Transcript Uncovering Community Voices: A Summary, Analysis and

North Carolina’s
Recent Infant
Mortality
Experience and
Women’s
Health
Joe Holliday, MD, MPH
Joe Holliday, MD, MPH
Belinda Pettiford, MPH
October 28, 2009
December 10, 2008
May/June 2004 Issue
Recent Infant Mortality in North
Carolina

1988 was a landmark year - NC was 49th in
among 50 states in the infant mortality rate.
 The NC infant mortality rate has declined by
over one-third since 1988.
 More recently, the downward trend in the NC
infant mortality rates has slowed and NC ranks
45th among 50 states.
Source: NC Center for Health
Statistics
www.schs.nc.us/SCHS/data/
Recent Infant Mortality in North
Carolina (cont.)

Since 1988 infant death rates have declined less
among African Americans and American Indians
than among whites, leading to increasing racial
disparities over time.
 With prenatal care participation rates improving,
maternal smoking and teen birth rates declining,
and other key indicators generally moving in a
favorable direction, the lack of recent progress in
infant mortality reduction is perplexing.
Infant Mortality Rate
North Carolina, 1988-2008
14
12
10
8
6
4
2
Year
20
08
20
04
20
00
19
96
19
92
0
19
88
Rate
Per
1,000
Live
Births
Infant Mortality Rate
North Carolina, 1988-2008
25.0
20.0
15.0
10.0
5.0
0.0
1988
1991
1994
1997
Af. Am.
2000
White
2003
2006
Infant Mortality
An issue of great magnitude
 Accounts
for 68% of all deaths to children
 Has multiple causes – serves as a proxy
measure for the broader issue
 Also associated with childhood morbidity
 Increasingly associated with origins of
some chronic diseases
Major Determinants of
Infant Mortality
 Preterm
Birth / Low Birth Weight
 Birth Defects
 Sudden Infant Death Syndrome
 Other Conditions During Pregnancy
Birth Weight Trends
 The
percent of live births that are low birth
weight has increased steadily.
 The
percent of increase of low birth weight
by weight category ranges from 5% to
35.1% with the greatest increase in the
under 500 gram birth weight category for
minorities.
Percentage of White and Minority
Low-Birthweight Live Births,
North Carolina, 1987-2008
12
10
Percent
Of
Live
Births
8
6
4
2
0
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2006 2007 2008
Whites 1500-2499 grams
Minorities 1500-2499 grams
Whites Under 1500 grams
Minorities Under 1500 grams
Birth-Weight-Specific
Infant Mortality Rates
 Most
of the decrease in the IMR in recent
years is due to improved survival at each
level of birth weight. Survival now at a
plateau?
 The
fetal death rate decreased 22% over
this time period (8.6 to 6.7). This suggests
that real improvement in both fetal and
neonatal survival has taken place.
Birthweight-Specific Infant Mortality Rates by Race,
North Carolina 1988-89 and 2006-2007
*Based on Birth Cohort
1000.0
Infant Mortality Rate
900.0
Whites 1988-89
Whites 2006-07
Minorities 1988-89
Minorities 2006-07
800.0
700.0
600.0
500.0
400.0
300.0
200.0
100.0
0.0
Under 500
500-749
750-999
1000-1499 1500-2499
Weight Category
2500+
Racial Disparity in Infant Mortality

The racial disparity in infant mortality has increased 1.95
in 1988 to 2.45 in 2008, although the minority infant
mortality rate fell to an all-time low in 2008 to 13.5 per
1,000 live births.

The neonatal survival advantage of low birth weight
African American babies has decreased over time. This
could be contributing to the increasing racial disparity in
infant mortality.

In 2008, nearly 17% of live births in the state were
among Hispanics, compared to only about 2% in the
early 1990s.
Racial Disparity in Infant Mortality
Role of Women’s Health
 Racial
disparities in birth outcomes
correlate with disparities in measures of
women’s health.
 These disparities increase with maternal /
female age.
 Increased education reduces but doesn’t
eliminate disparities.
Racial Disparities in Health
Outcomes Increase with Age
NC BRFSS SURVEY RESULTS
18-24
25-34
35-44
African American
27.9
43.5
46.4
White
21.0
29.8
28.3
Ratio
1.33
1.46
1.64
African American
4.0
11.2
15.8
White
7.1
6.6
8.3
Ratio
0.56
1.70
1.90
African American
8.9
15.6
26.9
White
4.5
7.4
16.3
Ratio
1.98
2.11
1.65
2008 - % Obese (BMI>=30)
2008 - % Who Report Their Health as Fair or Poor
2007 - % With High Blood Pressure
Racial Disparity in Birth Outcomes
Increase with Age
Birth Outcome Measures by Maternal Race
& Age, NC Residents, 2004-2008
15-19
20-34
35+
African American
3.1
3.5
4.8
White
1.6
1.2
1.6
Ratio
1.9
2.8
2.9
10.6
10.3
11.8
White
5.9
3.7
4.8
Ratio
1.8
2.8
2.5
% Very Low Birthweight
Neonatal Deaths per 1,000 Live Births
African American
Socio-Economic Disparities
Associated with Unintended
Pregnancies

29% women are more careful about using
contraception every time

12% women considering switching to long-term
contraceptive

18% women inconsistently used the pill as a
means of saving money

25% women put off gynecology or birth control
visit to save money
Source: Guttmacher Institute, September 2009
What North Carolina Women Say
About Their Health?

Quantitative Data Not Sufficient to Tell the
Story

Qualitative Research Project Provides Real
Insights


Why do (or do not) women adopt preventive health
behaviors?
Why do (or do not) women use preventive health
services?
Source: www.nchealthystart.org
What North Carolina Women Say About
….
North Carolina’s Recent Infant
Mortality Experience
 Decline
in birth weight specific mortality
until recently
 Increase in low birth weight births
 Racial disparities not improved
 Importance of women’s health throughout
the lifespan increasingly recognized

Need a cultural shift
Feto-Infant Mortality:
Birthweight
Distribution
Socio-Economic
Risk Factors
Smoking
Race
Medical Conditions
Prenatal Care
Smoking Cessation
Tocolytics
Health Insurance
Primary Care
Content Availability
Mortality by
Birthweight
Gender
Gestational age
Race
Medical Conditions
Interventions Perinatal Care
Quality Care
Referrals
Access
Referral Systems
Transport Systems
Expertise
Infant Mortality - Recent Directions:
Improve Access to Healthcare

Primary Healthcare for Women



High Risk Maternity Care





Extend Medicaid for women for 2 yrs postpartum.
Extend health insurance to parents
Regionalization of perinatal care challenged
CCNC adding high risk initiative
Preterm birth prevention and PQCNC projects
NC IOM Substance Abuse Study
New Electronic Birth Certificate
Infant Mortality - Recent Directions:
Reduce Unintended Pregnancies
 Approximately
half of live births in NC are
unintended
 Associated with late prenatal care, low
birth weight, poor maternal nutrition and
smoking, and less likely to breastfeed
 Expanded Medicaid income eligibility up to
185% FPL for family planning services for
men & women >18yrs age
Infant Mortality - Recent
Directions: Reduce Unintended
Pregnancies (cont.)

In Year 2 with very limited participation, an
estimated 1,139 births were averted and $12
million saved
 ACOG Supports Increased Access to LongActing Reversible Contraceptives (Implants &
Intrauterine devices) as safe, long-acting,
convenient & highly effective
 More Medicaid $$ to support these methods
through Family Planning Waiver Program
Infant Mortality - Recent Directions:
Education and Support
 Folic Acid Awareness
& Multivitamin
Distribution
 Educational

Resource Line and Healthy Start Foundation
 Case

Resources
Management & Home Visitation
MCC-CSC, Baby Love Plus, Nurse Family
Partnership, Teen Pregnancy Prevention
Initiatives
Infant Mortality - Recent Directions:
Education and Support

Baby Love Plus Model






Consortium comprised of consumers, community
leaders, providers
Case Management/Care Coordination
• Prenatal (Maternity Care Coordination)
Outreach and Client Recruitment
• Community Health Advocates
Education and Training
• Providers, Faith Entities
Interconceptional Care
• Working with mom and baby for 2 years
Depression Screening and Referral
Infant Mortality – Recent
Directions: Improve Maternal
Health
North Carolina’s Infant Mortality
and Women’s Health
Our Success and Future
Tchernavia “T” Ranesfore
Receives National
Recognition
2009 Healthy Teen
Network
Outstanding Teen Parent
Award