Transcript Bronx Center to Reduce and Eliminate Ethnic and Racial

Bronx Center to Reduce and Eliminate Ethnic
and Racial Health Disparities
Impact of Perinatal Health Issues on Infant Mortality
and Morbidity in the Bronx
Deborah Campbell, MD, FAAP
Division of Neonatology
June 15, 2007
Faculty Disclosure Form
In the past 12 months, I have not had any
significant financial interest or relationship
with the manufacturers of the products or
providers of the services that will be discussed
in my presentation.
This presentation will not include discussion of
pharmaceuticals or devices that have not been
approved by the FDA.
Bronx Health Center and Community
Districts
Overview Perinatal Health in the Bronx
♦ Rates for infant and maternal mortality, low
birth weight, teen pregnancy, late or no
prenatal care exceed city, state and US
averages
♦ Large racial disparities for black and Hispanic
women and infants
Overview of Bronx Perinatal Health
♦ Highest IMR are in Morrisania, Williamsbridge and
East Tremont sections of the Bronx
♦ > 10% infants are born LBW
♦ 12% of Bronx births are to teen mothers
♦ Mott Haven, Hunts Point, East Tremont, Morrisania
♦ ~ 66% Bronx births are to women on MA – NYS rate
is 20%
♦ Mott haven, Hunts Point, Unionport/Soundview,
Concourse/Highbridge, Fordham, Williamsbridge
♦ 25% pregnant women have late/no PNC
♦ Additional 41% inadequate PNC
♦ Fordham, Bronx Park, Central Bronx, Highbridge,
Morrisania, Mott Haven and Hunts Point
Overview of Bronx Perinatal Health
♦ > 50% delivering women in the Bronx are
immigrants
♦ Primarily from Latin America
♦ > 50% Spanish speaking
♦ Highest rates of asthma in NYC
♦ Breastfeeding rates
Live Births, Induced Terminations and
Spontaneous Terminations
Live Births, Induced Terminations and
Spontaneous Terminations, NYC 1986-2005
2005 Live Births, Spontaneous and Induced
Terminations of Pregnancy
Total Pregnancies
43621
Live births
20766
Spontaneous terminations
2271
Induced terminations
20584
Live Births, Induced Terminations
NYC, 2005
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
LiveBirth
TOP
Man
Bx
Bklyn
Qu
SI
Live Births by Maternal Ethnicity
Live Births by Race/Ethnicity &
Borough 2005
60
50
40
Hispanic
AA
Asian
30
20
10
0
Man
Bx
Bklyn
Qu
SI
Bronx Live Births 2005: 20,766
Bronx Lebanon Hospital Center
Level IIIC
2891
Jack D. Weiler Hosp (Montefiore)
IIIC/RPC
4572
Jacobi Medical Center
IIIC
2238
Lincoln Medical and Mental Health Center
IIIC
2421
North Central Bronx Hospital
IIB
1743
Our Lady of Mercy (2007 – Montefiore N)
IIIB
1668
St. Barnabas Hospital
IIIA
1294
Women’s Health and Birthing Center
120
Home
8
Foundling
1
Bronx resident births outside borough
3810
NYC Live Birth Characteristics
Distribution of Births By Gestational Age
Ancestry of Mother in 2005
♦ NYC - 122,725 LB
♦
♦
♦
♦
♦
♦
♦
Puerto Rican
Dominican
Mexican
African-Am.
Chinese
Jewish/Hebrew
Other Hispanic
9922
9907
7986
16448
7426
7632
6769
♦ Bronx – 20,766 LB
♦
♦
♦
♦
♦
♦
Puerto Rican
Dominican
Mexican
African-Am.
Jamaican
Other Hispanic
1337
4052
1754
4005
745
1132
Teen Childbearing
♦ Preliminary data for 2005
♦ Decline in birth rate by 2% to 40.4/1000 women
15-19 yrs.
♦ Greatest decline among 15-17 yr olds. to
21.4/1000
♦ Rate for 18-19 yr olds. stable at 69.9/1000
♦ Rate for 10-14 yr olds. unchanged: 0.7/1000
♦ 3% decline for non-Hispanic white and nonHispanic black teens 15-19 yrs old, between 20042005
♦ 6% for non-Hispanic black teens 15-17 yrs old
Teen Birth Rate for 15-19 year olds:
1991 v. 2005
Teen Live Births: 2003-2005
US rate for 2004: 10.3%
2005 rate for 15-19 y/o: 40.4
Infant, Neonatal and Post-Neonatal
Mortality Rates, NYC 1988-2005
Citywide Infant Mortality
♦ 2005
♦ 6.0/1000 LB v. 6.8/1000 LB for the entire US
♦ Decline in births by 1.1 % from 2004
♦ Decline in infant mortality by 3.8%
♦ Since 1990 there has been a 48% decrease in NYC’s
IMR
♦ Infant mortality is influenced by multiple factors
♦ Maternal health, SES over the perinatal care continuum,
substance use, access to and utilization of quality service,
levels of stress and social support
♦ Knowledge about safe sleep position and other risk factors
for SIDS
2005 IMR by Borough
Brooklyn
6.0*
Bronx
Manhattan
6.3
( from 7.1 in 2004)
4.4
Queens
5.1
Staten Island
5.2
Infant Mortality Rate by Borough:
NYC, 1994-2004
14
Rate per 1,000 live births
12
10
8
6
4
2
0
1994
1995
1996
1997
1998
1999
2000
Manhattan
Bronx
Queens
Staten Island
2001
2002
Brooklyn
2003
2004
Infant Mortality Rate/1000 LB:
Bronx Health Districts 2001-2005
2001
2002
2003
2004
2005
Bronx
5.9
6.5
8.6
7.1
6.3
FordhamRiverdale
5.2
5.6
8.2
5.2
4.9
Morrisania
5.3
5.9
8.8
8.9
7.4
Mott Haven
5.1
3.5
7.9
4.3
5.8
Pelham Bay
4.4
7.3
8.7
9.0
6.0
Tremont
7.0
6.1
10.2
6.5
7.0
Westchester
7.2
9.6
7.6
8.7
6.4
2005
Infant
Mortality
Rate by
Ethnicity
Trends in Infant Mortality Rate by
Race/Ethnicity: NYC, 1994-2004
Rate per 1,000 live births
18
12
6
0
1994
1995
1996
1997
1998
1999
2000
Black non-Hispanic
White non-Hispanic
Other Hispanic
Asian/PI
2001
2002
Puerto Rican
2003
2004
Distribution of Deaths:
Fetal-Neonatal-Infant Mortality
Non-Hispanic Black 13.6
Non-Hispanic white 5.7
Hispanic
5.65
US: 6.79
4.52
2.27
Components of Perinatal Period of Risk
The Role of Maternal Morbidity and
Mortality
Maternal Mortality Ratios for
White Women:1987-1996
3
.
0
9
.
2
6
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1
3
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6
3
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4
2
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7
3
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9
7
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6
3
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6
5
.
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.
6
3
.
9
3
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5
.
9
3
.
9
4
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5
4
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6
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5
5
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7
3
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8
6
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8
6
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6
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3
4
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9
4
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4
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64
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6
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Note: The colors on these maps show the states
divided into three terciles based on their MMR.
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A Regional Look at Maternal
Mortality Ratios* for the Year 2000
12.9 in NYS
15.9 in NYS
23.1
in NYC
23.1 in NYC
*Per 100,000 live births
Findings of the SMI
Causes of Death (n=33) August 2003 – June 2005
♦
♦
♦
♦
♦
♦
♦
Embolism
PIH
Hemorrhage
Infection
Cardiomyopathy
Anesthesia
Other/Unknown
24.2%
24.2 %
15.2 %
15.2 %
6.1 %
None
15.2 %
SMI: A Look at Chronic Disease
♦ 54% of the pregnancy-related deaths had a
history of chronic disease
♦ Hypertension
♦ Cardiac Disease
♦ DVT
♦ Diabetes
♦ Scleroderma
♦ Sickle Cell Disease
♦ Obesity was the most commonly identified
(66%)
Trends in Maternal Mortality Ratio by Race/Ethnicity:
NYC OVS, 1993-2004
90
80
Per 100,000 Live Births
70
60
50
40
30
20
10
0
1993 1994 1995 1996 1997 1998
1999 2000 2001 2002 2003 2004
Black non-Hispanic
White non-Hispanic
Other Hispanic
Asian/Pacific Islander
Source: NYC DOHMH Office of Vital Statistics
Standard surveillance
Puerto Rican
37
New York City Initiative
♦ Leadership – Gina Brown, MD
♦ Multi-disciplinary Committee on Maternal
Mortality
♦ Enhanced Surveillance and Case Reviews
♦ Bureau of Maternal Infant Reproductive
Health
BMIRH MMR Enhanced Surveillance Methods
• Case ascertainment
Vital Statistics, Medical Examiner, SPARCS
• Case Review
Medical records, ME reports, maternal death
certificates, infant birth certificates
• Data entry and analysis
Location of Death: BMIRH 1998-2000
80
70
60
Percent
50
40
30
20
10
0
Hospital
EMR
Home
In Transit
Percent of Live Births and Maternal Deaths
By Race/Ethnicity: BMIRH 1998-2000
60
60
40
40
Percent
White
Black
Hispanic
Asian/Pacific Isl
50
50
30
56.2
29.47
32.19
30
26.64
25.4
20
20
10.7
11.24
10
10
0
0
Race/Ethnicity
Live Births
6.5
Race/Ethnicity
Maternal Deaths
MMR and Race/ Ethnicity
BMIRH 1998-2003
100
90
80
70
60
50
40
30
20
10
0
93.2
33.3
19.9
19.2
MMR
White
Black
Hispanic
API
US Historical Perspective: Racial Disparities
Year
MMR White
MMR Black
Risk Ratio
1915
601.0
1056.0
1.76
1930
601.0
1174.0
1.95
1945
172.0
445.0
2.59
1950
61.0
222.0
3.64
1990
6.5
26.7
4.11
1991-1999
8.1
30.0
3.70
Sources: MMWR 2003; JAMWA 57(3), 2002
MMWR 2003:52(No.SS-2)
MMR by Birth Place
BMIRH 1998-2003
70
60
58.1
50.2
50
37.8
40
30
20
10
0
Birth Place
US
Puerto Rico
Non US
Comparing Leading Causes of Death (%)
Cause
International
PRMR*
National PRMR
N=4200**
NYC PRMR
N=119
Embolism
Negligible
20%
7%
Hypertensive
Disorders
12%
16%
10%
Hemorrhage
25%
17%
32%
Infection/Sepsis
15%
13%
7%
Other
Obstructed Labor
8%
Unsafe Ab 13%
Cardiomyopathy
8%
CVA 5.0%
Anesthesia 2%
Cardiomyopathy
8%
Anesthesia 7%
*International WHO 1993, JAMWA 2002
**National MMWR 2003
***NYC BMIRH 1998-2000
Hemorrhage Related Deaths
BMIRH 1998-2000
Black
Hispanic
White
Asian/Pacific Isl.
In hospital
64 %
21 %
8%
8%
97%
Obesity: Maternal Mortality Risk From Hemorrhage
BMIRH 1998-2000
NYC Live Births 19982000
(n=373,554; % of total)
Maternal Deaths
(n=169; % of total)
OR [CI]
Maternal Hemorrhage Deaths
(n=39; % of total)
OR [CI]
Yes
17
24
2.24
[1.5, 3.34]
38
3.88
[1.82, 8.26]
No
71
44
41
Missing
12
33
21
Obesity
Hemorrhage Initiative
♦ Hemorrhage alert – Commissioner of Health,
NYC
♦ Hemorrhage protocols
♦ Hemorrhage Poster
♦ Unusual collaboration between the NYC DOH,
NYS DOH and ACOG
What About the Bronx?
MMR by Borough
BMIRH 1998-2003
60
50
Manhattan
Bronx
Brooklyn
Queens
Staten Island
Non resident
40
30
20
10
0
Borough
Predictors of Maternal Mortality
and Near Miss Mortality
♦ Weiler Hospital – Jan. 95 – June 2001
♦ Cases of MM and NM identified
♦ ICD-9 codes
♦ QI records
♦ ICU logs
♦ 3 Controls from same delivery day
♦ Charts reviewed
Collaborators:
C. Chazotte, MD
E. A. Harrison, MD
D. Goffman, MD
I. R. Merkatz, MD
J. Choi, MD
R. Madden, PhD
Maternal Mortality and Near Miss
♦ Model containing all recognized risk factors:
race, maternal age, obesity, past medical
history, prior cesarean, and gravidity
♦ Multiple logistic regression
♦ Black race remained a significant factor -OR
5.0 (CI 1.5-17.0)
Where Do We Go From Here
♦ Preconception Care
♦ Medical Conditions
♦ Obesity
♦ Family planning
♦ Maternal age, number of children
♦ IVF and multiples
♦ Systems Issues
♦ SMI, NYC
♦ Hemorrhage Initiative
Newborn and Infant Care Issues
Leading Causes Infant Death: 2004
♦ Congenital malformations (20.1%)
♦ Disorders related to short gestation and LBW
♦ 16.6% deaths in 1st year life due to preterm birth
♦ SIDS (8%)
♦ Newborn affected by maternal complications of
pregnancy (6.1%)
♦ Accidents (unintentional injuries) (3.8%)
♦ Newborn affected by complications of placenta, cord
and membranes (3.7%)
Birth Weight Categories
Normal BW
> 2500 g
Low BW
< 2500 g
Very Low BW
< 1500 g
Extremely LBW < 1000 g
(5.5 lbs)
(5.5 lbs)
(3.3 lbs)
(2.2 lbs)
Infant Mortality Rate for
Birth Weight Categories,
NYC: 1994-2004
300
Rate per 1,000 live births
250
VLBW (< 1500
grams)
200
150
100
LBW (1500 - 2499
grams)
50
Normal BW (> 2500
grams)
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Martin JA, Hamilton BE, Menacker F, Sutton PD, Mathews T.J. Preliminary births for 2004: Infant and
maternal health. Health E-stats. Hyattsville, MD: National Center for Health Statistics. Released November
15, 2005.
Central Bronx: LBW and IMR
South East Bronx
Hunts Point – Mott Haven
2005 US Breastfeeding Rate:
Ever Breastfed (Annual Summary VS, Pediatrics 2007)
Bronx Initiative to Improve Perinatal Health
♦
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Nurse Family Partnership
Newborn Home Visiting Program
Healthy Women/Healthy Baby Initiative
Healthy Teens Initiative
Breastfeeding Initiative
Bronx Strategic Action Committee
Citywide Infant Mortality Case Review Committee
♦ Infant Mortality Reduction Initiative funded by the City
Council