Infant Mortality: Michigans Experience

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Infant Mortality Michigans Experience

• Alethia Carr Acting Director
• Bureau of Family, Maternal Child Health
• Michigan Dept. of Community Health
• May 5, 2008

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Infant Mortality

• Critical indicator of our citizens well being
• MIs well being is worse than most
• Unacceptable racial and ethnic disparity exists
  for Infant Mortality
• Understanding can lead to prevention

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Infant Mortality Rate (IMR) Michigan Compared
to United States
HP 2010 4.5
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Infant Mortality Rates, Michigan Compared to
U.S., 1996-2006
Healthy People 2010 goal 4.5/1000
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Infant Mortality Rate by Race Michigan Compared
to United States
Infant Mortality Rate
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Michigan Infant Mortality Rate by Race
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Snapshots of Some of Our Communities During This
Period
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1992 Infant Mortality Rates, Kalamazoo Comparisons
Arthur R. James, MD
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Kalamazoo HB/HS Conferences

• 1998 - Avoid Unplanned/Unwanted Pregnancies
• Unwanted pregnancies associated with higher risk
  of poor outcome.
• Back-to-Sleep, Back-to-Crib - Decrease SIDS
• Care as soon as possible - Early initiation of
  prenatal care
• 1999 - Discontinue Risky Behaviors
• Avoid drugs, risky sexual behavior, smoking,
  alcohol, etc.
• 2000 - Eliminate Disparity
• 2001 - Five Trimesters of Care
• Continue normal care thru traditional 3
  trimesters of pregnancy
• 1st Trimester Preconception (Folate, Rx.
  Infections, eliminate risky behaviors, diet
  counseling, medical check-up)
• 5th Trimester Continue support after birth for
  mother, new child, and family. (Takes community
  effort).

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Infant Deaths Genesee County1997-1998(City of
Flint Burton)
Robert M. Pestronk Health Officer Genesee County,
MI
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Genesee REACH Healthy Start

• Community Dialogue and Awareness
• 4 Undoing Racism 2 Healing Racism Workshops
  (218)
• 2 Community Dialogue Sessions (50)
• Mentoring and Support/Outreach Advocacy
• MIHAs, Birth Sisters (53)
• Community Rally, MIHAs Picnic (350)
• Education Training
• 1 Faculty training 3 in-class discussions
• Physician Consensus Sessions (26)

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Detroit Healthy Start ProjectMCH Health
Indicators
Carolynn Rowland, Detroit Healthy Start
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American Indian Healthy Start
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Improving American Indian Perinatal Outcomes The
Maajtaag Mnobmaadzid Project
Elizabeth Knurek, MPH, Geradine Simkins, RN, CNM,
MSN Rick Haverkate, MPH, Director, Sandra King,
RN, BSN, Program Manager Health Services
Division, Sault Ste. Marie , MI
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Michigan Works to Reduce Infant Mortality
Black
Other
White
MSS/ISS Begins 1988
SIDS Program Begins
Saginaw FIMR
Stakeholders Meeting
HMF Coalitions Start
Local FIMR Support
Nurse Family Partnership
Detroit Healthy Start
IM Task Force Report
R.E.A.C.H Genesee
Healthy Start Expansion
Infant Mortality Summit
Closing the Gap, Genesee
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Healthy Start Projects in Michigan

• Detroit
• Saginaw
• Kalamazoo
• Genesee
• Inter-tribal Council
• Kent

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2001 Infant Mortality Summit

• 400 stakeholders attend
• National support from CDC and HRSA
• Themes from Bill Sappenfield
• Infant Mortality is only the tip of the
  iceberg, many causes
• PPOR framework for study, excess deaths
• Michigan data demonstrates disparities
• Lessons learned from Local Strategies
• Urban vs Rural

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Infant Mortality
Maternal Deaths
Fetal Deaths
Prematurity
Growth Retardation
Teen Pregnancy
Disabilities
Birth Defects
Unintended Pregnancy
Development Delay
Substance Abuse
Learning Disorders
Violence
School Problems
Incomplete immunizations
Poverty
Crime
William M. Sappenfield, MD, MPH Medical
Epidemiologist
Division of Reproductive Health, CDC
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• White 106,322 637 6.0
• Asian 3,766 21 5.6
• Arab 3,391 20 5.9
• Hispanic 6,923 46 6.6
• Native American 674 9 13.4
• Black 24,069 437 18.2

David R. Johnson, MD, MPH Michigan Department of
Community Health
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2001 State Recommendations

• Amend the Public Health Code to study fetal death
• Explore data sources on associated risks of
  infant mortality
• Evaluate efficacy state funded infant mortality
  programs
• Provide funding and technical support for local
  FIMR teams
• Improve maternal health
• Expand knowledge of the importance of
  preconception care
• Support outreach and advocacy to at-risk
  populations
• Improve access to mental health and substance
  abuse treatment
• Provide social risk assessment of all pregnant
  women
• Assure safe sleep environment for infants
• Reduce barriers to women seeking contraception
• Support services for women with infant or fetal
  loss
• Expand the options for parenting classes

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2001 Local Recommendations

• Develop Fetal-Infant Mortality Review (FIMR)
  teams
• Facilitate prenatal care in the first trimester
• Support community based health care settings,
  programs and resources
• Develop and distribute community resource
  directories
• Encourage adopting policy of assessment of social
  risks for all providers
• Establish dialogue with community partners about
  the presence of racism in health care
• Develop local community/business/health care
  partnerships
• Develop systems to provide transportation and
  child-care to women seeking prenatal care

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2004 Stakeholder Feedback

• Black preterm births are driving the BIMR.
• Obesity other maternal health issues must be
  addressed before pregnancy.
• Increase the number of planned pregnancies.
• Reintroduce the perinatal regional system.
• Local communities need to own the problem.
• Understand the cultural barriers.
• Decreasing number of OB-GYN providers affects
  care.
• Excess deaths in post-neonatal period should be
  addressed.

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2004 Recommendations

• Maximize Medicaid match potential
• Attach pregnancy planning activities to Family
  Planning waiver
• Link vital record data with Medicaid user data
• Establish a quality assurance mechanism for
  interventions
• Explore housing, legal advocacy other womens
  health issues
• Identify in-state research related to pregnancy
  outcomes
• Increase partnerships to work on infant mortality
• Increase public visibility of infant mortality
  data

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State Administered Resources
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Infant Mortality Michigans Strategic Plan

• Brenda Fink Director
• Division of Family Community Health
• Michigan Dept. of Community Health
• May 5, 2008

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2004 Plan Guidelines

• Multi-causal factors
• Current and emerging science and research
• Sound data and analysis as the foundation
• Multi-system infrastructures
• Proactive management of resources
• Involved stakeholders
• Evaluation, ongoing improvements over time
• Political will
• Short term, intermediate and long term outcomes

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Low Birth Weight Births in Michigan, 1996-2006
In 2006, there were 10,720 low birth weight
births (lt2500g) in Michigan, 8.4 of live
births. The proportion of very low birth weight
births (lt1500g) has been consistent over
time. Between 1996 and 2006 the rate of low birth
weight births has increased about 9 instead of
moving closer to the Healthy People 2010 goal of
5.
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Initial Plan Focus

• Conceptual framework
• Statewide strategies
• Targeted communities
• Targeted programs
• Family Planning
• WIC
• Maternal Infant Support Program (MIHP)
• Nurse Family Partnership

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Perinatal Periods

• Maternal Health (preconception health status)
• Maternal Care (prenatal care)
• Newborn Care (neonatal period, 0 - 28 days)
• Infant Health (1 month - 1 year)

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Perinatal Period Objectives

• Maternal Health
• Improve the health status of women to maximize
  their chances for having healthy babies
• Increase the proportion of pregnancies that are
  planned
• Maternal Care
• Increase the proportion of births which are full
  term, at appropriate birth weight, and otherwise
  at low risk for infant morbidity and mortality
• Newborn Care
• Increase the proportion of newborns whose acute
  problems are immediately identified and
  effectively addressed
• Infant Health
• Increase the proportion of infants who never
  experience serious illnesses or injuries

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Michigan PPOR Rates by Race, 2006
(Neonatal)
African American infants die much more frequently
than white infants. Most deaths from both races
occur in the Pre-pregnancy Period. The Infant
period also has significantly more African
American deaths.
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Targeted Counties2002-2004 Black/White Ratio
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Targeted Programs
Family Planning
Medical Home
WIC
MIHP
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Michigans Strategic Plan Today

• Plan guidelines still relevant
• Organized around the four periods of risk
• Current objectives identified for each, as well
  as existing programs that address that objective
• Administrative strategies
• Fluid, constantly being updated

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Under Construction

• More defined activities (including roles and
  timeframes)
• Specific program objectives defined
• Outcomes and indicators
• Evaluation overall and program/objective
  specific
• Resource and funding development
• Expanded roles for partners

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The Plan Maternal Health

• Support healthy lifestyle behaviors for all women
  of child-bearing age (i.e. preconception health)
  and particularly women with previous poor
  pregnancy outcome (i.e. interconception care)
• Prevent maternal mortality and morbidity
• Assure access to primary care for all women of
  child-bearing age
• Reduce unintended pregnancies

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The Plan Maternal Care

• Assure early entry to prenatal care that includes
  screening and assessment of risk
• Provide in-home and/or in-community supports to
  at risk women, using a risk stratification
  approach, focused on healthy mothers and babies
  (mothers make healthy lifestyle choices and
  infants reach/exceed developmental milestones)

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The Plan Newborn Care(Neonatal)

• Assure delivery of high risk pregnancies at
  hospitals with NICU care
• Provide early identification of problems and link
  to services

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The Plan Infant Health

• Assure access to primary care for infants and
  support services for at-risk infants
• Assure developmental screening using objective
  screening tools for all infants with appropriate
  referral and follow-up whenever needed
• Reduce SIDS and other infant death
• Improve infant health relative to known risk
  conditions

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Administrative Strategies

• Develop a comprehensive strategic plan
• Engage a broad base of participating stakeholders
• Prioritize dedicated resources for eliminating
  racial disparities in infant and maternal deaths
• Support analysis of fetal and infant deaths in
  target communities
• Consider redevelopment of the regional perinatal
  system

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Administrative Strategies, cont.

• Conduct pilot interventions using evidence-based
  approaches that target the most at-risk groups
  women who have had a previous fetal or infant
  loss, preterm birth, or VLBW birth
• Develop and implement concurrent and ongoing
  evaluation processes that
• collects and analyzes necessary data,
• focuses on programs, systemic processes and
  outcomes
• drive policy and strategy decisions

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Administrative Strategies, cont.

• Increase interaction with national researchers
  and leaders in this area to both share, learn and
  assure Michigan is at the center of
  state-of-the-art practices and strategies
• Assure high satisfaction levels from
  women/families using services/supports in terms
  of both process and outcomes
• Assure access to advocacy, rights appeals and
  grievances for all at-risk women relative to
  available services and supports

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Todays Outcomes

• Political will strengthened and expanded as we go
  forward
• Strategic plan improvements identified
• Current missing programs and resources added
• New partners, opportunities and resources
  identified for inclusion
• Next step recommendations made

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Our Goal

• Healthy Women
• Healthy Mothers
• Healthy Newborns
• Healthy Infants
• How will you and your
• organization participate?