William Sappenfield

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Investigating Troubling Trends The State Infant
Mortality Initiative
State Infant Mortality Toolkit

• William SappenfieldCDC
• Greg AlexanderUSF

2006 Annual AMCHP Conference
Arlington, VA March 6, 2006
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Toolkit Purpose
State Infant Mortality Toolkit
To provide a systematic approach for state public
health agencies to examine their states high
and/or increasing infant mortality rate based on
current knowledge and available information.
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Toolkit Framework
State Infant Mortality Toolkit
Stage 1 Overview Investigation
Stage 2 Focused Investigation
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services
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U
A
B
SCHOOL OF PUBLIC HEALTH
Maternal and Child Health
      Infant Mortality Assessment
Manual   Greg R. Alexander, RS, MPH, ScDSara
Nabukera, M.D., MPHDeren Bader, MPHMartha
Slay-Wingate, MPH University of Alabama at
BirminghamSchool of Public HealthDepartment of
Maternal and Child Health  
Introduction Purposes and Objectives Data
Sources Questions for Assessment Statistical
Analysis and Interpretation SAS
Program References Appendix Home
Website http//www.soph.uab.edu/mch-imrm/index.ht
m
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services
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Birth Weight for Gestational Age Categories
Fetal growth categories 1985-88 1995-00
Preterm, lt2500g 3.95 4.95
Preterm, gt2500g 5.70 6.21
Term, lt2500g 2.70 2.56
Term SGA 9.42 8.59
Preterm SGA 1.16 1.51
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Temporal Change in Outcomes1985-88 (reference)
1995-2000
Outcome Parameters Unadjusted OR Adjusted OR
VLBW 1.17 0.97
LBW 1.11 0.95
SGA 0.95 0.91
Preterm 1.18 1.01
IMR 0.71 0.64
Adjusted for maternal age, race, marital status, education, parity, number at birth and prenatal care utilization Adjusted for maternal age, race, marital status, education, parity, number at birth and prenatal care utilization Adjusted for maternal age, race, marital status, education, parity, number at birth and prenatal care utilization
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services
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(No Transcript)
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Maturity Mortality TrendsUSA
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Maturity Mortality TrendsHawaii
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services
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(No Transcript)
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Why recommend themodified Dollfus method

• Has only 9 categories
• Good ICD-9 to ICD-10 comparability ratios
• Practical and preventive perspective
• Developed by a North Carolina researcher

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Cause-specific infant mortality rates in North
Carolina, 2001-2003 and the U.S., 2001-2002
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services
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Reported Vital Events
Conception
1 Year
Live Birth
Gestation
Infancy
20 wks
4 wks
Infant Death
Fetal Death
Feto-Infant Death
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Vital Events In-State Trends

• Reporting
• Change in reporting regulation, process, or
  training?
• Change in reporting type of event?
• Clarification of viability or gestation?
• Change in quality processing?

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Number of States by Percent of All Fetal Deaths
20 to 27 Weeks Gestation, 2000-02
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So What?

• Assumptions
• The real percentage of 20-27 wks is 73
• Your states percentage is 35 or 35 deaths of
  100 deaths
• (35 ?) / (100 ?) 73
• Answer 143 additional deaths

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Number of States by Percent of All Live Birth
lt1,500 Grams, 2000-02
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Infant Mortality Rates for lt500g Live
BirthsLouisiana US
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Toolkit Framework
Stage 1 Overview Investigation
Maturation-Specific
Maturation
Data Reporting
Age Cause
Stage 2 Focused Investigation
Environmental Attributes
Maternal Attributes
Health Services