Infant Mortality:

Juanita Graham MSN RNHealth Services Chief Nurse

Mississippi State Department of Health

A Discussion of Birth Outcomes Across MS& Neighboring Southern States

Agenda• List leading causes of infant mortality

in Mississippi

• Discuss similarities in trends in neighboring Southern states

• Discuss innovative strategy in Mississippi to reduce VLBW

Figure 1. Infant Mortality, Mississippi, 1998-2007

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Total White Nonw hite

Total 10.2 10.2 10.6 10.5 10.3 10.7 9.7 11.4 10.5 10.1

White 6.4 6.7 6.7 6.9 6.8 6.8 6.1 6.6 6.9 6.6

Nonw hite 14.5 14.1 15.1 14.7 14.4 15.4 14.2 17.0 14.4 14.1

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

IMR by County 1998-2007(10 Year Average)

Infant mortality rates vary throughout the state.

•10-year average 10.4

•Lowest: Perry 5.6

•Highest: Tunica 20.5

•Healthy People 2010 Goal 4.5

Produced 11/2/2008

Source: MSDH, Public Health StatisticsForrest 10.7

Attala 9.9

Tallahatchie 11.0

Sharkey 5.6

DeSoto 7.8

Marshall 11.0

Benton 12.0

Tippah 7.9

Alcorn 7.3

Prentiss 9.8

Tishomingo

6.8

Tate 10.1

Lafayette 9.7

Panola 10.4

Union 8.9

Pontotoc 5.9

Tunica 20.5

Itawamba 10.1

Monroe 9.8

Coahoma 16.5

Quitman 11.9

Yalobusha 9.1

Calhoun 9.4

Chickasaw 10.9

Bolivar 12.3

Sunflower 15.5 Leflore

13.3

Grenada 13.1

Carroll 10.6

Webster 7.8

Montgom

ery 16.4

Holmes 13.2

Yazoo 10.9

Leake 11.2

Neshoba 10.0

Winston 10.2

Choctaw 11.7

Oktibbeha 8.0

Noxubee 20.1

Kemper 13.3

Lowndes 10.5

Wayne 10.4

Hum

phreys 15.2

Scott 12.9

Newton 10.8

Smith 10.6 Jasper

12.1 Clarke 7.2

Jones 9.6

Greene 6.5 Perry

5.6

George 10.4 Stone

9.9 Pearl River 6.7

Hancock 7.2

Simpson 12.5

Covington 12.2

Lamar 7.9

Marion 8.5 Walthall

9.4 Pike 7.0

Amite 8.4

Wilkinson 6.4

Adams 11.9

Franklin 8.7

Jefferson 11.4

Lincoln 8.7

Copiah 13.6

Lawrence 9.8

Claiborne 13.6

Warren 9.4

Issaquena 5.0

Lee 10.9

Washington 12.1

Hinds 13.5

Madison 10.0

Rankin 7.7

Lauderdale 12.4

Harrison 9.5

Jackson 7.6

Clay 13.1

Jefferson D

avis 10.9

5.00-9.40

9.41-11.20

11.21+

State Avg~/= State Avg< State Avg

White & Non-white rates

1998 1999 2000 2001 2002Total 10.2 10.2 10.6 10.5 10.3

White 6.4 6.7 6.7 6.9 6.8

Nonwhite 14.5 14.1 15.1 14.7 14.4

2003 2004 2005 2006 2007Total 10.7 9.7 11.4 10.5 10.1

White 6.8 6.1 6.6 6.9 6.6

Nonwhite 15.4 14.2 17.0 14.4 14.1

58%

42%

Neonatal

Postneonatal

Infant Mortality by period of death, Mississippi 2007

Figure 3. Neonatal Mortality, Mississippi, 1998-2007

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Total White Nonw hite

Total 6.2 6.2 6.6 6.6 6.8 5.8 6.0 6.7 6.5 5.8

White 3.3 4.0 3.9 4.2 4.4 3.4 3.5 3.0 4.2 3.8

Nonw hite 9.5 8.8 9.6 9.3 9.6 8.7 9.0 11.0 9.1 8.2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 4. Postneonatal Mortality, Mississippi, 1998-2007

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Total White Nonw hite

Total 4.0 3.9 4.1 3.9 3.5 4.9 3.8 4.7 4.0 4.2

White 3.0 2.7 2.8 2.7 2.4 3.5 2.6 3.6 2.7 2.8

Nonw hite 5.0 5.3 5.5 5.4 4.9 6.6 5.1 6.0 5.4 5.9

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Infant death by infant weight

VLBW53%

LBW16%

Normal31%

Percent of infant deaths by birth weight, Mississippi, 2007

51.2%

14.9%

29.6%

4.3%

VLBW

LBW

Normal

Unknow n

Figure 13. Average Percent of Infant Deaths by birth weights, Mississippi, 1998-2007

0%

10%

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30%

40%

50%

60%

70%

Per

cent

< 1,500 g 1,500-2,499 g 2,500+ g Unknow n

< 1,500 g 50% 54% 52% 54% 57% 51% 55% 54% 54% 51%

1,500-2,499 g 16% 12% 14% 17% 15% 16% 15% 18% 15% 15%

2,500+ g 33% 31% 32% 27% 26% 32% 28% 28% 29% 30%

Unknow n 1% 3% 2% 1% 2% 1% 2% 1% 2% 4%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 8. Infant mortality rate by infant weight

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VLBW LBW Normal Total

VLBW 254.7 254.9 251.3 273.2 264.2 238.8 241.6 261.1 241.0 231.9

LBW 19.5 15.4 18.0 21.2 17.2 19.0 15.4 21.0 15.6 15.0

Normal 3.7 3.6 3.8 3.2 3.0 3.8 3.1 3.6 3.4 3.4

Total 10.2 10.2 10.6 10.5 10.3 10.7 9.7 11.4 10.5 10.1

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 9. Infant mortality by gestational age

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<37 w eeks 37+ w eeks

<37 w eeks 36.6 37.6 38.1 38.3 38.6 33.5 33.7 34.9 33.8 32.4

37+ w eeks 4.0 3.8 4.0 3.4 3.0 4.6 3.3 4.1 3.6 3.4

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 10. Infant mortality by mother's age (in years)

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<17 18-24 25-34 35+

<17 13.6 17.6 13.3 14.2 14.7 14.8 12.2 19.2 17.7 13.5

18-24 11.2 10.2 12.1 11.0 12.2 12.0 10.3 12.6 11.5 10.4

25-34 8.0 8.0 8.2 8.6 7.4 8.6 8.9 9.1 8.3 8.2

35+ 10.7 11.5 10.4 12.2 8.3 11.1 7.5 9.9 8.6 12.9

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Average Percent of Infant Deaths by birth weights, Mississippi, 1998-2007

0%

20%

40%

60%

80%

Per

cent

< 1,500 g 1,500-2,499 g 2,500+ g Unknow n

< 1,500 g 50% 54% 52% 54% 57% 51% 55% 54% 54% 51%

1,500-2,499 g 16% 12% 14% 17% 15% 16% 15% 18% 15% 15%

2,500+ g 33% 31% 32% 27% 26% 32% 28% 28% 29% 30%

Unknow n 1% 3% 2% 1% 2% 1% 2% 1% 2% 4%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 5. Comparison among SIDS rate and neonatal and postneonatal rates, Mississippi, 1996-2007

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Neonatal Postneonatal SIDS

Neonatal 6.2 6.2 6.6 6.6 6.8 5.8 6.0 6.7 6.5 5.8

Postneonatal 4.0 3.9 4.1 3.9 3.5 4.9 3.8 4.7 4.0 4.2

SIDS 1.4 1.4 1.4 1.3 1.3 2.2 1.6 2.2 1.5 1.2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 6. SIDS rate by race, Mississippi, 1998-2007

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Total White Nonw hite

Total 1.4 1.4 1.4 1.3 1.3 2.2 1.6 2.2 1.5 1.2

White 1.1 1.1 1.0 1.2 1.1 1.5 1.4 2.0 1.1 1.1

Nonw hite 1.8 1.8 2.0 1.3 1.5 3.2 2.0 2.3 1.9 1.4

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

• Retrospective cohort study using linked birth & death certificate files for Mississippi infants, 1996-2003 (N=341,780).

• A population of (n=297,418) non-Hispanic white & black singleton live-born infants studied

• Assessing relationship between chronic conditions and IM, LBW, PTB

Findings from Linked Data

Live BirthsPreterm Births

Low Birth Weights Infant Deaths

(n = 295,701) (n = 45,695) (n = 25,464) (n = 2,207)Characteristica n (% ) n (% ) n (% ) n (% )Maternal Characteristics:Race

Black/Non-Hispanic 141,426 (47.8) 27,423 (60.0) 16,526 (64.9) 1,406 (63.7)White/Non-Hispanic 154,275 (52.2) 18,272 (40.0) 8,938 (35.1) 801 (36.3)

Age Group (yrs)11-17 22,995 (7.8) 4,609 (10.1) 2,698 (10.6) 247 (11.2)18-24 136,765 (46.2) 21,306 (46.6) 12,564 (49.3) 1,128 (51.1)25-34 115,541 (39.1) 16,262 (35.6) 8,239 (32.4) 691 (31.3)35+ 20,400 (6.9) 3,518 (7.7) 1,963 (7.7) 141 (6.4)

Education levelLess than High School 77,104 (26.1) 13,917 (30.5) 8,500 (33.4) 789 (35.8)High School 97,210 (32.9) 15,517 (34.0) 8,778 (34.5) 777 (35.2)College 121,387 (41.0) 16,261 (35.6) 8,186 (32.2) 641 (29.0)

Marital StatusNot Married 140,848 (47.6) 26,007 (56.9) 15,759 (61.9) 1,376 (62.4)Married 154,853 (52.4) 19,688 (43.1) 9,705 (38.1) 831 (37.6)

Table 1. Live Births, Preterm Births, Low Birth Weights and Infant Deaths Among Infants by Selected Characteristics: Mississippi, 1996-2003 Birth Cohort

Live BirthsPreterm Births

Low Birth Weights Infant Deaths

(n = 295,701) (n = 45,695) (n = 25,464) (n = 2,207)Characteristica n (% ) n (% ) n (% ) n (% )Initiation of Prenatal Care

1st Trimester 241,065 (81.5) 34,710 (76.0) 19,699 (77.4) 1,638 (74.2)2nd Trimester 44,507 (15.0) 8,566 (18.8) 4,423 (17.4) 426 (19.3)3rd Trimester 7,341 (2.5) 1,405 (3.1) 675 (2.6) 59 (2.7)No care 2,788 (0.9) 1,014 (2.2) 667 (2.6) 84 (3.8)

Tobacco use10+ cigarettes/day 24,146 (8.2) 3,626 (7.9) 2,950 (11.6) 257 (11.6)1-9 cigarettes/day 12,934 (4.4) 2,067 (4.5) 1,517 (6.0) 128 (5.8)None 258,621 (87.5) 40,002 (87.5) 20,997 (82.5) 1,822 (82.6)

Previous Small Infant 3,688 (1.2) 1,473 (3.2) 1,130 (4.4) 89 (4.0)Maternal Medical Conditions:Diabetes 7,319 (2.5) 1,429 (3.1) 631 (2.5) 73 (3.3)Hydramnios/Oligohydramnios 3,180 (1.1) 871 (1.9) 798 (3.1) 109 (4.9)Hypertension 19,950 (6.8) 5,446 (11.9) 4,220 (16.6) 187 (8.5)Infant Characteristics:b

Birth WeightLBW: < 2,500 grams 25,464 (8.6) 16,012 (35.0) 25,464 (100.0) 1,213 (55.0)Normal: ≥ 2,500 grams 270,237 (91.4) 29,683 (65.0) n/a 994 (45.0)

Gestational AgePTB: < 37 weeks 45,695 (15.4) 45,695 (100.0) 16,012 (62.9) 1,194 (54.1)Term: ≥ 37 weeks 250,006 (84.6) n/a 9,452 (37.1) 1,013 (45.9)

PTB LBW Infant Dieda

Characteristic OR (95% CI)b OR (95% CI)b OR (95% CI)b

Maternal Characteristics:Race

Black/Non-Hispanic 1.6 (1.5-1.6) 2.1 (2.0-2.1) 1.7 (1.6-1.9)White/Non-Hispanic 1.0 (referent) 1.0 (referent) 1.0 (referent)

Age Group (yrs)11-17 1.1 (1.0-1.2) 1.2 (1.2-1.3) 1.2 (1.0-1.4)18-24 1.0 (0.9-1.0) 1.1 (1.0-1.1) 1.1 (1.0-1.2)25-34 1.0 (referent) 1.0 (referent) 1.0 (referent)35+ 1.2 (1.2-1.3) 1.3 (1.2-1.4) 1.1 (0.9-1.3)

Education levelLess than High School 1.2 (1.1-1.2) 1.2 (1.2-1.2) 1.4 (1.2-1.6)High School 1.1 (1.1-1.1) 1.1 (1.1-1.1) 1.2 (1.1-1.4)College 1.0 (referent) 1.0 (referent) 1.0 (referent)

Table 3. Adjusted Odds Ratios for Preterm Birth (PTB), Low Birth Weight (LBW) and Infant Death Among Infants by Selected Factors: Mississippi, 1996-2003 Birth Cohort

PTB LBW Infant Dieda

Characteristic OR (95% CI)b OR (95% CI)b OR (95% CI)b

Marital StatusNot Married 1.1 (1.1-1.2) 1.2 (1.2-1.2) 1.1 (1.0-1.3)Married 1.0 (referent) 1.0 (referent) 1.0 (referent)

Maternal Risk Factors:Initiation of Prenatal Care

1st Trimester 1.0 (referent) 1.0 (referent) 1.0 (referent)2nd Trimester 1.2 (1.2-1.2) 0.9 (0.9-1.0) 1.1 (1.0-1.2)3rd Trimester 1.1 (1.1-1.2) 0.8 (0.7-0.9) 0.9 (0.7-1.1)No care 2.7 (2.5-2.9) 2.4 (2.2-2.7) 3.1 (2.5-3.9)

Tobacco use10+ cigarettes/day 1.1 (1.1-1.2) 2.1 (2.0-2.2) 1.8 (1.5-2.0)1-9 cigarettes/day 1.1 (1.0-1.1) 1.7 (1.6-1.8) 1.4 (1.2-1.7)None 1.0 (referent) 1.0 (referent) 1.0 (referent)

Previous Small Infant 3.5 (3.3-3.8) 4.6 (4.3-5.0) 3.0 (2.4-3.7)Maternal Medical Conditions:Diabetes 1.2 (1.1-1.3) 0.8 (0.7-0.9) 1.4 (1.1-1.7)Hydramnios/Oligohydramnios 1.8 (1.7-2.0) 3.1 (2.8-3.4) 4.4 (3.6-5.3)Hypertension 2.1 (2.0-2.2) 3.2 (3.1-3.4) 1.2 (1.0-1.4)

• Evaluates prenatal care based on timing & number of visits

• Adequate prenatal care had lower infant mortality rate than inadequate group

• “Adequate plus” prenatal care had much higher infant mortality rate than adequate group (what does this tell us?)

• Mississippi boasts of nearly 85% rate of early entry into care

Kotelchuck Index

Figure 11. Infant mortality rate by Kotelchuck Index

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Inadequate Intermediate Adequate Adequate Plus

Inadequate 14.2 14.6 15.6 13.9 12.3 16.8 12.9 16.4 15.9 13.5

Intermediate 8.3 8.3 7.3 6.4 9.3 7.2 7.4 11.3 7.4 9.7

Adequate 6.1 5.9 5.0 5.2 5.3 5.5 4.9 5.4 5.0 4.7

Adequate Plus 12.9 11.8 14.3 14.6 12.6 13.1 12.5 13.3 13.0 12.1

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Southern States Data

• CDC State Profiles Data (mixture 2005 & 2006 data)– Available online at

http://www.cdc.gov/nchs/pressroom/data/2009_state_profiles.htm

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AL AR FL GA KY LA MS NC SC TN US

Teen Birth Rate % Births to Unmarried Mothers Cesarean Delivery Rate Early Prenatal Care

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Preterm Birth Rate Low Birthweight Rate Infant Mortality Rate

Preterm Birth Rate 17.1 13.7 13.8 14.1 15.1 16.2 18.8 13.6 15.4 14.8 12.8

Low Birthweight Rate 10.5 9.2 8.7 9.6 9.1 11.3 12.4 9.1 10.1 9.6 8.3

Infant Mortality Rate 6.83 8.29 7.24 8.35 6.79 9.79 10.74 8.58 9.03 8.87 6.83

AL AR FL GA KY LA MS NC SC TN US

0%

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40%

50%

60%

70%

80%

90%

100%

AL AR FL GA KY LA MS NC SC TN US

Heart Disease Cancer Diabetes Stroke Chronic Lower Respiratory Disease

0%

10%

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90%

100%

AL AR FL GA KY LA MS NC SC TN US

Accidents Alzheimer's Disease Influenza & Pneumonia Kidney Disease Septicemia

Percentage of Persons < 65 years old without Health Insurance

AL 23.70% LA 18.90%

AR 21.40% MS 18.80%

FL 20.80% NC 17.50%

GA 19.80% SC 16.60%

KY 19.40% TN 16.50%

US 14.80%

• Post-Katrina assessment of access to reproductive health care

• SIDS Knowledge among AA women• Evaluation of CHW use among high risk

populations• MS Coroner Survey

Other MS IM Studies

Problem: Many Mississippi babies die very small & very young despite prenatal care

Hypothesis: Mississippi women are not healthy enough to achieve a full term, normal weight delivery

Solution: Intervention PRIOR to conception

Method: IPC for small population with highest risk for poor delivery outcomes

Need for IPC

• Improve knowledge, attitudes, behaviors of men & women related to preconception health

• Assure all women of childbearing age in the U.S. receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) enabling entry to pregnancy in optimal health

• Reduce risks indicated by previous adverse pregnancy outcome through interventions during the interconception period, to prevent or minimize health problems for a mother and her future children

• Reduce the disparities in adverse pregnancy outcomes

CDC Recommendations for IPC

•Preconception / interconception care pilot programs

•Rural vs. Urban communities

•Delta Infant Mortality Elimination

•Metro Infant Mortality Elimination

MIME & DIME

Partnering organizations• UMMC – principal recruitment site & service provider.

• Healthy Linkages – referral service for identification of medical homes.

• Division of Medicaid – data source.

• World Health Organization Collaborating Center for Reproductive Health (WHO/CC/RH) – technical assistance.

• Community health centers – primary care medical homes.

MIME & DIME

IPC intervention package• Individualized interpregnancy care plan based on

assessments of medical/ social risks for subsequent poor pregnancy outcomes;

• Provision of primary health care & dental services in accordance with care plan for 24 months;

• Assistance in achieving a woman’s desire for subsequent pregnancies & need for optimum child spacing (ideally 18-20 months);

• Provision of appropriate social services & community outreach in each woman’s community.

MIME & DIME

Problems & solutions• Expansive & rural geographical area• Limited funding• Limited resources• Communication• Transportation

MIME & DIME

Role of Health Department• Lead agency & grant applicant

• Oversight & primary leadership for the project

• Contractual & logistical arrangements

• Local level support services:

– Case management & outreach

• Data analysis & evaluation

• Policy development

MIME / DIME

Project evaluation• On-going surveillance combined with evaluation at

the project’s end

• Acceptability and delivery of the IPC service package indicators followed on an on-going basis

• Health & Reproductive outcomes evaluated at project’s end

• Cost-benefit analysis to compare cost savings to costs of program

MIME / DIME

Goal for policy change• Medicaid lost 6 weeks post-partum

• No primary care during interim before subsequent pregnancies so poor chronic disease management

• Goal: Primary care for poverty-level Mississippi women who deliver VLBW

• Format: Medicaid waiver

MIME / DIME

Strategies to effect policy change• Cost analysis

– Reduction in Medicaid costs• >60 % of Mississippi births covered by Medicaid

– High risk pregnancy care

– High risk infant care

– Long term morbidities & developmental delay

– Low number of qualified women (n= ~800)

– Low cost of primary care

MIME / DIME

Women not prepared for pregnancy & motherhood

Classic Public HealthDoing a lot with a littleKeeping families healthy

Conclusions

Questions?