Reducing Infant Mortality in Maryland

S. Lee Woods, M.D., Ph.D.

Medical Director, Center for Maternal and Child Health

Maryland Department of Health & Mental Hygiene

April 21, 2010

2

Reducing Infant Mortality

Partners include ….

Office of Minority Health and Health Disparities

Medicaid

Behavioral Health Mental Hygiene Administration Alcohol and Drug Abuse Administration

WIC

Local Health Departments

Department of Human Resources

Governor’s Office for Children

3

Infant Mortality in Maryland & U.S.

Infant Mortality Rate, Maryland and U.S., 1982-2008

6

7

8

9

10

11

12

13

Year

Rate

per

1,0

00 li

ve b

irths

Maryland 11.7 11.7 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

United States 11.5 11.2 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 6.6 6.5

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 20062007

*2008

*

Data Source: MD DHMH:Vital Statistics Administration, CDC:NCHS* U.S. data for 2007 are preliminary, data for 2008 are provisional

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Leading Causes of Infant Mortality

Causes of Infant Death, Maryland, 2008

Preterm / Low Birth Weight, 26.1%

Congenital Abnormalities, 15.6%

SIDS, 12.0%Maternal Complications, 7.6%

All Other Causes, 26.6%

Respiratory Distress, 2.1%

Sepsis, 3.2%

Necrotizing Enterocolitis, 3.2%

Complications of Placenta/Cord, 3.6%

Data Source: MD DHMH, Vital Statistics Administrationn=617 deaths

5

Maryland Rankings

Infant Mortality 39th

Preterm Birth 34th

Low Birth Weight 43rd

SIDS / SUID 35th

6

Racial Disparity in Infant Mortality

Black:White ratio of 3:1

Infant Mortality Rates, Maryland, 1999-2008

0

5

10

15

20

Year

Rat

e p

er 1

,000

live

bir

ths

All Races 8.3 7.4 8.0 7.6 8.1 8.5 7.3 7.9 8.0 8.0

White 5.1 4.7 5.5 5.4 5.4 5.6 4.7 5.7 4.6 5.2

Black 14.7 13.0 13.6 12.7 14.7 14.9 12.7 12.7 14.0 13.4

Hispanic 5.1 6.2 5.3 6.0 5.3 4.6 3.0 3.8 3.2

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Data Source: MD DHMH, Vital Statistics Administration

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Racial Disparity in Leading Causes of Infant Mortality

In Maryland, a Black infant ….

is 1 ½ times as likely to be born prematurely,

almost twice as likely to be born at low birth weight,

almost 2 ½ times as likely to die of SIDS/SUID as a white infant.

8

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, 2003-07

Legend

Rate per 1000 live births

3.6 – 5.0

5.1 – 10.0

10.1 -14.8

Data Source: MD Vital Statistics Administration

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(1) 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., 1999-2008

78

81

84

87

90

% o

f Bir

ths

MD 87.0 86.4 83.7 84.1 83.7 82.3 81.3 80.4 79.5 80.2

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

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

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 not available

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(1) Health and Health Care Risks – Lack of Early Prenatal Care – Associated with Increased Infant Mortality

Percentage of Births to Women Receiving Late or No Prenatal Care, Maryland, 1999-2008

2

4

Per

cen

t

Maryland 3.1 3.1 3.7 3.6 3.8 3.9 4.3 4.3 4.7 4.2

U.S. 3.8 3.9 3.8 3.6 3.5 3.6 3.5 3.6

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

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

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(2) 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

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(3) Behavioral Risks – Unintended Pregnancy – Associated with Increased Neonatal Mortality *

* Bustan et al, AJPH, March 1994

Distribution of Mothers by Pregnancy Intention, Maryland, 2008

Didn't w ant to be pregnant then or later

8.9%

Wanted to be pregnant then

40.8%

Wanted to be pregnant sooner

16.7%

Wanted to be pregnant later

33.5%

Intendedpregnancies57.6%

Unintendedpregnancies42.4%

Data Source: Maryland PRAMS, 2008

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(3) Behavioral Risks – Substance Abuse

Percentage of Reports of Substance Problems among Women (ages 15-44 yrs) Enrolled in ADAA-Funded Treatment, Maryland, 2009

0

10

20

30

40

50

Alcohol

Heroin

Mar

ijuan

a/Hash

ish

Crack

Oth

er C

ocai

ne

Oxy

codo

ne

Oth

er O

piat

es

Benzo

diaz

epines PCP

Non-R

x Met

hado

ne

Oth

er

Oth

er A

mph

etam

ines

Halluc

inoge

ns

Met

hamph

etam

ines

Oth

er S

edat

ives

or H

ypnot

ics

Ove

r the

Cou

nter

Barbi

tura

tes

Inha

lant

s

Stimul

ants

Oth

er T

ranq

uilizers

Substance Abused

Per

cen

t

Data Source: MD DHMH, Alcohol and Drug Abuse Administration

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(3) Behavioral Risks – Substance Abuse

Non-pregnant women in treatment 48% White 49% Black 1.6% Hispanic

Pregnant women in treatment 45% White 52% Black 1.5% Hispanic

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(3) Behavioral Risks – Substance Abuse

Number of Alcoholic Drinks Consumed by Mothers During the Last Three Months of Pregnancy, 2001-2005

Nondrinkers92.3%

< 1 drink/wk6.2%

7 - 13 drinks/wk

0.1%

1 - 3 drinks/wk1.2%

4 - 6 drinks/wk0.2%

Data Source: Maryland PRAMS

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(3) Behavioral Risks – Substance Abuse

Data Source: Maryland PRAMS

Percentage of Mothers Who Reported Alcohol Use During the Last 3 Months of Pregnancy, 2001-2005

1.9

1.1

1.0

1.1 1.7

1.1

1.1

1.1

8.3

3.3

3.1

6.5

10.7

7.7

3.7

3.9

9.8

3.8

7.5

2.1

1.63.

3

0

2

4

6

8

10

12

14

Whi

te N

on-H

isp

Bla

ck N

on-H

isp

<25

25-3

4

+35

Mar

ried

Unm

arrie

d

<16

+16

<$2

0,00

0

+$2

0,00

0

Per

cent

Regular drinker, 1-14 drinks/wk Light drinker, <1 drink/wk

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Reducing Infant Mortality

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

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Reducing Infant Mortality –Targeting High-Risk Jurisdictions – 2007 Baseline

BaltimoreCity

PrinceGeorge’s

Somerset

112 Infant Deaths Rate 11.3/1000

150 Infant Deaths Rate 11.7/1000

6 Infant Deaths Rate 24.0/1000

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Reducing Infant Mortality – Intervention Points Across the Life Span

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)

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Reducing Infant Mortality – Strategy 1 – Before Pregnancy

Expand access to women’s comprehensive health and

wellness services

• Transition 3 family planning sites into Comprehensive Women’s Health Programs.

•Transition 3 sexually transmitted disease program sites and 3 behavioral health program sites to implement expanded referral services.

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

• Promote culturally-competent outreach and education efforts in the community.

21

Reducing Infant Mortality – Strategy 2 – During Pregnancy

Increase the # of women accessing early prenatal care

• Transition 3 local health department sites as pilot programs for implementing a Quick Start prenatal care program.

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

• Reduce the # of days between request for prenatal care and enrollment into Medicaid. Reduce the # of days between enrollment into Medicaid and first prenatal care visit.

22

Reducing Infant Mortality – Strategy 3 – During and Following Delivery

Expand access to more comprehensive, high quality

perinatal and neonatal care

• Ensure that pregnant women identified through these programs receive timely perinatal care and appropriate follow up referrals for substance abuse, mental health, domestic violence, and smoking cessation.

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

• Assure linkages to culturally-competent, community-based prevention services.

•Future data - Electronic Birth Certificate

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Reducing Infant Mortality in Maryland –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