Adina Ekwerike, MPH Health Program Manager
Philadelphia Interdisciplinary Mortality Review
Thursday, May 18, 2006
Understanding and Preventing Infant Deaths in Philadelphia
Local Practice
Infant MortalityInfant MortalityUnited States, 1925-2003United States, 1925-2003
0
10
20
30
40
50
60
70
80
1925 1935 1945 1955 1965 1975 1985 1995
Rate per 1,000 live births
Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002
2003 preliminary rate - 6.85
Philadelphia’s Philadelphia’s DemographicsDemographics
• 5th largest US city
• Population estimate – 1.49M (7/2000)
• Infant Mortality Rate 10.7, in 2003
Source: Philadelphia Department of Public Health, Vital Statistics Report
Philadelphia - 2003Philadelphia - 2003
• 21,313 births21,313 births– 50% African American or Black50% African American or Black– 30% White30% White– 20% Other20% Other
• 228 infant deaths228 infant deaths– 62% African American62% African American– 32% White32% White– 6% Other6% Other
Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003
2003 Causes of Death among 2003 Causes of Death among InfantsInfants
Perinatal Conditions,
37.8
Congenital
Anomalies, 16.1Infections, 4.8
Injury, 2.4
SIDS, 23.1
Ill-defined, 5.1
Other, 10.7
Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003
Philadelphia Infant Mortality by Philadelphia Infant Mortality by Race 1990-2003Race 1990-2003
Source: Philadelphia Department of Public Health, Vital Statistics Report, 1990 - 2003
15.4
13.5
6.1 6.67.8
16
10.8 10.6 10.7
17.1
20
14.1
7.47.9
12.3
10.3
0
5
10
15
20
25
1990 1995 2002 2003
Rat
e
Black
White
Total
Trends in Infant Mortality in Philadelphia, Trends in Infant Mortality in Philadelphia, 1992 through 20031992 through 2003
10
12
14
16
18
20
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Infa
nt
Dea
ths
per
1,0
00 L
ive
Bir
ths
All Races
Black or African American
Source: The Philadelphia Department of Public Health, Vital Statistics Report, 1992 - 2003
Infant Mortality in Infant Mortality in PhiladelphiaPhiladelphia
32.6
10.7
4.5
0 10 20 30 40
1960
2003
HP2010
Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003
Response to Local Public Response to Local Public Health ConcernHealth Concern
• 2003 MEO began death scene investigations
• “2004 A Bed of Tragedies”, Philadelphia Daily News
(City alerted to 43 deaths in 17 months while sleeping with others)
• City-wide Safe Sleeping Press conference
(The Philadelphia Department of Public Health and the Department of
Human Services)
Infant Deaths from Sudden Unexplained Infant Deaths from Sudden Unexplained Infant Death (SUID) and Hypoxia and Pending Infant Death (SUID) and Hypoxia and Pending
Deaths in Philadelphia, Deaths in Philadelphia,
71 Infant Deaths
48 in Co-sleeping Environment
8 Overlay Deaths
Location of Death
• Sofas/couches (5)
• In a crib w/ sibling (2)
• Adult bed (1)
23 not in Co-sleeping Environment
Source: Philadelphia Department of Public Health, April 1, 2003 – October 11, 2004
Collaboration with Community Collaboration with Community and Stakeholdersand Stakeholders
• Educate community and stakeholders about complex issues of infant safe-sleeping and bed sharing:
- safe sleeping initiative (e.g., cribs for Kids)- Sudden Unexplained Infant Death- back-to sleep- bed sharing- exposure to environmental tobacco smoke
Philadelphia Philadelphia Interdisciplinary Interdisciplinary Mortality Review Mortality Review
(PIMR)(PIMR)
Division of Maternal, Child & Family
Health
PIMR’s TeamsPIMR’s Teams
Rapid Review Infant Death Team
Fetal and Infant Mortality Review
Homicide Review Homicide Review
Non-Homicide Review Non-Homicide Review
Role of PIMRRole of PIMR
The PIMR program is a multidisciplinary, and multi-agency
process that reviews cases of deaths.
The team coordinates, collect and review data from law
enforcement, court systems, child protective services,
medical examiner, health and social services providers.
Philadelphia’s Rapid Philadelphia’s Rapid Review Review
Infant Death TeamInfant Death Team
Infant Deaths Receiving Rapid Infant Deaths Receiving Rapid ReviewReview
• 111 deaths111 deaths
– 27 in ’0327 in ’03– 46 in ’0446 in ’04– 38 from 01/05 – 09/05 (preliminary data)38 from 01/05 – 09/05 (preliminary data)– All reviewed by the same forensic investigatorAll reviewed by the same forensic investigator– All expired while sleepingAll expired while sleeping
Source: Philadelphia Department of Public Health, 2003 - 2005
Racial DisparitiesRacial Disparities’03 – 09/30/05’03 – 09/30/05
81
514
0
10
20
30
40
50
60
70
80
90
Black White Other
%
Source: Philadelphia Department of Public Health, 2003 - 2005
Gender DisparitiesGender Disparities’03 – 09/30/05’03 – 09/30/05
78
32
0
10
20
30
40
50
60
70
80
90
Male Female
%
Source: Philadelphia Department of Public Health, 2003 - 2005
Risk Factors PresentRisk Factors Present’03 – ‘04’03 – ‘04
ETS Not on back
Co-sleeping
2.9% 10.3%
0.0%
20.6%
35.3%
14.7%
7.4%
8.8% had no risk factorsSource: Philadelphia Department of Public Health, 2003 - 2005n=68, 5 missing
Comparing 03/04 through 09/04 to Comparing 03/04 through 09/04 to 03/05 through 09/0503/05 through 09/05
# of Deaths
# of Co-sleeping Deaths
03/04 – 09/04 03/05 – 09/05
19 25
14 15
p > 0.05Notes:
City-wide safe sleeping press conference and subsequent safe sleeping initiatives (e.g., Cribs for Kids) initiated in October ’04.
Time periods selected to control for seasonal differences.
Source: Philadelphia Department of Public Health, 2004 - 2005
Co-Sleeping and OverlayCo-Sleeping and Overlay52 Rapid Review Cases52 Rapid Review Cases
• Co-sleeping: 62% Co-sleeping: 62% (32 of 52 cases)(32 of 52 cases)
• Overlay: 16% Overlay: 16% (5 of 32 cases)(5 of 32 cases)
• Crib present, not used: 74% Crib present, not used: 74% (17 of 23 cases)(17 of 23 cases)
– 9 cases had no data on cribs9 cases had no data on cribs
Source: Philadelphia Department of Public Health, 2003 - 2005
PrematurityPrematurity52 Rapid Review Cases52 Rapid Review Cases
• Premature: 17% (9 cases of 52)Premature: 17% (9 cases of 52)
Source: Philadelphia Department of Public Health, 2003 - 2005
Funding SourceFunding Source
• City’s public funds
• Healthy Start federal grant
• Title V Block Grant
Proposed Recommendations Proposed Recommendations
Provide education and training on SIDS/SUID risk factors with emphasis on exposure to environmental
tobacco smoke (ETS) to the Department of Human Services (DHS) workers and community-wide providers.
Develop a specific focus on ETS prevention and education
Collaborate with the Fetal and Infant Mortality Review (FIMR) Community Action Team to create literature on ETS and infant health for childbirth and parenting classes
Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee
Proposed Recommendations Proposed Recommendations
Collaborate with the FIMR Community Action Team and DHS to develop a community education campaign/media strategy regarding ETS
Conduct a cross training between fire department staff and health department
Plan educational campaign for block captains
Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee
PIMR’s PlansPIMR’s Plans
• Conduct timely death reviews
• Facilitate PDPH’s access to medical records
• Link PIMR findings to MCFH, PDPH, DHS, state,
federal other citywide initiatives
• Link PIMR findings to community and policymaker’s
initiatives
• Maintain collaborate relationship with states and
national death reviews