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2011 BCBS Infant Mortality Best Practices Forum Giancarlo Mari, M.D. Professor and Chair Department of Obstetrics and Gynecology University of Tennessee Health Science Center Memphis, TN INFANT MORTALITY

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Definitions Infant mortality Death of a live-born infant under 1 year of age per 1,000 live births Neonatal Mortality Death in the first 28 days of life Postneonatal Mortality Death after 28 days of life but before 1 year Fetal mortality Fetal weight 350 g or more, or 20 weeks of gestation or more (NCHS 2010) Preterm Birth Birth before 37 completed weeks of gestation

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Infant mortality, fetal mortality, and preterm birth all represent important health challenges that have shown little recent improvement.

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Fetal and Infant Mortality Rates and Percentage of Preterm Births United States: 1990-2008 MacDorman MF. Semin Perinatol 2011;35(4):200-8.

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US Mortality Rates 1940-2006: Infant, Neonatal and Postneonatal

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US Infant Mortality Rate Per 1,000 Live Births: 2000-2008

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Global Ranking of Mortality Rates 1960 vs. 2004

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Healthcare Costs The US spends more than twice the average of other industrialized countries on healthcare : In 2006, Americans spent $6,714 per capita

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The Preterm Birth Connection Much of the infant mortality rate in the U.S. when compared to other countries is due to the high percentage of preterm births MacDorman MF, et al. NCHF 2009

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The Costs of Preterm Birth Annual costs in the United States related to preterm birth exceed $26 billion annually $51,500 per preterm infant Dhanireddy R. The Commercial Appeal, November 13, 2010.

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Percentage of Live Births and Infant Deaths by Gestational Age United States: 2006 MacDorman MF. Semin Perinatol 2011;35(4):200-8.

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Infant Mortality Rates for the 5 Leading Causes of Infant Death by Race and Hispanic Origin of Mother United States: 2006 MacDorman MF. Semin Perinatol 2011;35(4):200-8.

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Mathews TJ et al. Pediatrics 2011;127:146-157. Infant Mortality Rate by Race and Ethnicity United States: 2006

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African-American vs. Caucasian Infant Mortality United States: 2006 MacDorman MF. Semin Perinatol 2011;35(4):200-8.

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Infant Mortality by Location

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2008 Infant Mortality by State Ranged from 3.95 deaths/1,000 live births in New Hampshire to 9.97 deaths/1,000 live births in Mississippi Tennessee had 6 th highest infant mortality rate (8.1) Mathews TJ, et al. Pediatrics 2011;127:146-157

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Tennessee Infant Mortality by Age at Death 1997-2006

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Tennessee Infant Mortality by Race 1997-2006

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Tennessee Infant Mortality by Race and Ethnicity 1997-2006

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Tennessee Infant Mortality Due to Preterm Birth and Low Birthweight 1997-2006

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The Regional Medical Center (THE MED) Memphis Preterm Births 2006-2010

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Tennessee Infant Mortality Due to Accidents 1997-2006

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Tennessee Infant Mortality Due to Sudden Infant Death Syndrome 1997-2006

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Tennessee Infant Mortality Due to Congenital Defects 1997-2006

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Tennessee Infant Mortality by Maternal Age 2001-2005

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Regional Medical Center at Memphis (The MED) 2008-2009 Teenage Pregnancies 20082009 (Total of 1217) (Total of 933) Age Total Age Total 12 1 12 0 13 6 13 4 14 30 14 11 15 84 15 48 16 169 16 120 17 204 17 182 18 318 18 270 19 405 19 298 NICU Admissions: 224 NICU Admissions: 253

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Tennessee Infant Mortality by Maternal Marital Status 2001-2005

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Memphis Number of children under 18 in the city: 167,968 Number living in a "husband-wife family": 56,158 Number living in a family with a female householder, no husband present: 66,682 Number living in a family with a male householder, no wife present: 10,656 Number living with grandparents: 22,599 Number living with other relatives: 8,255 Number living with non-relatives: 3,034. Charlier T. The Commercial Appeal; August 29, 2011

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Tennessee Infant Mortality by Maternal Education 2001-2005

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Tennessee Infant Mortality by Household Income 2004-2005

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Tennessee Infant Mortality by Maternal Tobacco Use 2001-2005

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Tennessee Infant Mortality by Adequacy of Prenatal Care 2001-2005

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Year TotalCaucasianBlack 2006 13.8 6.819.0 2007 12.7 5.817.8 2008 12.3 4.717.6 Shelby County Infant Mortality

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No child should die in the dawn of life. -Danny Thomas, Founder of St. Jude Childrens Research Hospital

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Interventions Prevention Primary: Avoid the development of disease or condition; health promotion activities Secondary: Diagnose and treat disease or condition in its early stages before it results in significant morbidity Tertiary: Reduce the negative impact of established disease or condition by reducing disease or condition-related complications

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2007 Newborn Center Mortality Inborn and Outborn (Courtesy- R. Dhanireddy)

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Interventions BLUES Project Dr. Linda Moses, Project Director Ms. Teresa Franklin, Project Coordinator

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The Blues Project (BLUES) is a community service project that provides education, counseling, social support and community resources referrals to participants during pregnancy until the childs second birthday. BLUES is funded by Blue Cross Blue Shield of Tennessee Health Foundation. The BLUES Project

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Risk Factors Contributing social and economic factors: Race Poverty Low parental education Single parenthood Limited access to care Lack of insurance Transportation barriers

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The Mission The mission of The BLUES Project is to help families have full term healthy babies. We assist parents in identifying a strong support system. We empower mothers to establish and achieve attainable life goals.

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The BLUES Holistic Approach

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1.Healthier mothers (physically, mentally, intellectual and emotionally. 2.Increased social support 3.Comprehensive psycho-social screening, diagnosis, referrals, and treatment for mental and/or behavioral health services 4.Increased empowerment and self-sufficiency 5.Healthier families and communities. Benefits and Services

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The BLUES Path to Success

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Current Participants Memphis There are 131 women actively participating Chattanooga There are 75 women actively participating

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The BLUES Family Dr. Linda Moses, Director Teresa Franklin, Program Coordinator Netasha Bower, Health Educator Annteshae Maddox, Health Educator Rebecca Perez, Health Educator Toni Hampton, Outreach Specialist Ann Collins, Outreach Specialist

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Interventions Education and improvement of living conditions: Delay 1 st pregnancy Increase Interpregnancy Interval Prenatal care Smoking cessation Decrease drug use

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Why is the US Different? A 2009 CDC report stated that US rates were affected by high prematurity rate compared to European countries Reporting differences may also play a role, as France, the Czech Republic, Ireland, the Netherlands, and Poland do not report live births of babies

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WHO Definition The World Health Organization (WHO) defines a live birth as any born human being who demonstrates independent signs of life, including breathing, voluntary muscle movement, or heartbeatWorld Health Organization Many countries, including certain European states and Japan, only count as live births cases where an infant breathes at birth, which makes their reported IMR numbers appear somewhat lower

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CDC Findings While there are some differences among countries data collection, those differences cannot explain the relatively low international ranking of the US

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Prospective Fetal Mortality Rate by Single Weeks of Gestation United States: 2005 MacDorman MF. Semin Perinatol 2011;35(4):200-8.

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2005 US Infant Mortality Rates (per 100,000 live births for 10 leading causes)

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Causes of Neonatal Deaths by Race-Ethnicity for the 3 Leading Causes of Death Hauck FR et al. Semin Perinatol 2011;35(4):209-220.

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Causes of Postneonatal Deaths by Race- Ethnicity for the 3 Leading Causes of Death Hauck FR et al. Semin Perinatol 2011;35(4):209-220.

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Infant Mortality Rate Discrepancies However, the method of calculating IMR often varies widely between countries, and is based on how they define a live birth and how many premature infants are born in the country. Healy B. September 24, 2006. Behind the baby count. US News & World Report.

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Root Cause Some blame obesity and drug use Others point to the failure of our decentralized healthcare system Still others cite troubling trends in preterm births and Cesarean deliveries Root causes aside, more than 28,000 infants under the age of 1 die each year in the US

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Infant Mortality Risk Factors: Low Birthweight

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Tennessee Infant Mortality by Birthweight 2001-2005

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Tennessee Prevalence of Low Birthweight 1997-2006

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Tennessee Infant Mortality by Gestational Age 2001-2005

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Shelby County Infant Mortality Rate by Race and Hispanic Origin 2000-2005

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US Infant Mortality Rates 1996-2006

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Shelby County Infant Mortality Rates 1996-2006

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Tennessee Preterm Births 1998- 2008

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Shelby County Preterm Births by Gestational Age Category (2008)

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Definitions Infant Death Death of a live-born infant under 1 year of age Infant Mortality Rate Number of infant deaths per 1,000 live births Preterm Birth Birth before 37 completed weeks of gestation Very Preterm Birth Birth before 32 completed weeks of gestation Late Preterm Birth Birth from 34-36 completed weeks of gestation Term Birth Birth from 37 to 41 completed weeks of gestation

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Mortality Definitions Fetal mortality Fetal weight 350 g or more, or 20 weeks of gestation or more (NCHS 2010) Neonatal Mortality Death in the first 28 days of life Postneonatal Mortality Death after 28 days of life but before 1 year Child Mortality Death within the first 5 years after birth

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Fetal Mortality Rates by Period of Gestation United States: 1990-2005 Hogue CJR, Silver RM. Semin Perinatol 2011;35(4): 221-233.

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Tennessee Prevalence of Preterm Birth 1997-2006

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Fetal Mortality

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Impact of Infant Mortality The infant mortality rate is commonly included as part of standard of living evaluations in economics 1 The infant mortality rate correlates very strongly with, and is among the best predictors of state failure 2 1 Sullivan A, Sheffrin SM. 2003. Economics: principles in action. Upper Saddle River, NJ: Pearson Prentice Hall. p.474. 2 King G, Zeng L. July 2001. Improving forecasts of state failure. World Politics 53 (4):623-58.

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2000 vs. 2005: US Infant Mortality Rates by Race and Ethnicity

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2000 vs. 2005: US Infant Mortality Rates From Prematurity by Race and Ethnicity