North Carolina’s North Carolina’s Recent Infant Recent Infant Mortality Mortality Experience and Experience and Women’s Women’s HealthHealth

Joe Holliday, MD, MPHJoe Holliday, MD, MPH Joe Holliday, MD, MPH Belinda Pettiford, MPHBelinda Pettiford, MPHOctober 28, 2009October 28, 2009

December 10, 2008May/June 2004 IssueMay/June 2004 Issue

Source: NC Center for Health StatSource: NC Center for Health Statistics www.schs.nc.us/SCHS/datistics www.schs.nc.us/SCHS/data/a/

Recent Infant Mortality in North Recent Infant Mortality in North Carolina Carolina

1988 was a landmark year - NC was 49th in 1988 was a landmark year - NC was 49th in among 50 states in the infant mortality rate.among 50 states in the infant mortality rate.

The NC infant mortality rate has declined by The NC infant mortality rate has declined by over one-third since 1988. over one-third since 1988.

More recently, the downward trend in the NC More recently, the downward trend in the NC infant mortality rates has slowed and NC ranks infant mortality rates has slowed and NC ranks 45th among 50 states.45th among 50 states.

Recent Infant Mortality in North Recent Infant Mortality in North Carolina Carolina (cont.)(cont.)

Since 1988 infant death rates have declined less Since 1988 infant death rates have declined less among African Americans and American Indians among African Americans and American Indians than among whites, leading to increasing racial than among whites, leading to increasing racial disparities over time.disparities over time.

With prenatal care participation rates improving, With prenatal care participation rates improving, maternal smoking and teen birth rates declining, maternal smoking and teen birth rates declining, and other key indicators generally moving in a and other key indicators generally moving in a favorable direction, the lack of recent progress in favorable direction, the lack of recent progress in infant mortality reduction is perplexing.infant mortality reduction is perplexing.

Infant Mortality RateInfant Mortality Rate North Carolina, 1988-2008 North Carolina, 1988-2008

0

2

4

6

8

10

12

14

RatePer1,000Live Births

Year

Infant Mortality RateInfant Mortality Rate North Carolina, 1988-2008 North Carolina, 1988-2008

0.0

5.0

10.0

15.0

20.0

25.0

1988 1991 1994 1997 2000 2003 2006

Af. Am. White

Infant Mortality Infant Mortality An issue of great magnitudeAn issue of great magnitude

Accounts for 68% of all deaths to childrenAccounts for 68% of all deaths to children Has multiple causes – serves as a proxy Has multiple causes – serves as a proxy

measure for the broader issue measure for the broader issue Also associated with childhood morbidityAlso associated with childhood morbidity Increasingly associated with origins of Increasingly associated with origins of

some chronic diseasessome chronic diseases

Major Determinants of Major Determinants of Infant MortalityInfant Mortality

Preterm Birth / Low Birth Weight Preterm Birth / Low Birth Weight Birth DefectsBirth Defects Sudden Infant Death SyndromeSudden Infant Death Syndrome Other Conditions During PregnancyOther Conditions During Pregnancy

Birth Weight TrendsBirth Weight Trends

The percent of live births that are low birth The percent of live births that are low birth weight has increased steadily.weight has increased steadily.

The percent of increase of low birth weight The percent of increase of low birth weight by weight category ranges from 5% to by weight category ranges from 5% to 35.1% with the greatest increase in the 35.1% with the greatest increase in the under 500 gram birth weight category for under 500 gram birth weight category for minorities.minorities.

0

2

4

6

8

10

12

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2006 2007 2008

Whites 1500-2499 grams Whites Under 1500 grams

Minorities 1500-2499 grams Minorities Under 1500 grams

Percentage of White and Minority Percentage of White and Minority Low-Birthweight Live Births,Low-Birthweight Live Births,North Carolina, 1987-2008North Carolina, 1987-2008

PercentOfLiveBirths

Birth-Weight-SpecificBirth-Weight-Specific Infant Mortality Rates Infant Mortality Rates

Most of the decrease in the IMR in recent Most of the decrease in the IMR in recent years is due to improved survival at each years is due to improved survival at each level of birth weight. Survival now at a level of birth weight. Survival now at a plateau?plateau?

The fetal death rate decreased 22% over The fetal death rate decreased 22% over this time period (8.6 to 6.7). This suggests this time period (8.6 to 6.7). This suggests that real improvement in both fetal and that real improvement in both fetal and neonatal survival has taken place.neonatal survival has taken place.

Birthweight-Specific Infant Mortality Rates by Race, North Carolina 1988-89 and 2006-2007

*Based on Birth Cohort

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

800.0

900.0

1000.0

Under 500 500-749 750-999 1000-1499 1500-2499 2500+

Weight Category

Infa

nt

Mo

rtali

ty R

ate

Whites 1988-89

Whites 2006-07

Minorities 1988-89

Minorities 2006-07

Racial Disparity in Infant MortalityRacial Disparity in Infant Mortality

The racial disparity in infant mortality has increased 1.95 The racial disparity in infant mortality has increased 1.95 in 1988 to 2.45 in 2008, although the minority infant 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 mortality rate fell to an all-time low in 2008 to 13.5 per 1,000 live births. 1,000 live births.

The neonatal survival advantage of low birth weight The neonatal survival advantage of low birth weight African American babies has decreased over time. This African American babies has decreased over time. This could be contributing to the increasing racial disparity in could be contributing to the increasing racial disparity in infant mortality. infant mortality.

In 2008, nearly 17% of live births in the state were In 2008, nearly 17% of live births in the state were among Hispanics, compared to only about 2% in the among Hispanics, compared to only about 2% in the early 1990s.early 1990s.

Racial Disparity in Infant MortalityRacial Disparity in Infant Mortality Role of Women’s HealthRole of Women’s Health

Racial disparities in birth outcomes Racial disparities in birth outcomes correlate with disparities in measures of correlate with disparities in measures of women’s health.women’s health.

These disparities increase with maternal / These disparities increase with maternal / female age. female age.

Increased education reduces but doesn’t Increased education reduces but doesn’t eliminate disparities.eliminate disparities.

Racial Disparities in Health Racial Disparities in Health Outcomes Increase with AgeOutcomes Increase with Age

NC BRFSS SURVEY RESULTS 18-24 25-34 35-44

2008 - % Obese (BMI>=30)

African American 27.9 43.5 46.4

White  21.0 29.8 28.3

Ratio 1.33 1.46 1.64

2008 - % Who Report Their Health as Fair or Poor

African American 4.0 11.2 15.8

White  7.1 6.6 8.3

Ratio 0.56 1.70 1.90

2007 - % With High Blood Pressure

African American 8.9 15.6 26.9

White  4.5 7.4 16.3

Ratio 1.98 2.11 1.65

Racial Disparity in Birth Outcomes Racial Disparity in Birth Outcomes Increase with AgeIncrease with Age

Birth Outcome Measures by Maternal Race & Age, NC Residents, 2004-2008

15-19 20-34 35+

% Very Low Birthweight

African American 3.1 3.5 4.8

White  1.6 1.2 1.6

Ratio 1.9 2.8 2.9

Neonatal Deaths per 1,000 Live Births

African American 10.6 10.3 11.8

White  5.9 3.7 4.8

Ratio 1.8 2.8 2.5

Socio-Economic Disparities Socio-Economic Disparities Associated with Unintended Associated with Unintended

PregnanciesPregnancies

29% women are more careful about using 29% women are more careful about using contraception every timecontraception every time

12% women considering switching to long-term 12% women considering switching to long-term contraceptive contraceptive

18% women inconsistently used the pill as a means 18% women inconsistently used the pill as a means of saving moneyof saving money

25% women put off gynecology or birth control visit to 25% women put off gynecology or birth control visit to save moneysave money

Source: Guttmacher Institute, September 2009Source: Guttmacher Institute, September 2009

What North Carolina Women Say What North Carolina Women Say About Their Health?About Their Health?

Quantitative Data Not Sufficient to Tell the StoryQuantitative Data Not Sufficient to Tell the Story

Qualitative Research Project Provides Real Insights Qualitative Research Project Provides Real Insights

Why do (or do not) women adopt preventive health Why do (or do not) women adopt preventive health behaviors? behaviors?

Why do (or do not) women use preventive health Why do (or do not) women use preventive health services?services?

Source: www.nchealthystart.orgSource: www.nchealthystart.org

What North Carolina Women Say What North Carolina Women Say About ….About ….

North Carolina’s Recent Infant North Carolina’s Recent Infant Mortality ExperienceMortality Experience

Decline in birth weight specific mortality Decline in birth weight specific mortality until recentlyuntil recently

Increase in low birth weight birthsIncrease in low birth weight births Racial disparities not improvedRacial disparities not improved Importance of women’s health throughout Importance of women’s health throughout

the lifespan increasingly recognized the lifespan increasingly recognized Need a cultural shift Need a cultural shift

Feto-Infant Mortality:

Birthweight Distribution

Mortality by Birthweight

Risk Factors

Interventions

Access

Socio-Economic Smoking Race Medical Conditions

Gender Gestational age Race Medical Conditions

Prenatal Care Smoking Cessation Tocolytics

Perinatal Care Quality Care Referrals

Health Insurance Primary Care Content Availability

Referral Systems Transport Systems Expertise

Infant Mortality - Recent Directions: Infant Mortality - Recent Directions: Improve Access to HealthcareImprove Access to Healthcare

Primary Healthcare for WomenPrimary Healthcare for Women Extend Medicaid for women for 2 yrs postpartum.Extend Medicaid for women for 2 yrs postpartum. Extend health insurance to parentsExtend health insurance to parents

High Risk Maternity CareHigh Risk Maternity Care Regionalization of perinatal care challengedRegionalization of perinatal care challenged CCNC adding high risk initiativeCCNC adding high risk initiative Preterm birth prevention and PQCNC projectsPreterm birth prevention and PQCNC projects NC IOM Substance Abuse StudyNC IOM Substance Abuse Study

New Electronic Birth CertificateNew Electronic Birth Certificate

Infant Mortality - Recent Directions: Infant Mortality - Recent Directions: Reduce Unintended PregnanciesReduce Unintended Pregnancies

Approximately half of live births in NC are Approximately half of live births in NC are unintendedunintended

Associated with late prenatal care, low Associated with late prenatal care, low birth weight, poor maternal nutrition and birth weight, poor maternal nutrition and smoking, and less likely to breastfeedsmoking, and less likely to breastfeed

Expanded Medicaid income eligibility up to Expanded Medicaid income eligibility up to 185% FPL for family planning services for 185% FPL for family planning services for men & women >18yrs agemen & women >18yrs age

Infant Mortality - Recent Infant Mortality - Recent Directions: Reduce Unintended Directions: Reduce Unintended

Pregnancies (cont.)Pregnancies (cont.) In Year 2 with very limited participation, an In Year 2 with very limited participation, an

estimated 1,139 births were averted and $12 estimated 1,139 births were averted and $12 million savedmillion saved

ACOG Supports Increased Access to Long-ACOG Supports Increased Access to Long-Acting Reversible Contraceptives (Implants & Acting Reversible Contraceptives (Implants & Intrauterine devices) as safe, long-acting, Intrauterine devices) as safe, long-acting, convenient & highly effective convenient & highly effective

More Medicaid $$ to support these methods More Medicaid $$ to support these methods through Family Planning Waiver Programthrough Family Planning Waiver Program

Infant Mortality - Recent Directions: Infant Mortality - Recent Directions: Education and SupportEducation and Support

Folic Acid Awareness & Multivitamin Folic Acid Awareness & Multivitamin DistributionDistribution

Educational Resources Educational Resources

Resource Line and Healthy Start FoundationResource Line and Healthy Start Foundation

Case Management & Home Visitation Case Management & Home Visitation

MCC-CSC, Baby Love Plus, Nurse Family MCC-CSC, Baby Love Plus, Nurse Family Partnership, Teen Pregnancy Prevention Partnership, Teen Pregnancy Prevention InitiativesInitiatives

Infant Mortality - Recent Directions: Infant Mortality - Recent Directions: Education and SupportEducation and Support

Baby Love Plus ModelBaby Love Plus Model Consortium comprised of consumers, community Consortium comprised of consumers, community

leaders, providersleaders, providers Case Management/Care CoordinationCase Management/Care Coordination

• Prenatal (Maternity Care Coordination)Prenatal (Maternity Care Coordination) Outreach and Client RecruitmentOutreach and Client Recruitment

• Community Health AdvocatesCommunity Health Advocates Education and TrainingEducation and Training

• Providers, Faith EntitiesProviders, Faith Entities Interconceptional CareInterconceptional Care

• Working with mom and baby for 2 yearsWorking with mom and baby for 2 years Depression Screening and ReferralDepression Screening and Referral

InfantInfant Mortality – Recent Mortality – Recent Directions: Improve Maternal Directions: Improve Maternal

HealthHealth

North Carolina’s Infant Mortality North Carolina’s Infant Mortality and Women’s Healthand Women’s Health

Our Success and Future Our Success and Future

Tchernavia “T” RanesforeTchernavia “T” Ranesfore

Receives National Receives National RecognitionRecognition

2009 Healthy Teen 2009 Healthy Teen Network Network

Outstanding Teen Parent Outstanding Teen Parent AwardAward