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Perinatal Health: A PublicPerinatal Health: A PublicHealth ApproachHealth Approach

November 16, 2009November 16, 2009

Virginia Commonwealth UniversityVirginia Commonwealth University

Joan CorderJoan Corder--Mabe, RNC, M.S., WHNPMabe, RNC, M.S., WHNP

Director, Division of Women’s and Infants’ HealthDirector, Division of Women’s and Infants’ Health

Virginia Department of HealthVirginia Department of Health

Core Functions of Public HealthCore Functions of Public Health

Assessment

Assurance

Policy

AssessmentAssessment

• Analysis of birth certificate data

• Fetal and Infant Mortality Review(FIMR)

• Child Fatality Review

• Pregnancy Risk AssessmentMonitoring System (PRAMS)

• Maternal Death Review

Infant Mortality in Virginia

Infant Mortality as a Measure ofInfant Mortality as a Measure ofHealthHealth

“Infant death is a critical indicator of the healthof the population. It reflects the overall state ofmaternal health as well as the quality andaccessibility of primary health care available topregnant women and infants. Despite steadydeclines in the 1980’s and 1990’s, the rate ofinfant mortality in the United States remains oneof the highest in the industrialized world.”

Healthy People 2010 Report

“Perhaps the mostglaring health failureis our infant mortalityrate.”

-Governor Timothy M. Kaine

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Setting a Goal for Reduction ofSetting a Goal for Reduction ofInfant DeathsInfant Deaths

• Virginia is working toward the goal toreduce its infant death rate to 7.0 perthousand live births by 2009.

• This would surpass the Healthy People2010 goal of reducing the infantmortality rate to 7.2 per thousand.

Infant Mortality: The ProblemInfant Mortality: The ProblemWorld RankWorld Rank

Infant Mortality: The ProblemInfant Mortality: The ProblemWorld RankWorld Rank

29th

23th

12th1960

1990

2004

Total Infant Mortality Rates PerTotal Infant Mortality Rates Per1,000 Births in Virginia1,000 Births in Virginia

7.4

7.2

6.8

7.47.3

7.6

7.4

7.1

7.7

6.7

7.4

1998 2000 2002 2004 2006 2008

Infant Mortality Rates Per 1,000 BirthsInfant Mortality Rates Per 1,000 BirthsBy Race/Ethnicity 1998By Race/Ethnicity 1998--20082008

14.5

12.912.4

13.8

15.5

12.2

14.413.9

14.4

15.5

14.5

0

2

4

6

8

10

12

14

16

18

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

White

Black

Asian

Hispanic

Top 4 Causes of Infant Death, VirginiaTop 4 Causes of Infant Death, Virginia19981998--20082008

0

50

100

150

200

250

1998 2000 2002 2004 2006 2008

Disorders Related to Short Gestation and Low Birth Weight P07

Congenital Malformations, Deformations, and Chromosomal Abnormalities Q00-Q99

Sudden Infant Death Syndrome R95

Newborn Affected By Maternal Complications of Pregnancy P01

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Top Causes of DeathTop Causes of DeathCause of Death 2007 2008

Disorders Related to Short Gestation and Low BirthWeight

194 158

Congenital Malformations, Deformations, andChromosomal Abnormalities

135 119

SIDS 81 59

Maternal Complications of Pregnancy 63 45

Other Conditions in the Perinatal Period 42 24

Abnormal Clinical Findings 29 36

Complications of Placenta, Cord, and Membranes 26 22

Unintentional Injury (Accidents) 25 25

Prematurity*Prematurity*-- the problemthe problem

0

2

4

6

8

10

12

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Prematurity and Late PretermPrematurity and Late PretermBirthsBirths

Low Birth Weight is associatedLow Birth Weight is associatedwith multiple factors:with multiple factors:

• Medical Risk Factors

- High parity

- Chronic diseases

- Previous Low Birth Weight infants

- Genetic factors

- Multiple gestation

- Poor weight gain

- Infection

- Placental problems

- Premature rupture of membranes

- Fetal anomalies

- Maternal stress

Low Birth Weight (continued)Low Birth Weight (continued)

• Demographic Risk Factors

- Age < 17 years and > 34 years

- African-American race

- Low socioeconomic status

- Unmarried

- Low education

• Behavioral Risk Factors- Smoking

- Poor nutrition

- Toxic exposure

- Inadequate prenatal care

- Substance abuse

LongLong--term effects of Lowterm effects of LowBirth WeightBirth Weight

• Neurologic disorders

• Learning disabilities

• Delayed development

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The etiology of pretermThe etiology of pretermlabor and premature birthlabor and premature birth

is unknown.is unknown.

Prematurity and Cesarean BirthsPrematurity and Cesarean Births

35%

22%1996

2007

Maternal Mortality Has NotMaternal Mortality Has NotChanged Since 1982Changed Since 1982

0

5

10

15

20

25

1970

1980

1990

Year

Death

sp

er

100,0

00

Liv

eB

irth

s

Source: U.S. data from National Center for Health Statistics, 1970-1999.

Reasons for reduction inReasons for reduction inmaternal mortalitymaternal mortality

• Sulfa and antibiotic drugs

• Decrease infections secondary toillicit abortions

• Availability of banked blood

• Safer surgical procedures, includingCesarean

The 3 leading causes of naturalThe 3 leading causes of naturalmaternal death in the United Statesmaternal death in the United States

and Virginiaand Virginia

• Hemorrhage, including ectopicpregnancy

• Pregnancy-Induced Hypertension

• Pulmonary Embolism

What can we do?

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• Natisha Jones: 19 year old, G3 P1A1, A.A. woman

• Infant died of SUID

• 5’5” tall and weighs 185 lbs

• 185% of poverty

• Works part-time at Walmart

• The boyfriend is unemployed

Prematurity and SIDSPrematurity and SIDS

• A premature infant less than 37

weeks sleeping prone is 85times more likely to die of SIDS

• A premature infant lying on its

side is 40 times more likely todie of SIDS

Prematurity: SIDS Rate andPrematurity: SIDS Rate andSleep PositionSleep Position

Babies Sleepingon their Backs

Babies Sleepingon their Backs

Obesity in PregnancyObesity in Pregnancy

• Pregnancy loss

• Diabetes and hypertension

• Preeclampsia

• Indicated Preterm Birth

• Operative delivery and complications

• Birth injury

• Childhood obesity

• Anesthesia complications

Women are more at risk of infant deaths aspoverty increases in their communities

Fact

FactResident Infant Death Rates byResident Infant Death Rates by

Method of Payment and Race/EthnicityMethod of Payment and Race/Ethnicity

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Total White Black Hispanic Total White Black Hispanic Total White Black Hispanic

2007

2008

Medicaid Private Insurance Self Pay

6

Infant Mortality by Education andInfant Mortality by Education andRace/EthnicityRace/Ethnicity

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

White,

NH

Black,

NH

Hispanic Other/NR White,

NH

Black,

NH

Hispanic Other/NR White,

NH

Black,

NH

Hispanic Other/NR

2005-2007

2008

Less than 12 Years 12 Years > 12 Years

Women with less than12 years of educationare 2.1 times morelikely to experienceinfant death

Fact

Fact

African Americanwomen experiencesignificantly higherrates of infantmortality in theCommonwealthBabies born to AfricanAmerican females are2.5 times more likelyto die during the firstyear of life than otherbabies

Smoking

Prematurity and SmokingPrematurity and Smoking

Exposure to smoking isassociated with•20% of all low birth weight babies•8% of preterm births•SIDS

Alcohol/Illicit Drugs

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Why?

Early prenatal care is anEarly prenatal care is anindicator for access toindicator for access tohealth care services.health care services.

Resource Mothers ProgramResource Mothers Program

• Lay home visitors who mentor pregnant teenagers

• Decrease infant mortality and low weight births

• 25 contractors enrolling approximately 1100 newlypregnant teens per year in 88 Virginia localities

• Early and regular prenatal care, increased healthybehaviors, delay of repeat pregnancy, enrollment inschool or employment, and creation of a stablehome environment

• Staff aim to motivate program participants to stopsmoking

Loving Steps/Virginia HealthyLoving Steps/Virginia HealthyStart ProgramStart Program

Goal of reducing infant deaths andimproving birth outcomes through earlyintervention:

• Case management and health education• Registered nurses provide medical nursing

care• Registered dietitians provide medical

nutrition therapy services• Resource Mothers (Community Health

Workers)• FIMR

Role Periodontal Disease inRole Periodontal Disease inPreterm BirthPreterm Birth

• Inflammation associated breakdownof membranes

• Associated with preterm labor andlow weight birth

• Treatment not harmful

• Treatment reduce preterm

Poor Nutrition

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• 18 week prenatal visit – no show

• Home visit by Loving Stepsnurse

• Natisha reported she was busyworking

• Several facial and arm bruisesnoted

Racism

• Natisha reported some back painand not feeling well

• Referred to the local ER

• Admitted for 24 hours

• 20 weeks prenatal visit

• Wants to breastfeed

•Lower rates of SIDS•Fewer ear infections•Fewer asthma/allergy cases•Less obesity•Less diabetes•Fewer childhood leukemia cases•Fewer infections in premature babies

Breastfeeding: The Benefits

•Educate mothers beforebirth•Provide support fromfamily, friends,healthcare workers,employers, society•Provide safe places tonurse and pump

Promote BreastfeedingPromote Breastfeeding Interventions That May Reduce Prematurity/Infant Deaths

Education aboutpreterm labor signsand symptoms

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•34 weeks admitted again forpreterm labor

•Delivered a 4lb 6oz baby boy

•Baby had bradycardia, apneaand oxygen desaturation

Public Health Approach toPublic Health Approach toInfant MortalityInfant Mortality

P ro v id in g A cce ss to P er in a ta l a nd In fa n t C a re

R ed u cin gIn fan t

M o rta lity

H ea lth y S ta r tM ed icaid

&S C H IP

C h ild h o o dIm m u n iza tio n

In itia tiv e

R ed u c in gU n in tend edP reg n an cy

“B ack to S leep ”C am p a ig n

M C HS erv ices

F o lic A c idC am p a ig n

R ed u c in g m o th e rto ch ild H IVtran sm issio n

P ro m o tin g resea rchto red u ce in fan t

m o rta lity

P ro m o tin g h ea lth y ch o ices to red u cem o rta lity r is ks

Safety Net ProvidersSafety Net Providers

• Prenatal care in local healthdepartments

• WIC in local health departments

• Community Health Centers

• Car seat program

PreconceptionPreconception

• Prevention of birth defects

• Treatment of chronic conditions

• Promotion of healthy lifestyles(smoking, alcohol)

Regional PerinatalRegional PerinatalCouncils (RPCs)Councils (RPCs)

Regional Perinatal Councils (RPCs)improve the infrastructure through whichperinatal health is provided within theCommonwealth.

•• Conduct Fetal and Infant Mortality ReviewConduct Fetal and Infant Mortality Review

•• Engage communities to address local systemsEngage communities to address local systemsissuesissues

Newborn ScreeningNewborn Screening

• Coordinated and comprehensive systemconsisting of education, blood screeningtests, follow-up and referrals,diagnosis, medical and dietarymanagement, and treatment

• Effective March, 2006, Virginia screensfor 28 disorders

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Setting Standards/Quality ofSetting Standards/Quality ofCareCare

• Neonatal Regulations

• Screening for domestic violence,perinatal substance use, and perinataldepression

• Web-based training on Bright Futuresand Perinatal Depression

• Provision of culturally competent care

Policy and PlanningPolicy and PlanningImplementation of Codes Regarding Perinatal

Substance Use:

• 54.1-2403.1 of the Code of Virginia Substance UseScreening in Prenatal Care

• 63.2-1509 of the Code of Virginia Physician referralof Substance Exposed Newborns

• 32.1-127 of the Code of Virginia Hospital DischargePlanning for Substance using Postpartum Women

• 32.1-134.01 of the Code of Virginia DischargeEducation on Postpartum Blues, PerinatalDepression, Shaken Baby Syndrome

Interagency Substance Exposed NewbornWorkgroup (DMHMRSAS, DSS, DCJ)

Analysis of proposed legislation

Supports Governor’s task forces and commissions

Early and regular use ofEarly and regular use ofprenatal care is a strongprenatal care is a strong

predictor of positivepredictor of positivepregnancy outcomes.pregnancy outcomes.

Health Commissioner’sHealth Commissioner’sWorkgroup on Infant MortalityWorkgroup on Infant Mortality

• Diverse groups represented

• Identify evidence-based effectiveprograms

• Develop unified message on howeveryone can make a difference

ConclusionsConclusions

• Studies of underlying factors thatcontribute to morbidity and mortality areneeded

• Review of quality of health care and accessto care for all women and infants is needed

• Racial/ethnic disparities need to beeliminated

• Research to determine effective publichealth programs to make a difference

• Resource and implement programs weknow work

THANK YOU