Preliminary Findings

2004 Infant Deaths

TFIMR is a collaborative effort of the Tulsa Health Department, the Oklahoma State Department of Health, the Tulsa Healthy

Start Initiative and the Tulsa Family Health Coalition.

Case Selection Criteria Infant <365 days old Resident of Tulsa County at birth and death Born and died in Tulsa County Died from causes other than an accident (infant

deaths with unsafe sleeping environment are eligible for case review)

Formal legal proceedings beyond initial investigations, not initiated

Mother must have obtained PNC in Tulsa County

Case Selection N=87TFIMR 2004 Infant Deaths

30

2

2

1

1

1

46

1

1

1

1

0 5 10 15 20 25 30 35 40 45 50

Non-resident of Tulsa County

Died outside Tulsa County

Excluded, unknow n reasons

Homicide

Ineligible, unkow n reason

Born outside Tulsa County

Data abstracted

Excluded, PNC outside Tulsa Co.

Excluded, criminal charges

Excluded, non-resident of Tulsa County

Included as case, no data retained

Exc

lude

dC

ases

Sel

ecte

d

Number of Infant Deaths

Hospital Abstractions

40

81

0

10

20

30

40

Num

ber

of In

fant

D

eath

s

1 Hospital 2 Hospitals 3 Hospitals

Number of Hospitals

Hospital Abstractions TFIMR 2004 Infant Deaths

32 (69.6%)

11 (23.9%)3 (6.5%)

0

10

20

30

40

Num

ber

of in

fant

de

aths

Reviewed by CRT Received late Lengthy case preparationtime

Infant Deaths Included in Review

Not reviewed by CRT

Case Review TeamTFIMR 2004 Infant Deaths N=46

Home InterviewsTFIMR 2004 Infant Deaths

1

2

8 (25%)

12 (37.5%)

10 (31.3%)

1 (3.1%) 1 (3.1%)

11

0

2

4

6

8

10

12

14

Languagebarrier

Long caseprep time

Deathcertif icate

received >1yr afterdeath

Agreed Declined Unable tolocate

Possiblelitigation

No show

Not requested - 14 (30.4%) Requested - 32 (69.6%)

Home Interview Request Status

Nu

mb

er

of

infa

nt

de

ath

s

Infant Characteristics and Risk Factors

Infant Deaths by Month of Occurrence

0

1

2

3

4

5

6

7

Sel

ecte

d In

fant

Dea

ths

Month of Occurrence 2004 Infant Deaths

TFIMR 2004 Infant Deaths N=46

Post Neonatal11 (23.9%)

28 days to <365 days

Neonatal35 (76.1%)<28 days old

Post Neonatal11 (23.9%)

10 (21.7%)8 to <28 days

9 (19.6%)1 day to <8 days

16 (34.8%)< 24 hours

0

10

20

30

40

50

Num

ber o

f inf

ant d

eath

s

Infant Age at Death

N=46

16

45

10

6

3

1 1

-1

1

3

5

7

9

11

13

15

17

Nu

mb

er

of

De

ath

s

<24

hour

s

1 da

y

2-7

days

8-27

day

s

1 m

onth

s

2 m

onth

s

3 m

onth

s

4 m

onth

s

5 m

onth

s

6 m

onth

s

7 m

onth

s

8 m

onth

s

9 m

onth

s

10 m

onth

s

11 m

onth

s

Neonatal Post neonatal

Infant Deaths by Age of Infant TFIMR 2004 Infant Deaths

N=46

Cause of DeathTulsa County 2004 TFIMR

2, 1

1

2

4

1

1

3

4

3

1

2

2

1

1

1

1

1

1

1

1

1

1

22, 1

3

9, 3

1, 4

1,1

3

1, 1

1

1

1

1

1

0 5 10 15 20 25 30

Newborn affected by oligohydramnios Newborn affected by complication of labor and delivery, unspecified

Extreme immaturity Other preterm infants

Necrotizing entercolitis of newborn Respiratory distress syndrome of newborn

Neonatal cardiac failure Neonatal cardiac dysrhythmia

Bacterial sepsis of newborn, unspecified Sepsis of newborn due to other and unspecified streptococci

Anencephaly Congenital malformation of the heart, unspecified

Hypoplasia and dysplasia of lung Gastroschisis

Other congenital malformations of musculoskeletal system Congenital malformation syndromes predominantly involving limbs

Congenital malformation, unspecified Edwards' syndrome, unspecified

Other ill-defined and unspecified causes of mortality Sudden infant death syndrome

Respiratory syncytial virus pneumonia Pneumonia, unspecified

Noninfective gastroenteritis and colitis, unspecified

Accidental suffocation and strangulation in bed

Intercranial and intraspinal phlebitis and thrombophlebitis

Essential (primary) hypertension

Neonatal Post Neonatal

Diseases of the Nervous System (G00-G98)

Note: Bold italicized headings refl ect mortality category.

Individual causes are listed below the category.Diseases of the Ci rculatory System (I00-I99)

External Causes of Morbidity & Mortal i ty (V01-Y89)

Diseases of the Digestive System (K00-K92)

Diseases of the Respiratory System (J 00-J 21)

Other Symptoms, Signs and Abnormal Cl inical and Laboratory Findings, not Elsewhere

Classifi ed (R00-R53, R55-R94, R96-R99)

Congenital Mal f ormations, Def ormations, and Chrosomal Abnormal i ties (Q00-Q99)

Certain Conditions Or iginating in the Per inatal System (P00-P96)

Race of InfantTFIMR 2004 Infant Deaths

Black14, 30.4%

White27, 58.7%

Native American, 4,

8.7%

Vietnamese, 1, 2.2%

Infant Deaths by Race and Cause of DeathTFIMR 2004 Infant Deaths

9

11

3

9

1 1 1

5

1 11 1 1 1

0

2

4

6

8

10

12

White Black Native American Other

Num

ber o

f Dea

ths

Certain Conditions Originating in the Perinatal System

Congenital Malformations, Deformations, and Chrosomal Abnormalities

Other Symptoms, Signs and Abnormal Clinical and Laboratory Findings, not Elsew here Classified

Diseases of the Respiratory System

Diseases of the Digestive System

External Causes of Morbidity & Mortality

Diseases of the Nervous System

Diseases of the Circulatory System

Hispanic Ethnicity

3 (6.8%) Hispanic ethnicity unknown

7 (17.1%) Hispanic ethnicity 34 (82.9%) Non-Hispanic ethnicity

Gestational Age (weeks) Term Births 37+ weeks10 (25%) Preterm <37 weeks 30 (75%)

Birth Weight VLBW <1,500g 22 (55.0%) LBW 1,500-2,499g 8 (20.0%) Normal 2,500g-3,900 10 (25.0%)

Gestation and Cause of Death, Singleton Births TFIMR 2004 Infant Deaths

8 8

1 11

3 3 3

2

11

1 1

2

3

1

0

1

2

3

4

5

6

7

8

9

<24 24-28 33-36 37-40 41+

Gestational Age

Nu

mb

er

of

Infa

nt

De

ath

s

Certain Conditions Originating in the Perinatal Sy Congenital Malformations, Deformations, and Chrosomal Abnormalities Diseases of the Circulatory SystemDoseases of the Nervous SystemDiseases of the Respiratory SystemExternal Causes of Morbidity and MortalityOther Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not elsewhere Classified

Location of Death2004 TFIMR Infant Deaths

Home 7 (15.2%) Hospital 39 (84.8%)

Birth Hospital34 deaths (73.9% of all deaths87.2% of hospital deaths)

Hospital re-admission5 (10.9% of all deaths12.8% of hospital deaths)

4

Grief/Loss Support 12 (26%) No clear documentation on who if any

gave grief support to the mother after the infant died.

13 (28.3%) More than one person listed as providing grief support.

21 (45.7%) One person listed as providing grief support

Grief support provided by Social Workers, Clergy,Nurses, volunteer pregnancy loss support group.

Father’s Information

Father’s Information

Of the 44 fathers there is no information for 4 fathers

Of the data collected, unknown values range from 22.5% to 40.0% making data reliability very low.

Mother

Maternal Characteristics and Risk Factors

Age of MotherTFIMR 2004 Selected Infant Deaths

6 6

13

5

8

3 3

0

16.4

11.1

4.82.0

4.2 3.8

19.6

0.00

5

10

15

20

25

Age of Mother

Num

ber a

nd R

ate

of In

fant

De

aths

Number of deaths IMR per 1000 live births

Number of deaths 6 6 13 5 8 3 3 0

IMR per 1000 live births 16.4 11.1 4.8 2.0 4.2 3.8 19.6 0.0

15-17 Yrs

18-19 Yrs

20-24 Yrs

25-29 Yrs

30-34 Yrs

35-39 Yrs

40-44 Yrs

45-54 Yrs

Age of Parents at Birth of InfantTFIMR 2004 Infant Deaths

**

**

0

10

20

30

40

50

60

Age of Mother

Age

in Y

ears

Mother

Father

Two toned -planned pregnancy*In vitro fertilization

Mother’s Educational Attainment

Of the 44 mothers who lost infants during 2004Educational attainment is unknown for 6

(13.6%)6 were over the age of 19 and had less than a

high school education4 mothers were under the age of 20 and were

below their expected grade level

Mother’s Educational AttainmentAge of Mother

Grade Completed 15 16 17 18 19 20-24 25-29 30-34 35-39 40-44

<7th . 1 . . . . 1 . . .

7th . 1 . . . . . . . .

8th . . . . . . . . . .

9th 1 1 . . . 1 . . . .

10th . . . 1 1 . . . .  

11th . . 1 . . 4 . . .  

High School Grad or GED . . . 2 1 5 2 2 .

1st year of College & above . . . . . 2 1 4 3 2

Total 1 3 1 3 2 12 4 6 3 2

Shaded area is below expected grade level.

Mother’s Employment

Employed 20Employed, hours worked unknown 14Employed full-time 6

Incarcerated 1 Student 6 Unemployed 16 Unknown 1

Mother’s Primary Language English 40 (90.9%) Spanish 3 (6.8%)

PNC interpreter available for 1 mother, unknown if services were available for 2 mothers

L&D interpreter available for 2 mothers, 1 is unknown if services were available

Vietnamese 1 (2.3%) PNC mother provided her own interpreter part of the

time, unknown if one was available at any PNC visit L&D hospital provided an interpreter part of the time

Mother's Pre-pregnancy WeightTFIMR 2004 Infant Deaths

N=38

Normal, 12, 31.6%

Overweight, 8, 21.1%

Obese, 16, 42.1%

Under, 2, 5.3%

BMIUnderweight <18.5Normal 18.5-24.9

Overweight 25-29.9

Obese 30+

Number and Percent of Mothers by Maternal Pre-pregnancy BMI and Race

TFIMR 2004 Infant DeathsN=34

1

5

6

10

1

4

1

6

0

2

4

6

8

10

12

Underweight Normal Overweight Obese

BMI

Nu

mb

er o

f M

oth

ers

White Black

By race, 77.3% of white mothers and 66.6 % of black mothers were above or below the recommended BMI.

Was nutrition discussed and documented in mother’s medical record?

Yes 18 (26 mothers were under or over ideal body weight. Of those nutrition was discussed and documented for 12 (46%))

Nutritional risk factors identified and documented1 folate deficiency1 calcium, protein deficiency1 caloric deficiency1 PICA (eating non-food items)

Pregnancy IntentTFIMR 2004 Infant Deaths

18

29

14

1

1115

4

40

0

10

20

30

40

50U

nkno

wn

Non

e

Dep

oPro

vera Ye

s No

Unk

now

n

Yes No

Birth Control Method at Conception Pregnancy Planned In Vitro Fertilization

Num

ber

of M

othe

rs

Marital Status

Married 23 (52.3%) 16 living with FOB 6 unknown living situation 1 living with other relatives

Single 21 (47.7%) 5 living with FOB 3 living with her parent(s) 6 living alone or alone with siblings of infant 1 other relatives 1 incarcerated 5 unknown living situation

Mother’s Living Arrangement Unknown 11(25%) Father of the baby 21

9 FOB alone 12 FOB and siblings

Significant other 0 Mother’s parents 3

2 parents alone 1 parents and infant’s siblings

Alone 6 2 alone 4 alone with infant siblings

Other family 2 1 other only 1 other and infant’s siblings

Incarcerated 1

Mother’s Health Insurance Medicaid 24 (54.6%)

91.7% of the black mothers had Medicaid as their primary insurance

33.3% of the white mothers had Medicaid as their primary insurance

Private 16 (36.4%) Only 1 black mother had her private insurance as her

primary insurance 51.9 % of the white mothers had private insurance as

their primary insurance Self-pay 3 (6.8%)

100% of the self-pay mothers were of Hispanic ethnicity, 2 were not born in the U.S., 1 birthplace was unknown, all had Spanish as their primary language

Medicaid & private 1 (2.3%)

Mother’s Tobacco Use

Unknown tobacco use 3 (6.8%) No tobacco use 24 (58.5%) Smoked during pregnancy 17 (41.5%)

8 smoked 10 or fewer cigarettes per day6 smoked 1 pack of cigarettes per day2 smoked, unknown amount1 smoked cigars

Mother’s Alcohol Use

Three mothers admitted to alcohol use at PNC visits or at the hospital yet there was no documentation that they received a referral or education on the dangers of drinking during pregnancy

Alcohol use unknown 7 (15.9%)

Mother’s Drug Use Marijuana use was unknown for 6 (13.6%) mothers. 5 mothers admitted marijuana use at either PNC visits or

at the hospital but only 1 referral was documented. Of these 5 mothers, 3 were given drug screens, all were negative.

No documentation was found for drug screens for 32 mothers

Of the 12 drug screens administered: 8 were negative 4 were positive• 3 were positive for marijuana (1 positive for THC, opiates,

barbiturates)• 1 positive for cocaine and opiates • No referrals were noted in the medical records for any of these

positive drug screens.

Prenatal Care

31 (70.5%) mothers began PNC during their 1st trimester of pregnancy

11 (25%) mothers began PNC during their 2nd trimester of pregnancy

1 (2.3%) attended PNC but it is unknown the week gestation she began PNC

1 (2.3%) mother did not receive PNC

Missed PNC AppointmentsNumber and Percent Missed PNC Visits

TFIMR 2004 Infant DeathsN=43

29 (67.4%)

8 (18.6%)

3 (7.0%) 2 (4.7%) 1 (2.3%)

0

5

10

15

20

25

30

35

No Missed PNCAppts.

1 PNC Appt.Missed

2 PNC Appt.Missed

3 PNC Appt.Missed

5 PNC Appt.Missed

Nu

mb

er o

f m

oth

ers

Method of Delivery

Spontaneous vaginal 27 (58.7%) Primary C-section 13 (28.3%) Repeat C-section 3 (6.5%) Vaginal breech 2 (4.3%) Forceps 1 (2.2%)

Indications for C-Section

Fetal Indications 6 3 Footling breech 3 Fetal indications unspecified

Maternal Indications 9 3 Hemorrhage 2 Previous C-section 2 Chorioamnionitis 1 Pre-eclampsia 1 Failure to progress

Unknown Indications 1

Conditions Noted at Birth Amniotic fluid 7

3 Bloody 3 Foul odor1 Bloody and foul odor1 Cloudy1 Meconium stained

Abruptions Placental infection 1

Placental Exams

No placental exams 9 (20.%) Placental exams 35 (79.5%)

23 (65.7%) Chorioamnionitis, Funisitis, Villitis 20 (57.1%) Chorioamnionitis 8 (22.9%) Funisitis 5 (14.3%) Villitis

Maternal Infections Infection Present 19 (43.2%)

Sexually Transmitted Infection present 15 (34.1%) Other Infection Present 10 (22.7%)

Group B Strep 11 (25%) Chlamydia 7 (15.9%) Bacteriodes fragilis 4 (9.1%) Trichomonas 2 (4.6%) E. coli 2 (4.6%) One each of the following: 7 (15.9%)

Herpes, syphilis, gonorrhea, bacterial vaginosis, yeast, diptheriodes and prevotella, coccal

UTI-organism not specified

Maternal Infections con’t. No Placental exams - 9

2 GBS positive Placental Exams - 35

No Chorio/funisitis/villitis present - 13 2 Chlamydia present 1 E.coli 1 GBS, Trichomonas, Yeast 1 E. coli, Chlamydia

Chorio/funisitis/villitis present - 22 1 GBS, bacteriods, Chlamydia 1 GBS, syphilis 3 GBS 2 Bacteroides 1 GBS, gonorrhea 1 diptheroides, prevotella 1 GBS, bacteroides 1 GBS, herpes, trichomonias

Did a Social Worker contact the mother during the hospital stay? Yes 25 (56.8%)

Documentation was found in the medical record of a Social Worker contacting the mother during the hospital stay.

Were any of the following problems identified during the mother’s hospital stay?

None Depression Inadequate support system Inadequate housing Need for public assistance, Medicaid, food

stamps, WIC Drug/alcohol abuse Crime/legal problems other

Discharge Instructions*

Nothing noted in chart 2 (4.5%) Follow-up in __ weeks 35 (79.5%)

1-2 weeks 13 3-4 weeks 9 5-6 weeks 13

Standard discharge instructions 29 (65.9%) Other discharge instructions 8 (18.2%)

Mothers could be given more than one discharge instructions. Percents do not add up to 100.

How was the mother instructed to make her post partum follow-up appointment? Call for an appointment 24 (54.5%) Not mentioned 19 (43.2%) Appointment made before leaving the

hospital 1 (2.3%)

Did the mother attend her post partum visit?

Yes 20 No 8 Unknown 16 (36.4%)