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

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Presentation on theme: "Reducing Infant Mortality in Maryland Donald Shell, M.D., MA Center for Health Promotion Family Health Administration Department of Health and Mental Hygiene."— Presentation transcript:

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 2 Infant and Child Deaths

3 3 Infant Mortality in Maryland & U.S.

4 4 Leading Causes of Infant Mortality Maryland National Rankings  Infant Mortality nd  Preterm Birth th  Low Birth Weight st  VLBW – th

5 5 Leading Causes of Infant Mortality

6 6 Timing of Infant Deaths Data Source: MD Vital Statistics Administration

7 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 8 Birth Weight and Neonatal Deaths Data Source: MD Vital Statistics Administration

9 9 Racial Disparity in Infant Mortality

10 10 Racial Disparity in Preterm Births

11 11 Racial Disparity in Low Birth Weight

12 12 Racial Disparity in VLBW Births

13 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 14 Baltimore City Anne Arundel Howard Caroline Queen Anne’s Prince George’s St. Mary's Charles Kent Wicomico Dorchester Worcester Montgomery Talbot Calvert Somerset Geographic Disparity in Maryland Average Infant Mortality Rate, By Jurisdiction,

15 15 Behavioral Risks: Unintended Pregnancy Associated with Increased Neonatal Mortality * * Bustan et al, AJPH, March 1994

16 16 Behavioral Risks: Teen Births Associated with Increased Infant Mortality

17 17 Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality

18 18 Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality

19 19 Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality

20 20 Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors From NCHS data, Preterm Birth, IOM, 2007

21 21 Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors From NCHS data, Preterm Birth, IOM, 2007

22 22 Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors Data Sources: MD DHMH, Vital Statistics Administration Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland

23 23 Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors Data Sources: MD DHMH, Vital Statistics Administration Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland

24 24 Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors

25 25 Maryland’s 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 26 Governor’s 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 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, MCO’s

28 28 What Works…Maryland 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 29 Maryland Infant Mortality Plan Broad 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 Infant Mortality Breakout  “The Role of Community Pediatricians in Preventing Infant Mortality” – Meeting  Web-based survey 339 Marylanders

30 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 31 Infant Mortality Epi Work Group 2011 Findings/Data Analysis/Recommendations  Timing and effectiveness of risk- targeted prenatal care  Maternal age teens (Hispanic), > age 35  Prior pre-term birth  Birth hospital level of care for VLBW  Early term deliveries (37-38 weeks)

32 32 Partners include Office of Minority Health and Health Disparities Maryland Medicaid – coordinate MCO’s, 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 Governor’s Office for Children – Home Visitation Program Community Health Resources Commission - $ and data sharing

33 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 <39 weeks, VLBW, breast feeding and tobacco cessation  FQHC case mgt, care coordination, community referrals, provider training

34 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 PNC  UMD and JHU Med & SPH expertise and support

35 35 Intervention Across the Lifespan PRECONCEPTION (Before pregnancy) Healthier women at time of conception, planned pregnancies Earlier entry into prenatal care Comprehensive, high quality perinatal and neonatal care Healthier Children and Adults PRENATAL (During pregnancy) PERINATAL NEONATAL (After delivery)

36 36 Oversight and Evaluation – Governor’s 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 37 Strategy 1 – Before Pregnancy Expand access to women’s comprehensive health and wellness services Transition family planning sites into Comprehensive Women’s 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 38 Oversight and Evaluation – Strategy # 1 Governor’s Delivery Unit and State Stat  #comprehensive women’s 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 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 40 Oversight and Evaluation – Strategy # 2 Governor’s 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 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 B’more “Safe Sleep. Alone. Back. Crib” DVD 4/1/2011 implemented standardized d/c referral form for high risk mothers to CBO’s Monitoring level I and II (MMQRC), level III (MIEMSS) birthing hospital compliance with Perinatal Standards VLBW deliveries

42 42 Oversight and Evaluation – Strategy # 3 Governor’s Delivery Unit and State Stat  # comprehensive women’s health  #LHD postpartum referrals received  # level I/II site visits conducted  # Safe Sleep DVD’s distributed  % VLBW level III hosp  #postpartum home visits conducted

43 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 Women’s Health Centers Expediting Medicaid eligibility / Quick Start Prenatal Care Standardized hospital discharge protocols

44 44 Infant Mortality in Maryland & U.S.

45 45 Governor’s 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 Infant Mortality in Maryland

47 Infant Mortality in Maryland

48 48 What’s 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 49 What’s Next?  Development of an integrated statewide Fetal Infant Mortality Review (FIMR) and State Child Fatality Review (SCFR) database DHMH, MD Medical Chirurgical Society, LHD’s, FIMR, SCFR Define at-risk groups/factors ID’ed by Infant Mortality Epidemiology Work Grp Targeted interventions

50 50 Questions?


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