1. Preventing Infant Mortality: What We Know, What We Don’t, and What You Can Do Tom Ivester, MD, MPH UNC School of Medicine Division of Maternal Fetal Medicine UNC Center for Maternal and Infant Health June 12, 2007

2. 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

3. 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

4. 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

5. 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 Defects2072092195% Other birth- related conditions 55752057511% SIDS961001033% Illnesses2832852860% Unintentional injuries 27927131315% Homicide48465111% Suicide2623 0% All other504937-24% TOTAL1546150316076.9% Source: NC Division of Public Health

6. 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.

7. 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

8. Preterm Birth in NC In 2004, 1 out of every 7 babies was born preterm. The rate increased 8% in the past decade.

9. 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.

10. 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

11. What we know Infant mortality rates are stagnant Premature birth is rising Birth defect rates have stayed about the same Health disparities persist

12. 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

13. Where can we intervene? The Socio-ecological Model (Source: Gebbie, 2003 #174)

14. 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?

15. 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

16. 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

17. What to recommend Interconception Health Folic Acid Optimal control of maternal medical conditions Health education

18. 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

19. Professional Resources Resources available on www.mombaby.org:www.mombaby.org Preconception Health Resources Public Health Maternal Child Health Links OB Management Algorithms Patient / Provider Resources Infant Mortality data And More!

20. Questions?