Preventing Infant Mortality: What We Know, What We Don’t,

and What You Can Do

Tom Ivester, MD, MPHUNC School of Medicine

Division of Maternal Fetal Medicine

UNC Center for Maternal and Infant Health

June 12, 2007

Overview

Snap shot of infant death in North Carolina What providers know and don’t know about

preventing infant death Items to study when reviewing cases The importance of obstetricians in the review

process

Infant Deaths in North Carolina

Each week 19 babies die before their first birthday

Half of “excess” infant death occurs in 13 counties

29% of infant deaths occur in the first hour of life

The percent of multiple births has increased

22% of postnatal deaths were to babies weighing less than 1,500 grams

Causes of Infant Mortality in NC

All leading causes of infant death are higher in North Carolina compared to the U.S. mean in 2004

Infant Deaths in NC

Infant deaths accounted for 65% of all child deaths from 2000 to 2004

Birth defects and other birth-related conditions make up almost 50% of all child deaths

Your case reviews can shape how North Carolina addresses infant mortality and reduces future risk

Child Death by Cause in NC

Ages Birth through 17 years

Cause of Death

Average Annual Number 2000-2004

Number in 2003

Number in 2004

% change

from last year

Birth Defects 207 209 219 5%

Other birth-related conditions

557 520 575 11%

SIDS 96 100 103 3%

Illnesses 283 285 286 0%

Unintentional injuries

279 271 313 15%

Homicide 48 46 51 11%

Suicide 26 23 23 0%

All other 50 49 37 -24%

TOTAL 1546 1503 1607 6.9%

Source: NC Division of Public Health

Infant Mortality Disparities in NC

African American infants are 2.3 times more likely to die than Caucasian infants.

Between 2002 and 2004, preterm births were highest among African American infants, at 18.7% of all live births, compared with 11.9% of live births for Caucasian infants

Racial disparities increase with maternal

age

The neonatal survival advantage of AA babies has decreased over time.

Birth Defects: Causes & Related Factors

Genetics Teratogenic medications

Isotretinoin (e.g., Accutane) Anti-epileptic drugs (e.g., valproic acid) Levothyroxine (for hypothyroidism) Oral anticoagulants (e.g., Warfarin)

Inadequate folate consumption Alcohol and tobacco Obesity and Diabetes Toxic exposures at work and at home Many unanswered questions

Preterm Birth in NC

In 2004, 1 out of every 7 babies was born preterm.

The rate increased 8% in the past decade.

Premature Birth Facts

Preterm births are defined as live births occurring at <37 completed weeks gestation.

Preterm births are the leading cause of newborn death.

The best known risk indicator is a previous preterm birth.

Premature Birth Facts

The main routes leading to preterm labor are Maternal or fetal stress Trauma Preeclampsia (high blood pressure) Infections Bleeding Uterine stretching Drug intoxication

What we know

Infant mortality rates are stagnant

Premature birth is rising

Birth defect rates have stayed about the same

Health disparities persist

What we don’t know

All the triggers for early birth - the causes of preterm birth are complex and multi-factorial

The causes of many birth defects How to stop preterm labor once it has started

Where can we intervene?

The Socio-ecological Model

(Source: Gebbie, 2003 #174)

What to consider in a review

Where was the baby born? Were the mother and baby cared for at appropriate

facilities by the right providers? What were the details leading up to the birth?

Were steroids given prior to delivery to improve lung development for preterm babies?

Prenatal care Did she have it? When? Cultural and/or physical access issues

How does this case fit in with local mortality?

Consider…

Family violence & stress Tobacco, Alcohol and illicit substance use Chronic disease management Access to health care Exposures (teratogenic drugs, environmental,

infections) Nutrition (folate, overweight, underweight) Closely spaced pregnancies Maternal health conditions Maternal age Consanguineous pregnancies

What to recommend

17 P in subsequent pregnancies to prevent preterm birth

Early prenatal care in next pregnancy Policy advocacy: improved preconception,

prenatal, and interconception health care funding

What to recommend

Interconception Health Folic Acid Optimal control of maternal medical conditions Health education

Obstetricians are Key Resources

Encourage medical facilities to conduct their own internal infant death reviews and share findings with the team

Ask for periodic in-services by local obstetricians

If you have a health care provider vacancy – consider inviting an obstetrician

Professional Resources

Resources available on www.mombaby.org:

Preconception Health Resources Public Health Maternal Child Health Links OB Management Algorithms Patient / Provider Resources Infant Mortality data And More!

Questions?