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Reducing Infant Mortality in Maryland

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... rate of 7.2/1,000 births Babies Born Healthy Initiative Perinatal Collaborative High-risk OB consultation ... Maryland Infant Mortality Epidemiology ... – PowerPoint PPT presentation

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Title: Reducing Infant Mortality in Maryland


1
Reducing Infant Mortality in Maryland
  • Donald Shell, M.D., MA
  • Center for Health Promotion
  • Family Health Administration
  • Department of Health and Mental Hygiene

2
Infant and Child Deaths
3
Infant Mortality in Maryland U.S.
4
Leading Causes of Infant Mortality Maryland
National Rankings
  • Infant Mortality - 07 42nd
  • Preterm Birth - 07 37th
  • Low Birth Weight - 08 41st
  • VLBW 08 47th

5
Leading Causes of Infant Mortality
6
Timing of Infant Deaths
Data Source MD Vital Statistics Administration
7
Percent of MD Births by Birth Weight 2009
Births
Note Includes only births to MD mothers in MD
hospitals Data Source MD Health Services Cost
Review Commission
8
Birth Weight and Neonatal Deaths
Data Source MD Vital Statistics Administration
9
Racial Disparity in Infant Mortality
10
Racial Disparity in Preterm Births
11
Racial Disparity in Low Birth Weight
12
Racial Disparity in VLBW Births
13
Racial Disparities in Birth Outcomes
  • In Maryland, a Black infant .
  • is 1 ½ times as likely to be
    born prematurely,
  • almost 2 times as likely to be
    born at low birth weight,
  • 3 times as likely to be VLBW
  • and 2 ½ to 3 times as likely to die in the first
    year of life as a white infant.

14
Geographic Disparity in Maryland Average Infant
Mortality Rate, By Jurisdiction, 2005-09
Baltimore City
Kent
Howard
Montgomery
Anne Arundel
Queen Annes
Caroline
Prince Georges
Talbot
Calvert
Charles
Dorchester
Wicomico
St. Mary's
Worcester
Somerset
15
Behavioral Risks Unintended Pregnancy
Associated with Increased Neonatal Mortality

Bustan et al, AJPH, March
1994
16
Behavioral Risks Teen Births Associated
with Increased Infant Mortality
17
Health and Health Care Risks Lack of Early
Prenatal Care Associated with Increased Infant
Mortality
18
Health and Health Care Risks Lack of
Early Prenatal Care Associated with Increased
Infant Mortality
19
Health and Health Care Risks Lack of
Early Prenatal Care Associated with Increased
Infant Mortality
20
Socio-demographic Risks Racial Disparities
Go Beyond Socio-Economic Factors
From NCHS 1998-2000 data, Preterm Birth, IOM, 2007
21
Socio-demographic Risks Racial Disparities
Go Beyond Socio-Economic Factors
From NCHS 1998-2000 data, Preterm Birth, IOM, 2007
22
Socio-demographic Risks Racial Disparities
Go Beyond Socio-Economic Factors
Infant Mortality Rate by Maternal Education and
Race / Ethnicity, Maryland 2005-2009
Data Sources MD DHMH, Vital Statistics
Administration
23
Socio-demographic Risks Racial Disparities
Go Beyond Socio-Economic Factors
Infant Mortality Rate by Maternal Education and
Race / Ethnicity, Maryland 2005-2009
Data Sources MD DHMH, Vital Statistics
Administration
24
Socio-demographic Risks Racial Disparities
Go Beyond Socio-Economic Factors
25
Marylands Challenges
  • Racial disparities/System barriers
  • Fiscal resources to address health
  • Uninsured
  • Safety net providers difficulties
  • OB/GYN malpractice premiums
  • Few providers for prenatal care
  • Providers to see high risk patients

26
Governors Strategic Goal
  • Reduce infant mortality in Maryland
  • by 10 by 2012
  • 2007 Baseline 622 deaths, rate of 8.0/1,000
    births
  • 2012 Goal 60 fewer deaths, rate of 7.2/1,000
    births

27
Babies Born Healthy Initiative
  • Perinatal Collaborative
  • High-risk OB consultation outreach through the
    two academic medical centers
  • Updated standards for perinatal care
  • Real time access to data
  • Birth records, death records, Pregnancy Risk
    Assessment forms (PRAMS), hospital and practice
    specific outcomes, sleep-related deaths, FIMR,
    Child Fatality Review, MCOs

28
What WorksMaryland Plan Built on Evidence Based
Practices
  • Reducing unintended pregnancy
  • Promoting the health of women
  • Improving access to prenatal and postpartum care
  • Improving the safety and quality of obstetric
  • and neonatal care

29
Maryland Infant Mortality PlanBroad and
Substantive Input
  • Maryland Infant Mortality Epidemiology Work Group
    2011 Findings from Data Analysis and Overall
    Recommendations
  • Summarize research/recommendations
  • Gov. Forum on Children and Health 2011 - Infant
    Mortality Breakout
  • The Role of Community Pediatricians in
    Preventing Infant Mortality Meeting
  • Web-based survey 339 Marylanders

30
Infant Mortality Epi Work Group 2011
Findings/Data Analysis/Recommendations
  • Chronic conditions before/during pregnancy
  • Htn disorders during preconception
  • GDM, pre-preg DM, Ht Dz, IPV, asthma
  • Depression, obesity, ETOH, tobacco use
  • Fertility treatment
  • Infant sleep position, co-sleeping
  • Maternal postpartum tobacco use

31
Infant Mortality Epi Work Group 2011
Findings/Data Analysis/Recommendations
  • Timing and effectiveness of risk-targeted
    prenatal care
  • Maternal age
  • teens (Hispanic), gt age 35
  • Prior pre-term birth
  • Birth hospital level of care for VLBW
  • Early term deliveries (37-38 weeks)

32
Partners include
  • Office of Minority Health and Health Disparities
  • Maryland Medicaid coordinate MCOs, birth
    outcome data
  • Behavioral Health referrals to and from
  • Mental Hygiene Administration
  • Alcohol and Drug Abuse Administration
  • Local Health Departments
  • DHMH coordination/data - WIC, Chronic Dz,
    Tobacco
  • Department of Human Resources (DSS) Medical
    Assistance
  • Governors Office for Children Home Visitation
    Program
  • Community Health Resources Commission - and
    data sharing

33
Partners include
  • MD Institute for Emergency Medical Services
    Systems (MIEMSS) with MD Perinatal Standards
    Level III
  • MD Patient Safety Center hosp d/c
  • MSDE home visiting program data
  • Birthing Hospitals prohibit elective deliveries
    lt39 weeks, VLBW, breast feeding and tobacco
    cessation
  • FQHC case mgt, care coordination, community
    referrals, provider training

34
Partners include
  • MD Chapter AAP expertise and resources infant and
    child health
  • MD Chapter ACOG expertise and resources maternal
    health/birth out
  • Maryland Breast Feeding Coalition
  • CareFirst BC/BS home visitation
  • MCO facilitate early PNC entry
  • Community Peds coordination and communication
    with OB/GYN providers
  • Cert. Nurse Midwives high risk _at_ PNC
  • UMD and JHU Med SPH expertise and support

35
Intervention Across the Lifespan
PERINATAL NEONATAL (After delivery)
PRENATAL (During pregnancy)
PRECONCEPTION (Before pregnancy)
Healthier Children and Adults
Healthier women at time of conception, planned
pregnancies
Earlier entry into prenatal care
Comprehensive, high quality perinatal and
neonatal care
36
Oversight and Evaluation Governors Delivery
Unit and State Stat
  • Performance measurement system
  • Developed by DMHM, GDU, State Stat
  • Monthly Program and Health Outcomes
  • Collection/Reporting target jurisdiction
  • Annual Assessments
  • State and Jurisdictional
  • Vital Statistics
  • Medicaid
  • Title X
  • PRAMS

37
Strategy 1 Before Pregnancy
  • Expand access to womens comprehensive health
    and
  • wellness services
  • Transition family planning sites into
    Comprehensive Womens Health Programs.
  • Include screening/referral for Medicaid
    eligibility, WIC, substance abuse, mental health,
    domestic violence, smoking cessation, weight
    management services.
  • FQHC integration of reproductive primary care,
    Title X FP Primary Provider training
  • Culturally-competent outreach and education
    efforts in the community, Perinatal Navigators

38
Oversight and Evaluation Strategy 1
Governors Delivery Unit and State Stat
  • comprehensive womens health
  • referred to/from STD clinics
  • referred to/from behavioral health
  • FQHC Primary trained thru Title X
  • new Medicaid FP enrollees
  • enrollees utilizing Medicaid FP
  • visits to Title X FP clinics
  • unintended pregnancies

39
Strategy 2 During Pregnancy
  • Increase the of women accessing early
    prenatal care
  • LHD maternity sites implementation of Quick Start
    prenatal care program.
  • 12/1/09 Accelerated Certification of Eligibility
    (ACE) for pregnant women seeking Medicaid
    coverage, LHD, DSS
  • Screening/referral - Medicaid eligibility, WIC,
    substance abuse, mental health, domestic
    violence, and smoking cessation.
  • PGCHD/UMD OBGYN Midwife Perinatology Tapestry
    Program
  • 2011 PGC FQHC initiation prenatal care

40
Oversight and Evaluation Strategy 2
Governors Delivery Unit and State Stat
  • Medicaid ACE processed 10 days
  • total applications
  • weeks pregnant at application
  • women receiving Quick Start Ser.
  • Perinatal navigator pt encounters
  • pregnant women home visits

41
Strategy 3 During After Delivery
  • Expand access to more comprehensive, high
    quality
  • perinatal and neonatal care
  • Develop a standardized hospital postpartum
    discharge process that ensures risk appropriate
    follow-up care for mother and infant.
  • Breast feeding support, MH/SA services, DV
    support, smoking cessation, FP, Safe sleep
    instruction Distributed thousands of Bmore
    Safe Sleep. Alone. Back. Crib DVD
  • 4/1/2011 implemented standardized d/c referral
    form for high risk mothers to CBOs
  • Monitoring level I and II (MMQRC), level III
    (MIEMSS) birthing hospital compliance with
    Perinatal Standards VLBW deliveries

42
Oversight and Evaluation Strategy 3
Governors Delivery Unit and State Stat
  • comprehensive womens health
  • LHD postpartum referrals received
  • level I/II site visits conducted
  • Safe Sleep DVDs distributed
  • VLBW deliveries _at_ level III hosp
  • postpartum home visits conducted

43
Summary of the Plan
  • APPROACH
  • Assessing the Data Targeting Disparities
  • Building on Strengths Partnerships
  • Comprehensive Systems Approach
  • GOALS
  • Healthier Women/ Planned Pregnancies
  • Earlier Entry into Prenatal Care
  • Improve Quality of Perinatal and Post-Delivery
    Care
  • STRATEGIES
  • Comprehensive Womens Health Centers
  • Expediting Medicaid eligibility / Quick Start
    Prenatal Care
  • Standardized hospital discharge protocols

44
Infant Mortality in Maryland U.S.
45
Governors Strategic Goal
  • Goal Re-Set in October 2010
  • Reduce both total and Black infant mortality
  • in Maryland by 10 by 2012
  • 2007 Total baseline 622 deaths, Rate of
    8.0/1,000
  • Black infant baseline 369 deaths, Rate of
    14.0/1,000 births
  • 2009 Status 541 deaths, Rate of 7.2/1,000
  • Black infant status 343 deaths, Rate of
    13.6/1,000 births
  • 2012 Goal Total rate 7.2/1,000
  • Black infant goal 319 deaths, Black rate
    12.6/1,000 births

46
2010 Infant Mortality in Maryland
47
2010 Infant Mortality in Maryland
48
Whats Next?
  • January 1, 2012
  • Expanded Maryland Medical Assistance program
    eligibility for family planning to include all
    women at or below 200 of the federal poverty
    level
  • Developing standardized 34 hospital postpartum
    discharge process
  • DHMH, MD Pt Safety Center Perinatal and Neonatal
    Learning Network, MD Perinatal System Standards,
    MIEMSS

49
Whats Next?
  • Development of an integrated statewide Fetal
    Infant Mortality Review (FIMR) and State Child
    Fatality Review (SCFR) database
  • DHMH, MD Medical Chirurgical Society, LHDs,
    FIMR, SCFR
  • Define at-risk groups/factors IDed by Infant
    Mortality Epidemiology Work Grp
  • Targeted interventions

50
Questions?
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