Preventing Infant Mortality: What Can Local Teams Do?

Sarah Verbiest, DrPH, MSW, MPH March 2009

Presentation Objectives

• •

Review causes of infant death in NC Discuss preterm birth

• • •

Incidence Cost Risk factors

•

Share strategies and promising practices for preventing preterm birth

Causes of Infant Death in 2007 1,107 babies

• • • • • Prematurity & other birth-related conditions (580) Birth Defects (231) Sudden Infant Death Syndrome (98) Unintentional Injuries: motor vehicle, drowning, suffocation, Shaken Baby, falls, poisoning, others Intentional Injuries: abandonment, homicide

• 67% of the child deaths in NC are among babies before their first birthday. Preterm birth is the leading cause of child death in NC.

• Infant deaths are most likely to occur in the first 28 days after birth. • The interventions to protect our babies can be complex and unclear. Science does not yet have all the answers.

Preterm Birth

• Babies born before 38 weeks of pregnancy are preterm.

• In NC, 1:7 babies and 1:5 African American babies are born preterm. 16,868 babies were born early in 2005.

10% 6% 13% 71% 34-36 w ks 32-33 w ks 28-31 w ks <28 w ks

Preterm Birth Trend Data Comparing North Carolina and the United States

1990-2007 NC Resident Births: Percentage Preterm by Clinical Estimate of Gestation: TOTAL

10.0

9.0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0

199 0 199 1 199 2 199 3 199 4 199 5 199 6 199 7 199 8 199 9 200 0 200 1 200 2 200 3 200 4 200 5 200 6 200 7 Very Preterm: <=32 Weeks 2.5 2.6 2.6 2.7 2.6 2.7 2.6 2.7 2.7 2.8 2.8 2.8 2.7 2.6 2.7 2.7 2.6 2.6

Late Preterm: 33-36 Weeks 6.8 7.2 7.5 7.6 7.5 7.6 7.8 7.7 7.9 8.3 8.4 8.4 8.4 8.7 8.8 8.9 8.6 8.4

1990-2007 NC Resident Births to African-American, Non-Hispanic Mothers : Percentage Preterm by Clinical Estimate of Gestation

12.0

10.0

8.0

6.0

4.0

2.0

0.0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Very Preterm: <=32 Weeks 4.4 4.5 4.6 4.6 4.5 4.8 4.7 4.7 4.8 4.7 4.9 4.6 4.8 4.5 4.8 4.8 4.6 4.6

Late Preterm: 33-36 Weeks 9.2 9.3 9.9 10.0 9.8 9.9 9.9 9.5 9.6 10.1 10.1 10.2 10.2 10.6 10.2 10.7 10.6 10.3

Impact

• NC experienced a 9% increase in the past decade. • PTB accounts for more than 70% of neonatal deaths and almost half of long-term neurological disabilities.

• Babies born preterm are at risk for developmental delays, ADHD, cerebral palsy, visual and auditory issues, and cardiovascular and metabolic diseases as the grow.

• Price tag: $26.2 billion nationally, $700 million in NC, $49,000-$60,000/year for families for first year of life.

Cost of Preterm Birth Healthy Baby - $3,640

Infant Condition Total Cost Number of Infants

4,546

Average Cost

$ 8,032 Late Preterm $ 36,515,327 Preterm Very Preterm Very Low Birthweight Birth Defect Infant Death Neonatal Death (< 28 days of life) At Risk Birth 6,686 1,332 1,217 1,622 485 263 3,523 $19,781 $59,320 $63,877 $34,713 $35,327 $ 16,581 $36,976 $132,255,522 $ 79,013,727 $ 77,738,693 $ 56,304,736 $17,133,818 $ 4,360,854 $130,268,583

• • •

A Note About Low Birthweight

A baby born weighing < 2500 grams (5lb 8 oz) is low birthweight. A baby weighing 1500 grams or less is very low birthweight.

67% of low birthweight babies are also preterm.

However, babies can be small at birth for other reasons – – – – Parents are smaller than average Growth restriction during gestation Birth defects Multiple births

• •

Causes

Spontaneous Labor and Premature Rupture of the Membranes (PROM) • • • Causes not fully understood Response to infection No way to delay labor beyond 48 hours once it has started Early Induction of Labor or C-Section Delivery • Due to pregnancy complications or health problems in mother or fetus • Late preterm births due to elective inductions/c-sections

No Easy Answers

• • • • • Complex problem with multiple causes and interactions at play.

A syndrome in which different disorders contribute to the initiation and progression of labor.

Interactions among biological, genomic and social factors have not been well evaluated.

There will be no silver bullet.

The most effective interventions may well be BEFORE a woman becomes pregnant.

• • •

Highest Risk

Having a prior preterm birth – 15% to 50% chance of recurrence - the earlier the PTB the greater the risk – 5,423 women in 2005 fell into this category in NC Mothers who are African American – 2.5 times more likely to have an early birth than other women Women with uterine distention or cervical abnormalities – Women carrying twins or higher are 5 times more likely to have an early birth – Multiple births increased 33% over the past 10 years in NC

• • • • • • • • • •

Medical Conditions

Infections in the mother Infections in the fetus Placental problems Birth defects Clotting disorders Folate deficiency Chronic health conditions in the mother Short time period between pregnancies Being over or under weight Being pregnant with a single fetus after in vitro fertilization

• • • • • • • •

Life Style & Socioeconomic Conditions

Smoking Alcohol & Illicit Drugs Late or no prenatal care Maternal age High levels of stress Poverty / Education Lack of social support Domestic Violence

Unintended Pregnancy

• • • • Women who are younger than 20, African American, have less than a high school education, are unmarried and received Medicaid are at greatest risk. Almost half of all pregnancies in NC were unintended or unplanned.

In the US in 2001, 44% ended in live birth, 45% in abortions and 14% in miscarriages.

NC ranks 36 th in the nation for high rates of pregnancy among women ages 15-19.

Women’s Health

• • • • • • • • • 11% engage in binge drinking 24% use tobacco and 8% admit to use of illicit drugs 47% do not meet minimum physical activity standards 28% are obese and 26% are overweight 26% have poor mental health 10% have hypertension and 3% have diabetes 25% are uninsured 71% do not take folic acid at least 5 days a week 14% may not be rubella immune

Questions to Ask for Reviews and Strategies for Action

Where was the baby born?

• • Preterm infants as well as those with complex birth defects have improved mortality rates and lower morbidity rates if born in hospitals with intensive care nurseries equipped to care for them.

These NICUs should have – – – High volume of preterm infants High level of care Babies with birth defects need access to pediatric subspecialty services – What hospitals advertise they can do and what they can do well may be different

Is this the mother’s second or higher preterm birth?

• Women who have had one preterm birth are at risk for having another early birth.

• Did she have access to medical care, support and family planning services between pregnancies?

• Did she receive 17P?

17 Alpha Hydroxyprogesterone Caproate (17P)

• 17P is a synthetic form of progesterone that has been shown to reduce the risk of preterm birth among women with a history of a prior preterm birth by 33%.

• ACOG recommends the use of 17P for secondary prevention of preterm birth.

• Studies show no serious side effects for mother or baby and no increase in the rate of birth defects for infants whose mothers use 17P.

Protocol for 17P Use

• History of a previous singleton spontaneous preterm birth (20 0 to 36 6 weeks). Women who delivered multiple infants preterm and/or who are pregnant with multiples are not eligible for treatment • Current singleton pregnancy • Initiate treatment between 16 0 Receive 17P injections

weekly

- 21 6 weeks gestation* until 36 6 weeks gestation or she delivers • For more info go to www.mombaby.org

and click on 17P

Did the mother smoke?

• Smoking increases the risk that a baby will be born preterm and/or low birthweight. Second hand smoke puts an infant at risk for SIDS. • Health care providers should be screening women for smoking at many different points in their prenatal care. They should use the 5As method for screening. • For more information and resources go to www.youquittwoquit.com

Did the mother use drugs and/or alcohol?

• • • Was the mother screened for and counseled about drug and/or alcohol use during pregnancy? Was she referred for services if appropriate?

Health care providers should screen all women using a validated tool for substance use during pregnancy. If she screens positive she can be referred to the NC Division of MH/D/SAS Perinatal and Maternal Substance Abuse Initiative. For more info go to www.nchealthystart.org/PerSubUse or call 1-800-367-2229 for a referral.

Was the baby a twin or higher?

• Mothers who are older and mothers who use Assisted Reproductive Technology to become pregnant are more likely to have multiples than other mothers.

• Watch for trends in your community particularly if you are seeing large numbers of multiple births.

Did the mother plan for this pregnancy?

• Mothers who have unintended pregnancies are often at risk for many reasons.

• Did the mother have access to family planning services in her community? • How are these services regarded by the community? Do they provide good reproductive planning counseling ? Do women have access to long lasting contraceptives if they want them?

How far apart was this baby’s conception from the birth of his/her sibling?

• • • The ideal time in between the delivery of one baby and the conception of the next is between 18 and 59 months. The risk for a preterm birth increases considerably the shorter the interval becomes.

Was this a planned pregnancy? What access did the mother have to family planning?

What is the knowledge within the community about the importance of birth spacing?

What was the mother’s health status?

• • • • • • Did she have chronic conditions such as diabetes, hypertension, lupus, sickle cell anemia that were not under control prior to / during pregnancy?

Was mom under or overweight?

What was mom’s mental health condition?

Was mom taking a multivitamin? Was she anemic?

Was mom screened for sexually transmitted diseases? Did she have them or other infections during her pregnancy?

Did mom have access to health care – both prenatal and primary? Did she have access to dental care?

What was the mother’s environment like?

• • • • • • What kind of social support did she have? Was the father of the baby involved in the pregnancy?

Did she have access to adequate food?

What kind of stress did she have in her life?

Was she employed? Did she have to stand for long period of time?

What is her neighborhood like?

What was her exposure to violence?

Other Ideas for Action

• Map your community .It may be helpful to develop a map and see where infant deaths occur in your community. Then look at that areas rates of chronic disease, obesity, crime, property damage and access to food.

• Review services available in your community for women of reproductive age. • Raise awareness among health care providers and the community about trends that you are seeing in the data.

A word of caution

• The goal of these questions is not to “blame” the mother for her baby’s birth outcome. It is to get a better picture of some of the potential issues behind the early birth.

• There are many complex social and environmental factors that influence preterm birth.

• As a community, understanding the impact of these factors on infant mortality can help prompt action.

Don’t Give Up!

• • • Infant death is the most sensitive indicator we have about the health of a community. It is important that we study these deaths and then share information learned with each other. The Perinatal Health Committee as part of the Child Fatality Task Force wants to hear what you’re learning and what you’re worried about.

We can work together to address the larger issues one policy and community at a time.

Questions?

Sarah Verbiest Executive Director Center for Maternal and Infant Health 919-843-7865 [email protected]

www.mombaby.org