pre-
  and interconception care

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• 3.
• Medicaid
• Innovations

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What Can Medicaid Do to Improve Perinatal
Outcomes?

• Single largest payer of perinatal healthcare in
  U.S.
• Pays for gt 40 of all births
• Spends 39 billion a year on perinatal healthcare
• 21 billion for pregnancy and delivery
• 18 billion for newborn care

Andrews RM. The national hospital bill The most
expensive conditions by payer, 2006. Healthcare
Cost and Utilization Project. Statistical brief
59. September 2008
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Medicaid Innovations

• New York
• Denial of payment for elective delivery lt 39 wks
• Texas
• Denial of payment for elective delivery lt 39 wks
• Minnesota
• Require providers to submit information on nature
  of labor delivery incl induction before payment
  is made
• Washington
• Reducing payment for uncomplicated cesarean
• Incenting hospitals providers to engage in QI
  activities to reduce elective delivery lt 39 wks
  NSTV cesarean
• North Carolina
• Incentive payments for meeting target outcomes
  (e.g. postpartum visit, 17P, elective delivery lt
  39 wks, NTSV Cesarean)
• Ohio
• Mandate state-wide reporting of perinatal quality
  measures

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Medicaid Innovations

• North Carolinas Pregnancy Medical Homes
• Use payment innovations to drive quality
  improvement systems integration
• Projected cost-savings to Medicaid

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• 4.
• Title V MCH Programs

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Title V and MCH Programs

• Improve design impact of MCH programs
• e.g. Healthy Start as agent of change for service
  coordination, systems integration, and community
  transformation

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• 5.
• Healthcare Reform
• Financing

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Healthcare Reform Financing

• Support implementation of the Affordable Care Act
• Access
• Content and quality
• Organization Delivery
• Community health centers expansion
• Centers for Medicare and Medicaid Innovations
• Public health prevention investments
• Maternal, Infant, and Early Childhood Home
  Visiting Programs

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Healthcare Reform Financing

• The Committee is deeply concerned about spending
  cuts to vital programs that may drive up infant
  mortality

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Perinatal Outcomes
Childhood Diseases
Adult Diseases
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Developmental Origins of Health Disease

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• 6.
• Health
• Equity

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Health Equity

• The Committee urges a broad-based approach that
  addresses both clinical factors and social
  determinants using a life-course approach

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Community Development
Economic Development
Best Babies Zone
Health Development
Educational Development
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Rural Health and Infant Mortality

• Need a rural strategy on infant mortality
• Workforce development
• Access to healthcare facilities
• Mental and behavioral issues
• Social determinants

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• Data
• Research

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Data and Research

• Need a national research agenda on causes and
  prevention of disparities in maternal and infant
  mortality
• Improve population surveillance of maternal
  infant mortality
• Need for data capacities and data support

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Richmond-Kotelchuck Model
Knowledge Base
Political Will
Social Strategy
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• Collaborative
• Innovations

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• The definition of insanity is doing the same
  thing over and over and expecting different
  results

Benjamin Franklin
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• We hold these truths to be self-evident, that
  all men are created equal, that they are endowed
  by their Creator with certain unalienable
  rightsm, that among these are Life, Liberty, and
  the Pursuit of Happiness.

Declaration of Independence
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