High FetalInfant Mortality in Lane County

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High Fetal-Infant Mortality in Lane County
Lane County Public Health Services Sarah
Hendrickson, M.D. Lane County Health Officer
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The Problem

• Lane Countys overall fetal-infant mortality
  rate is higher than the nation higher than the
  state higher than Multnomah, Clackamas, or
  Washington Counties and higher than the Portland
  metropolitan area.

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Comparison Fetal-Infant Mortality Rates
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Lane County is losing too many babies...WHY?

• Perinatal Periods of Risk (PPOR) approach was
  chosen to help Lane County Public Health better
  understand local fetal-infant mortality
• PPOR has been used in developing and developed
  countries by the Centers for Disease Control
  (CDC) and the World Health Organization (WHO)
  for more than a decade
• PPOR has been used by US cities since 1997

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PPOR Data Analysis

• Utilizes
• Lane County resident data
• Fetal death files
• Linked infant birth/death certificate files
• ( 99-03, awaiting 00-04)

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PPOR Data Analysis

• Includes Fetal and Infant Deaths ( 24 weeks)
• Includes Very Low Birthweight (500-1499 grams)
• and Higher Birthweight ( 1,500 grams)
• Examines birthweight and gestational age at the
  same time
• Generates a Map for targeting strategic actions

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Example of PPOR Map Lane County 1999-2003
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PPOR Map of fetal-infant deaths
Age at Death
Fetal Death
Post- neonatal
Neonatal
Birthweight
500-1499 g
1500 g
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Map of Fetal-Infant Deaths
Lane County 1999-2003
56/ 3.1 Maternal Health/ Prematurity (fetal
deaths, live births)
174 Fetal-Infant Deaths 18,334 live births and
fetal deaths 9.5 overall rate
43/2.3 Maternal Care (fetal deaths)
31/1.7 Newborn Care (live births)
44/ 2.4 Infant Health (live births)
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1999 2003 Lane County Fetal-Infant Mortality
Rate by Group
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National PPOR Reference Group

• Defined by maternal characteristics
• 20 or more years of age
• 13 or more years of education
• Non-Hispanic white women

2.2
Total Fetal-Infant Mortality Rate 5.8
1.5
1.1
1.0
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Excess Fetal-Infant Mortality Rates
__________________________________________________
__________
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EXCESS NUMBER OF DEATHSLane County 1999-2003
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Lane County 1999-2003 Excess Fetal-Infant Deaths
Based on US Reference Group
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Implications

• Appear to be /- 12 extra late fetal and
  infant deaths each year.
• Assumption Mortality reflects Morbidity
• Is this unacceptable?
• This figure is at least worrisome to a broad
  range of community groups
• Ex economic development

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Next Steps,PPOR process

• Further Data Analysis Why Excess deaths?
• Community Response
• What can we do now?

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Community Involvement

• Realistic and necessary, since Lane County has NO
  resources
• (found part-time staffer for several months)
• Convened interested parties
• March of Dimes, Insurance, LIPA,
• OSU (anthropologist/lay midwife), U of O (FEAT)
• Hospitals, Medical and mental health providers
• Social Services, Public and non-profits, DHS
• Sub groups to look at
• Data, Maternal Care, Infant Care

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Data Sub-GroupFurther Population Data Analysis

• PRAMS (Pregnancy Risk Assessment Monitoring
  System)
• Census data
• Alcohol and Drug data
• Mental Health data
• Health care availability studies
• Other studies/data

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PRAMS Data (2001 only)

• Women in Lane County
• 86.1 knew about folic acid pre-pregnancy
• 33.9 took folic acid pre-pregnancy
• 19.3 smoked during pregnancy (vs. OR 15)
• 21.1 smoked post partum (vs. OR 15.5)
• 25.3 binge drank at least once pre-pregnancy
  (vs. OR 16.2)
• 15.6 breastfed for 11 or more months (vs.
  OR 18.7)

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PRAMS (2000-04, weighted)

• Women in Lane County
• 35.9 took folic acid pre-pregnancy (OR 37.3)
• 26.1 smoked during the three months before
  pregnancy (vs. 23.0 OR)
• 11.9 smoked during last 3 months of pregnancy
  (vs. OR 11.9)
• 19.7 smoked post partum (vs. OR 16.3)
• 24.9 binge drank at least once pre-pregnancy
  (vs. OR 17.3)

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Geographical clustering

• Limited data, BUT
• Appears that there may be rural high rates, esp
  NW
• (JC, Creswell, Veneta, Springfield have
• rates 10)
• Await further data analysis and amalgamation

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Analysis of Individual CasesFetal-Infant
Mortality Review

• Infant death as a sentinel event
• Retrospective case review very difficult
• Multi-disciplinary review team ( similar to CAT
  review)
• -Health, Social Service, ME
• De-identified medical and social information
• -Pre- peri-natal care, interconceptual care
• -Behaviors smoking, drugs
• -Social context
• Maternal Interview
• -Facilitates bereavement transition
• -Voice for the consumer

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Fetal-Infant Mortality Review- FIMR

• National Fetal and Infant Mortality Review
  Program is a collaboration of the Federal
  Maternal/Child Health Bureau and the American
  College of Obstetricians and Gynecologists
• Similar to existing Child Fatality Review with a
  Public Health orientation and multi-disciplinary
  focus on Gap-finding on policy/system change,
• Identify factors associated with these deaths
• Determine if those factors represent
  community-wide service system problems that
  require change
• If so, to develop recommendations for change
• Assist in the implementation of change
• Lane County Public Health pursuing grant funding
• Cooperation with Child Fatality Review

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Lane Countys Excess Fetal-Infant Mortality
Rates Numbers (recap)
Infant Health
Maternal Health/Prematurity
2nd highest excess mortality rate
Highest excess mortality rate
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Community Response

• Three Work Groups
• Infant
• Maternal and Intra-partum Care
• Data
• Identify and prioritize best practices
• Hard working Folks with lots of Good Ideas

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Maternal Health/ Prematurity

• Preconception Health
• Health Behaviors
• Perinatal Care

• Prenatal Care
• High Risk Referral
• Obstetric Care

Maternal Care

• Perinatal Management
• Neonatal Care
• Pediatric Surgery

Newborn Care

• Sleep Position
• Breastfeeding
• Injury Prevention

Infant Health
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Providers Insights

• From your experience, what do you see as
  recurring contributors to infant mortality?
• What additional information do we need to know?
• What is currently happening within our community
  to address this issue?
• Who have we missed who needs to be part of this
  discussion?

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Thank You For all you do for our families

• Lane County Public Health
• Our mission is to preserve, protect, and promote
  the health of all people in Lane County