reducing infant mortality in maryland donald shell, m.d., ma center for health promotion family...

Reducing Infant Mortality in Maryland

Donald Shell, M.D., MACenter for Health Promotion

Family Health AdministrationDepartment of Health and

Mental Hygiene

2

Infant and Child Deaths

Percentage of Child Deaths By Age, Maryland, 2009

<1 year68.1%

1-4 years 8.4%

5-9 years 4.8%

10-14 years 7.8%

15-17 years10.8%

Data Source: MD DHMH, Vital Statistics Administration

3

Infant Mortality in Maryland & U.S.

Infant Mortality Rate, Maryland and U.S., 1984-2009

6

7

8

9

10

11

12

13

Year

Rate

per

1,0

00 l

ive b

irth

s

Mary land 11.7 11.9 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2

United States 10.8 10.6 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Source: MD DHMH:Vital Statistics Administration, CDC:NCHS* U.S. data for 2008, 2009 are not available

4

Leading Causes of Infant Mortality Maryland National Rankings

Infant Mortality - 07 42nd

Preterm Birth - 07 37th

Low Birth Weight - 08 41st

VLBW – 08 47th

5

Leading Causes of Infant Mortality

Causes of Infant Death, Maryland, 2009

Preterm/Low Birth Weight, 25.0%

Congenital Abnormalities, 15.9%

SIDS, 11.3%Maternal Complications,

7.6%

All Other Causes, 26.6%

Respiratory Distress, 2.4%

Sepsis, 3.0%

Necrotizing Enterocolitis, 3.1%

Complications of Placenta/Cord, 5.2%

Data Source: MD DHMH, Vital Statistics Administrationn = 541 deaths

6

Timing of Infant Deaths

Percent of Total Infant Deaths by Age at Death, Maryland, 2009

Postneonatal Mortality

29%

Neonatal Mortality

71%Data Source: MD Vital Statistics Administration

7

Percent of MD Births by Birth Weight 2009 Births

1.6%7.1%

91.3%

0%

20%

40%

60%

80%

100%

<1500 gm 1500-2500 gm >2500 gm

Birth Weight

Note: Includes only births to MD mothers in MD hospitalsData Source: MD Health Services Cost Review Commission

8

Birth Weight and Neonatal Deaths

Percent of Total Neonatal Deaths by Birth Weight, Maryland, 2007

≥2500 g9%

1500-2499 g9%

<1500 g82%

Data Source: MD Vital Statistics Administration

9

Racial Disparity in Infant Mortality

Infant Mortality Rates, Maryland, 2000-2009

0

5

10

15

20

Year

Rat

e p

er 1

,000

live

bir

ths

All Races 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2

White 4.7 5.5 5.4 5.4 5.6 4.7 5.7 4.6 5.2 4.1

Black 13.0 13.6 12.7 14.7 14.9 12.7 12.7 14.0 13.4 13.6

Hispanic 5.1 6.2 5.3 6.0 5.3 4.6 3.0 3.8 3.2 3.1

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


10

Racial Disparity in Preterm Births

Percentage of Births that are Preterm (<37 weeks gestation), Maryland, 2000-2009

6.0

8.0

10.0

12.0

14.0

16.0

Calendar Year

% P

rete

rm B

irths

All Races 10.8 10.8 10.9 11.0 11.3 11.3 11.4 10.9 11.0 10.4

White Non-Hisp 9.1 9.5 9.6 9.7 10.0 10.0 10.4 9.6 9.6 9.0

Black 14.5 13.9 14.2 14.3 14.3 14.3 14.1 13.9 13.9 13.9

Hispanic 8.6 9.1 8.8 9.1 9.4 9.7 9.3 8.9 9.4 8.6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Source: MD DHMH, Vital Statistics Administration* Gestational age computed via clinical estimate of gestationStarting in 2007, MD data include births of unknow n gestational age in the denominator

11

Racial Disparity in Low Birth Weight

Percentage of Low Birth Weight (<2500g) Infants, Maryland, 2000-2009

4

6

8

10

12

14

16

Pe

rce

nt

All Races 8.7 9.0 9.0 9.1 9.4 9.2 9.4 9.1 9.3 9.2

White 6.4 7.0 7.0 7.1 7.4 7.1 7.4 7.1 7.2 7.0

Black 12.9 13.0 13.3 13.1 13.2 13.2 13.4 12.9 13.2 13.0

Hispanic 6.5 6.9 6.9 7.0 7.3 7.2 6.8 7.3 7.1 6.6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Sources: MD DHMH, Vital Statistics Administration

12

Racial Disparity in VLBW Births

Percentage of Very Low Birth Weight (<1500g) Infants, Maryland, 2000-2009

0

2

4

6

8

Pe

rce

nt

All Races 1.9 2.0 1.9 1.9 2.1 1.9 1.9 1.9 1.9 1.8

White non-Hisp 1.2 1.4 1.3 1.3 1.3 1.3 1.3 1.2 1.2 1.1

Black 3.3 3.3 3.3 3.4 3.6 3.3 3.1 3.2 3.2 3.2

Hispanic 1.1 1.4 1.1 1.3 1.5 1.2 1.2 1.3 1.4 1.3

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


13

Racial Disparities in Birth Outcomes

In Maryland, a Black infant ….

is 1 ½ times as likely to be born prematurely,

almost 2 times as likely to be born at low birth weight,

3 times as likely to be VLBW

and 2 ½ to 3 times as likely to die in the first year of life as a white infant.

14

BaltimoreCity

AnneArundel

Howard

Caroline

QueenAnne’s

PrinceGeorge’s

St. Mary's

Charles

Kent

Wicomico

Dorchester

Worcester

Montgomery

Talbot

Calvert

Somerset

Geographic Disparity in MarylandAverage Infant Mortality Rate, By Jurisdiction, 2005-09

BaltimoreCity

AnneArundel

Howard

Baltimore

Caroline

QueenAnne’s

PrinceGeorge’s

St. Mary's

Charles

AlleganyCarroll Harford

Cecil

Kent

Wicomico

Dorchester

Worcester

WashingtonGarrett

Frederick

Montgomery

Talbot

Calvert

Somerset

Geographic Disparity in MarylandAverage Infant Mortality Rate, By Jurisdiction, 2005-09

Legend

Rate per 1000 live births

2.7 – 5.0

5.1 – 9.0

9.1 -16.5


15

Behavioral Risks: Unintended Pregnancy Associated with Increased Neonatal Mortality *

* Bustan et al, AJPH, March 1994

Distribution of Mothers by Pregnancy Intention, Maryland, 2009

Didn't w ant to be pregnant then or later

12%

Wanted to be pregnant then

37%

Wanted to be pregnant sooner

18%

Wanted to be pregnant later

33%

Intendedpregnancies55%

Unintendedpregnancies45%

Data Source: Maryland PRAMS, 2009

16

Behavioral Risks: Teen Births Associated with Increased Infant Mortality

Birth Rate Among Adolescents (15-19 years), Maryland, 2000-2009

0

20

40

60

80

100

120

Rat

e p

er 1

,000

po

pu

lati

on

All Races 41.2 37.8 35.4 33.3 32.3 31.8 33.6 34.4 32.7 31.2

White 29.2 26.4 24.5 22.7 23.7 24.2 26.0 26.7 24.3 23.0

Black 67.5 61.0 57.6 53.0 49.9 48.0 49.6 50.8 49.7 47.4

Hispanic 63.9 72.6 74.1 81.0 77.5 87.2 91.6 95.5 84.0 66.4

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


17

Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality

Percent of Births to Women Receiving 1st Trimester Prenatal Care, Maryland and U.S., 1998-2009

78

81

84

87

90

% o

f Bir

ths

MD 87.9 87.0 86.4 83.7 84.1 83.7 82.3 81.3 80.4 79.5 80.2 80.2

U.S.* 82.8 83.2 83.2 83.4 83.7 84.1 84.2 83.9 83.2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Sources: MD: DHMH, Vital Statistics Administration, US: National Center for Health Statistics* US data for 2003-2006 represents 32 states using 1989 birth certif icate, US Data for 2007, 2008, 2009 for states using the 1989 birth certif icate w as not available

18


Percentage of Births to Women Receiving Late or No Prenatal Care, Maryland, 2000-2009

2

4

6

Per

cen

t

Maryland 3.1 3.7 3.6 3.8 3.9 4.3 4.3 4.7 4.2 4.7

U.S. 3.9 3.8 3.6 3.5 3.6 3.5 3.6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Sources: MD DHMH, Vital Statistics Administration, NCHS, National Vital Statistics Reports, U.S. data for 2007,2008, 2009 not available

19


Infant Mortality Rate by +/- Receipt of Prenatal Care and Race/Ethnicity, Maryland 2004-2008

0

10

20

30

40

50

Ra

te p

er

1,0

00

bir

ths

(i

n P

NC

su

bc

ate

go

ry)

1st, 2nd, 3rd Trim PNC 6.5 5.9 9.4 3.4

No PNC 35.9 31.6 43.1 22.9

All Races White Non-Hisp Black Non-Hisp Hispanic


20

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors

0

20

Pre

term

Bir

th R

ate

(Per

cent)

Maternal Race-Ethnicity

< Grade 8 Grades 8-12 Grades 13-15 > Grade 15

< Grade 8 19.6 11.0 10.7 11.5

Grades 8-12 16.8 9.9 10.4 10.5

Grades 13-15 14.5 8.3 9.3 9.1

> Grade 15 12.8 7.0 8.4 7.5

Black White Hispanic Asian

From NCHS 1998-2000 data, Preterm Birth, IOM, 2007

21


0

20

Pre

term

Bir

th R

ate

(Per

cent)


< Grade 8 Grades 8-12 Grades 13-15 > Grade 15

< Grade 8 19.6 11.0 10.7 11.5

Grades 8-12 16.8 9.9 10.4 10.5

Grades 13-15 14.5 8.3 9.3 9.1

> Grade 15 12.8 7.0 8.4 7.5

Black White Hispanic Asian

From NCHS 1998-2000 data, Preterm Birth, IOM, 2007

22


0

5

10

15

20


Infa

nt

Mo

rtali

ty R

ate

(death

s p

er

1,0

00

liv

e b

irth

s)

<12 yrs 12 yrs 13-15 yrs 16+ yrs

<12 yrs 8.3 14.1 8.0 2.6

12 yrs 9.9 14.7 6.7 4.6

13-15 yrs 7.0 11.1 4.5 2.6

16+ yrs 4.8 9.5 3.2 2.2

All Race/Ethnic Black White non-Hisp Hispanic


Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009

23


0

5

10

15

20


Infa

nt

Mo

rtali

ty R

ate

(death

s p

er

1,0

00

liv

e b

irth

s)

<12 yrs 12 yrs 13-15 yrs 16+ yrs

<12 yrs 8.3 14.1 8.0 2.6

12 yrs 9.9 14.7 6.7 4.6

13-15 yrs 7.0 11.1 4.5 2.6

16+ yrs 4.8 9.5 3.2 2.2

All Race/Ethnic Black White non-Hisp Hispanic


Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009

24


Infant Mortality Rates by Maternal Education and Race/Ethnicity, Maryland, 2005-2009

8.06.7

4.53.2

14.1 14.7

11.19.5

0

5

10

15

20

<12 yrs 12 yrs 13-15 yrs 16+ yrs

Years of Education Completed

Rat

e p

er 1

,000

live

bir

ths

0

1

2

3

4

Rat

io

White non-Hisp Black Black/White Ratio

Data Source: MD DHMH Vital Statistics Administration* Note - There w ere 95 infant deaths and 2,315 births among w omen in these race/ethnicity categories for w hom education level w as not stated.

25

Maryland’s Challenges

Racial disparities/System barriers Fiscal resources to address health Uninsured Safety net providers difficulties OB/GYN malpractice premiums Few providers for prenatal care Providers to see high risk patients

26

Governor’s Strategic Goal

Reduce infant mortality in Maryland

by 10% by 2012

*************************

2007 Baseline – 622 deaths, rate of 8.0/1,000 births

2012 Goal – 60 fewer deaths, rate of 7.2/1,000 births

27

Babies Born Healthy Initiative

Perinatal Collaborative

High-risk OB consultation outreach through the two academic medical centers

Updated standards for perinatal care

Real time access to data Birth records, death records, Pregnancy Risk Assessment

forms (PRAMS), hospital and practice specific outcomes, sleep-related deaths, FIMR, Child Fatality Review, MCO’s

28

What Works…Maryland Plan Built on Evidence Based Practices

Reducing unintended pregnancy

Promoting the health of women

Improving access to prenatal and postpartum care

Improving the safety and quality of obstetric

and neonatal care

29

Maryland Infant Mortality PlanBroad and Substantive Input

Maryland Infant Mortality Epidemiology Work Group – 2011 “Findings from Data Analysis and Overall Recommendations” Summarize research/recommendations

Gov. Forum on Children and Health 2011 - Infant Mortality Breakout

“The Role of Community Pediatricians in Preventing Infant Mortality” – Meeting

Web-based survey 339 Marylanders

30

Infant Mortality Epi Work Group 2011 Findings/Data Analysis/Recommendations

Chronic conditions before/during pregnancy Htn disorders during & preconception GDM, pre-preg DM, Ht Dz, IPV, asthma Depression, obesity, ETOH, tobacco use

Fertility treatment Infant sleep position, co-sleeping Maternal postpartum tobacco use

31

Infant Mortality Epi Work Group 2011 Findings/Data Analysis/Recommendations

Timing and effectiveness of risk-targeted prenatal care

Maternal age teens (Hispanic), > age 35

Prior pre-term birth Birth hospital level of care for VLBW Early term deliveries (37-38 weeks)

32

Partners include

Office of Minority Health and Health Disparities

Maryland Medicaid – coordinate MCO’s, birth outcome data

Behavioral Health referrals to and from Mental Hygiene Administration Alcohol and Drug Abuse Administration

Local Health Departments

DHMH coordination/data - WIC, Chronic Dz, Tobacco…

Department of Human Resources (DSS) Medical Assistance

Governor’s Office for Children – Home Visitation Program

Community Health Resources Commission - $ and data sharing

33

Partners include

MD Institute for Emergency Medical Services Systems (MIEMSS) with MD Perinatal Standards – Level III

MD Patient Safety Center – hosp d/c MSDE home visiting program & data Birthing Hospitals prohibit elective

deliveries <39 weeks, VLBW, breast feeding and tobacco cessation

FQHC case mgt, care coordination, community referrals, provider training

34

Partners include

MD Chapter AAP expertise and resources infant and child health

MD Chapter ACOG expertise and resources maternal health/birth out

Maryland Breast Feeding Coalition CareFirst BC/BS home visitation MCO facilitate early PNC entry Community Peds coordination and

communication with OB/GYN providers Cert. Nurse Midwives high risk @ PNC UMD and JHU Med & SPH expertise and

support

35

Intervention Across the Lifespan

PRECONCEPTION (Before

pregnancy)

Healthier women at time of

conception, planned

pregnancies

Earlier entry into prenatal

care

Comprehensive, high quality

perinatal and neonatal care

Healthier Children

and Adults

PRENATAL (During

pregnancy)

PERINATAL NEONATAL

(After delivery)

36

Oversight and Evaluation – Governor’s Delivery Unit and State Stat

Performance measurement system Developed by DMHM, GDU, State Stat Monthly Program and Health Outcomes Collection/Reporting target jurisdiction Annual Assessments State and Jurisdictional

Vital Statistics Medicaid Title X PRAMS

37

Strategy 1 – Before Pregnancy Expand access to women’s comprehensive health and

wellness services

• Transition family planning sites into Comprehensive Women’s Health Programs.

• Include screening/referral for Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, smoking cessation, weight management services.

•FQHC integration of reproductive & primary care, Title X FP Primary Provider training

• Culturally-competent outreach and education efforts in the community, Perinatal Navigators

38

Oversight and Evaluation – Strategy # 1 Governor’s Delivery Unit and State Stat

#comprehensive women’s health #referred to/from STD clinics #referred to/from behavioral health #FQHC Primary trained thru Title X #new Medicaid FP enrollees #enrollees utilizing Medicaid FP #visits to Title X FP clinics % unintended pregnancies

39

Strategy 2 – During Pregnancy Increase the # of women accessing early prenatal care

•LHD maternity sites implementation of Quick Start prenatal care program.

•12/1/09 Accelerated Certification of Eligibility (ACE) for pregnant women seeking Medicaid coverage, LHD, DSS

• Screening/referral - Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, and smoking cessation.

•PGCHD/UMD OBGYN Midwife Perinatology “Tapestry Program”

•2011 PGC FQHC initiation prenatal care

40


#Medicaid “ACE” processed 10 days #total applications #weeks pregnant at application #women receiving Quick Start Ser. #Perinatal navigator pt encounters #pregnant women home visits

41

Strategy 3 – During & After Delivery Expand access to more comprehensive, high quality

perinatal and neonatal care•Develop a standardized hospital postpartum discharge process that ensures risk appropriate follow-up care for mother and infant.

•Breast feeding support, MH/SA services, DV support, smoking cessation, FP, Safe sleep instruction: Distributed thousands of B’more “Safe Sleep. Alone. Back. Crib” DVD

•4/1/2011 implemented standardized d/c referral form for high risk mothers to CBO’s

•Monitoring level I and II (MMQRC), level III (MIEMSS) birthing hospital compliance with Perinatal Standards VLBW deliveries

42


# comprehensive women’s health #LHD postpartum referrals received # level I/II site visits conducted # Safe Sleep DVD’s distributed % VLBW deliveries @ level III hosp #postpartum home visits conducted

43

Summary of the Plan

APPROACH

• Assessing the Data & Targeting Disparities

• Building on Strengths & Partnerships

• Comprehensive Systems Approach

GOALS

• Healthier Women/ Planned Pregnancies

• Earlier Entry into Prenatal Care

• Improve Quality of Perinatal and Post-

Delivery Care

STRATEGIES

• Comprehensive Women’s Health Centers

• Expediting Medicaid eligibility / Quick Start

Prenatal Care

• Standardized hospital discharge protocols

44

Infant Mortality in Maryland & U.S.


6

7

8

9

10

11

12

13

Year

Rat

e p

er 1

,000

liv

e b

irth

s

Mary land 11.7 11.9 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2

United States 10.8 10.6 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Data Source: MD DHMH:Vital Statistics Administration, CDC:NCHS* U.S. data for 2008, 2009 are not available

45

Governor’s Strategic Goal

Goal Re-Set in October 2010: Reduce both total and Black infant mortality

in Maryland by 10% by 2012*************************

2007 Total baseline – 622 deaths, Rate of 8.0/1,000 Black infant baseline – 369 deaths, Rate of 14.0/1,000

births

2009 Status – 541 deaths, Rate of 7.2/1,000 Black infant status – 343 deaths, Rate of 13.6/1,000 births

2012 Goal –Total rate ≤ 7.2/1,000 Black infant goal – 319 deaths, Black rate ≤ 12.6/1,000

births

46

2010 Infant Mortality in Maryland


6

7

8

9

10

11

12

Rate

per

1,0

00 li

ve b

irths

Maryland 11.7 11.4 11.2 10.4 9.6 9.1 9.8 9.8 8.8 8.7 8.4 8.6 8.6 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2 6.7

United States 10.4 10.1 10.0 9.8 9.2 8.9 8.5 8.3 8.0 7.6 7.3 7.2 7.2 7.1 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8 6.6 6.4

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20072008

*2009

*2010

*

Data Source: MD Vital Statistics Administration, National Vital Statistics System* U.S. data for 2008, 2009 are preliminary. Data for 2010 are not available.

47

2010 Infant Mortality in Maryland

Infant Mortality Rates by Race, Maryland, 2001-2010

0

2

4

6

8

10

12

14

16

Rat

e p

er 1

,000

live

bir

ths

All Races 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0 7.2 6.7

White 5.5 5.4 5.4 5.6 4.7 5.7 4.6 5.2 4.1 4.1

Black 13.6 12.7 14.7 14.9 12.7 12.7 14.0 13.4 13.6 11.8

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


48

What’s Next?

January 1, 2012 Expanded Maryland Medical Assistance

program eligibility for family planning to include all women at or below 200% of the federal poverty level

Developing standardized 34 hospital postpartum discharge process DHMH, MD Pt Safety Center Perinatal

and Neonatal Learning Network, MD Perinatal System Standards, MIEMSS

49

What’s Next?

Development of an integrated statewide Fetal Infant Mortality Review (FIMR) and State Child Fatality Review (SCFR) database DHMH, MD Medical Chirurgical Society,

LHD’s, FIMR, SCFR Define at-risk groups/factors ID’ed by

Infant Mortality Epidemiology Work Grp Targeted interventions

50

Questions?

reducing infant mortality in maryland donald shell, m.d., ma center for health promotion family...

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