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

Infant and Child Deaths Infant deaths account for the majority of all deaths among children under 18 years of age in Maryland.

Infant Mortality in Maryland & U.S. As the plan was developed and implemented, the 2009 infant mortality data became available. The 2009 data showed a 10% drop in the infant mortality rate compared with 2007 and 2008, bringing the rate down to 7.2, which is the lowest rate ever in Maryland, although still above the national average. Putting this in real numbers, in 2009, even with that drop in infant deaths, there were still 541 infants who died in Maryland before their first birthday. That’s 45 babies dying every month, about 10 infants every week. Infant mortality is a key indicator of the health of a population because it is impacted by so many factors: the underlying health of women, the incidence of chronic diseases, access to health care, the quality of health care, behaviors like smoking and substance abuse. And infant mortality is a critical public health issue for Maryland. Although by many measures Maryland is one of the wealthiest states in the nation, the infant mortality rate in Maryland has been above the national average for over 2 ½ decades. The infant mortality rate is defined as the number of deaths, per 1,000 live births, occurring to infants under one year of age. Infant mortality fell dramatically in the 1980s and 1990s. From 1984 to 2000, there was almost a 37% reduction in the infant mortality rate in the state, and a 36% drop nationally. Much of that progress was due to improvements in perinatal and neonatal care – better ventilator management, better nutrition, surfactant. But in the past decade that progress has stalled. Although there is some fluctuation year to year, there has been virtually no change in infant mortality in Maryland over the past decade.

Leading Causes of Infant Mortality Maryland National Rankings Infant Mortality - 07 42nd Preterm Birth - 07 37th Low Birth Weight - 08 41st VLBW – 08 47th Maryland has also consistently ranked worse than the national average in these leading causes of infant mortality. In the most recent national rankings: 42nd in IM (2007) [39th in 2006] 37th in preterm births(2008) [34th in 2007] 41st in LBW (2008) [43rd in 2007] 47th in VLBW (2008) [35th in SIDS deaths 2006] Clearly, very preterm births and VLBW births are a major driving force in infant mortality in MD, not to mention expensive hospital care and long term follow-up needs.

Leading Causes of Infant Mortality Low birth weight and preterm birth are the leading cause of infant deaths in MD, followed by congenital abnormalities and SIDS. In 2009, there were almost 7,000 LBW infants born in MD, almost 1,400 of them VLBW, and almost 8,000 preemies.

Timing of Infant Deaths Almost ¾ of these infant deaths occur in the neonatal period, the first 27 days of life. Only about ¼ of infant deaths occur from 28 days through the end of the first year. Data Source: MD Vital Statistics Administration

Percent of MD Births by Birth Weight 2009 Births And yet VLBW babies are only 1.6% of all births – 1.6% of births that account for more than half of all infant deaths. Note: Includes only births to MD mothers in MD hospitals Data Source: MD Health Services Cost Review Commission

Birth Weight and Neonatal Deaths Of those neonatal deaths, 82% are VLBW babies (with birth weight less than 1500 grams). If you do the math, 82% of neonatal deaths which are 71% of all infant deaths means that VLBW infants account for 58% all infant deaths. (VLBW babies account for 39% of all child deaths.) So VLBW babies are an extremely important contributor to infant mortality. Data Source: MD Vital Statistics Administration

Racial Disparity in Infant Mortality Another important factor in infant mortality is racial disparity. Black infants have a higher infant mortality rate than white infants, both in Maryland and the U.S. Over the past decade, although there have been yearly variations in MD, there has been no consistent trend in the racial differences in infant mortality. A Black infant in MD has been about 2 ½ to 3 times more likely to die in the first year than a white infant. And although the overall infant mortality rate in Maryland improved in 2009, the racial disparity did not. The improvement was primarily in the white infant mortality rate. The rate among Black infants actually increased slightly, making the disparity greater. So in 2009, a Black infant was 3.3 times as likely to die in the first year as a white infant. [[ Race-specific IMRs lower in Maryland than national averages (by ~1%). Both white and Black IMRs in MD generally below the U.S. rates; high overall IMR in MD is result of demographics in state. ]]

Racial Disparity in Preterm Births As with infant mortality, there is a racial disparity for all the leading cause of infant death. In MD, a Black infant is 1 ½ times as likely to be born prematurely as a white infant. The percentage of preterm births in Maryland is also above the national average, and like the national trend, after a long and unrelenting increase in preterm births, we have finally seen a decrease for the last 3 years in MD. We’ve seen a 6% drop in preterm births since 2006 (~5% nationally). Preterm births have actually decreased in all racial and ethnic groups in MD, but most of the improvement has been in white preterm births, some in Hispanic births, and a small decrease in Black preterm births. [[ In past decade - %LBW and %preterm increasing nationally and in MD. Rate of rise slower in MD. Race specific % of both lower in MD for Blacks, same for whites as US ] ]

Racial Disparity in Low Birth Weight In terms of low birth weight births, there is less improvement and persistent disparity. A Black infant is almost twice as likely to be born at low birth weight as a white infant. Although in 2009 there was a slight overall decrease in the percent of low birth weight births, and a small improvement in every racial and ethnic group, it’s too early to call this a trend.

Racial Disparity in VLBW Births In terms of VLBW births, there is essentially no improvement and persistent disparity.

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. So in terms of racial disparity in birth outcomes in Maryland - a Black infant is 1 ½ times as likely to be born prematurely, almost twice as likely to be low birth weight, 3 times as likely to be VLBW, and 2 ½ to 3 times as likely to die in the first year as a white infant. It’s these disparities that are driving our poor outcomes. If Black infants had the same outcome as white infants in MD, we would have an IMR below the national average. So addressing the racial disparity is essential in addressing infant mortality. [Other 2 leading causes of infant deaths – Black infant is 1 ½ times as likely to die of congenital anomalies as white infant and almost 2 ½ times as likely to die of SIDS]

Geographic Disparity in Maryland Average Infant Mortality Rate, By Jurisdiction, 2005-09 Baltimore City Kent Howard Montgomery Anne Arundel Queen Anne’s Caroline Prince George’s Talbot Calvert Charles Dorchester Wicomico There is a geographic disparity as well. Infant mortality in MD is not uniform across the state; there is considerable variability by jurisdiction. The geographic disparity is as much as 6:1 comparing the jurisdictions with the highest IMR to those with the lowest. Looking at average IM rates over the last 5 years, the jurisdictions with the highest infant mortality rates (in order) are and Dorchester County, Baltimore City, Prince George’s and Somerset Counties. All are considerably higher than the state average. Baltimore City and PG County are of particular concern because they contribute the largest proportion of infant deaths, with 20% in PG County and 24% in Baltimore City in 2009. Together these two jurisdictions account for 44% of all infant deaths in the state. St. Mary's Worcester Somerset

Behavioral Risks: Unintended Pregnancy Associated with Increased Neonatal Mortality * Infant mortality is a complex issue, that involves many risk factors. There’s no single cause and no simple solution. There are behavioral risks, which includes things like drug, alcohol and cigarette use. But it also includes things we don’t think of as often like unintended pregnancies. Unintendedness of pregnancy has been shown to increase neonatal mortality more than two-fold. Maryland PRAMS (Pregnancy Risk Assessment Monitoring System) has shown that mothers with unintended or unplanned pregnancies are less likely to receive early prenatal care, or to stop smoking during their pregnancy, or to breastfeed. They are more likely to be victims of domestic violence, and to deliver low birth weight babies than mothers with planned pregnancies. In 2009, 45 percent of all births in Maryland were the result of an unintended pregnancy. (slowly increasing – 38% in 2005) The percentage of unintended pregnancies is highest among adolescents (79%). And teens have the highest IMR of any age group of mothers. There is a U-shaped curve for IM by maternal age, with the highest rate among teens, then dropping for women in their 20’s and 30’s, then increasing again after age 40. The same is true for preterm birth and low birth weight. * Bustan et al, AJPH, March 1994

Behavioral Risks: Teen Births Associated with Increased Infant Mortality In MD, teen birth rate (15 - 19 y.o.) declined 1998 to 2005. In 2006 and 2007, there was also an increase in the teen birth rate in all racial and ethnic groups, and an increase in the overall state rate (trend seen nationwide). The Hispanic teen birth rate increased by 50% 2000 to 2007. We’ve now had 2 years of decline in all racial and ethnic groups, and a 5% drop in overall teen birth rates each of these two years; largest decrease among Hispanic teens, down 12% in 2008 and 21% in 2009. MD actually does well in terms of teen births - ranked 14th in teen births in 2007.

Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality There are also health and health care risks contributing to infant mortality. This includes chronic health problems like DM, HTN, obesity. Also pregnancy related problems like GDM and PIH. But also access to health care coverage and access to care impact birth outcomes. Early prenatal care is an important factor in addressing infant mortality. In the 1980s and 90s, Maryland was well above the national average in the per cent of women receiving first trimester prenatal care. Since 1998, however, that percentage has dropped steadily, dropping below the national average since 2003 and falling below 80% in 2007. In 2008 there was the first sign of a reversal of that trend. But the % early PNC was steady in 2009. Early prenatal care varies by race and ethnicity in MD, from 88% of non-Hispanic white women who received early prenatal care, to 74% of African American women, and only 68% of Hispanic women in the state. The recent decline in early prenatal care has affected all racial and ethnic groups, but the decline has been greatest among Hispanic women (20% vs 5% for white and AA).

Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality As the % of women receiving early prenatal care has dropped, the % of women receiving late or no PNC has increased. MD is now above the national average. [Every year over 3,500 MD women have inadequate PNC. About 100 women deliver every month without any PNC.] [The increase in the percent of women receiving late or no prenatal care from 2000-2007 is greatest among Hispanic women (↑ 105%) and least among Black women (↑ 14%). Among white women there was a 56% increase.]

Health and Health Care Risks: Lack of Early Prenatal Care – Associated with Increased Infant Mortality The importance of this is that infant mortality is about 2 times higher among women of all racial and ethnic groups who receive late or no prenatal care compared to those who started prenatal care earlier, shown here in Maryland 5-year average data.

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors There are socio-demographic risks for poor birth outcomes as well. Race and maternal age are two, that we’ve talked about. The racial disparities are often attributed to differences in socio-economic status. Certainly socio-economic status impacts many things, including underlying health, behaviors, and access to healthcare. But racial disparities go beyond socio-economic factors. This slide looks at preterm birth rates in the U.S. by maternal education and race & ethnicity. Education level is a good proxy for socio-economic status. You can see that in every racial and ethnic group, preterm birth rates go down as maternal education level (and SES) increases. From NCHS 1998-2000 data, Preterm Birth, IOM, 2007

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors But if you look at the circled numbers, it also shows that in the U.S., college-educated Black women have worse pregnancy outcomes than white, Hispanic, or Asian women with less than an 8th grade education. From NCHS 1998-2000 data, Preterm Birth, IOM, 2007

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009 This is now MD data, looking directly at infant mortality rates. For both Black and white mothers in MD (maybe less so for Hispanic women), infant mortality rates drop as maternal education level (or SES) increases. Data Sources: MD DHMH, Vital Statistics Administration

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors Infant Mortality Rate by Maternal Education and Race / Ethnicity, Maryland 2005-2009 And again, a Black woman in MD with a college education or more still has a higher IMR than a white or Hispanic woman with less than a high school education. Data Sources: MD DHMH, Vital Statistics Administration

Socio-demographic Risks: Racial Disparities Go Beyond Socio-Economic Factors In fact, if we look specifically at the Black:white disparity, the disparity actually gets worse at higher education (or SES) levels. The ratio increases from 1.8 to almost 3 for college-educated Black women. Clearly for birth outcomes, racial disparities involve more than socioeconomic differences. There is growing evidence that chronic stressors play a role – housing, economic stress, chronic health problems, violence, racism. And that these stressors have even cross-generational effects. So stressors affecting a woman’s mother or grandmother can impact her and her chance of having a poor birth outcome.

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

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 In early 2009, Governor O’Malley made reducing infant mortality in Maryland one of his strategic goals. Specifically, the goal was to reduce infant mortality in the state by 10% by 2012. We started at that time with 2007 data as a baseline, so the goal was a reduction of about 60 infant deaths per year, and a reduction in the IMR to 7.2 per 1,000 live births. Progress towards meeting this goal is being tracked by the Governor’s Delivery Unit. Activities have been underway Statewide, with a special emphasis on target high risk jurisdictions Development of a statewide plan began with assessing the data, targeting high-risk areas and disparities, building on existing strengths and partnerships, and taking a comprehensive systems approach.

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 In 2007, the Department of Health and Mental Hygiene (DHMH) launched the Babies Born Healthy Initiative, a broad public health initiative which focused on prevention services and quality improvement that included: A Perinatal Collaborative was established, in collaboration with the Maryland Patient Safety Center, bringing Maryland birthing hospitals together to share best practices and quality improvement strategies. Subsequently a Neonatal Collaborative was formed, and this year, the two have merged. Currently 31 of Maryland’s 34 birthing hospitals are members, covering more than 90% of births in the state. High-risk pregnancy consultation was made available to local OB providers around the state under a partnership between the University of Maryland and Johns Hopkins University Schools of Medicine. The voluntary standards for perinatal care in Maryland hospitals were updated in collaboration with MIEMSS. Vital Statistics developed a new state-of-the-art web-based electronic birth certificate, improving the quality and timeliness of data reporting. The Office for Minority Health and Health Disparities launched new programs in several counties to organize community coalitions and deploy perinatal navigators to assist pregnant women.

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 The plans to address infant mortality in MD was built on evidence-based practice, on what we know works. These include: Reducing unintended pregnancy (including teen births) Promoting the health of women before and between pregnancies Improving access to care during and after pregnancy Providing the safest and highest quality care for mothers and infants

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 2011 - Infant Mortality Breakout “The Role of Community Pediatricians in Preventing Infant Mortality” – Meeting Web-based survey 339 Marylanders

Chronic conditions before/during pregnancy 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

Timing and effectiveness of risk-targeted prenatal care Maternal age 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)

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

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

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 risk @ PNC UMD and JHU Med & SPH expertise and support

Intervention Across the Lifespan PERINATAL NEONATAL (After delivery) PRENATAL (During pregnancy) PRECONCEPTION (Before pregnancy) Healthier Children and Adults Healthier women at time of conception, planned pregnancies Earlier entry into prenatal care Comprehensive, high quality perinatal and neonatal care Our plan to address infant mortality begun in 2009 initially targeted interventions in three jurisdictions with high infant mortality rates and racial disparities, specifically Baltimore City, Prince George’s County and Somerset County. This July 2011, Dorchester Co. was added to those three, and eventually efforts will be expanded statewide. There are 3 specific focus areas for interventions that span a woman’s reproductive life: The first addresses the preconception period, before pregnancy, with a goal of healthier women at the time of conception and more planned pregnancies. The second addresses the prenatal period, during pregnancy, with a goal of earlier entry into prenatal care and providing risk-appropriate care. And the third, addressing the periods around birth and after birth, with a goal of more comprehensive and high quality care for women and infants, and specifically with risk-appropriate referral to follow-up services for both mother and baby. You see the arrow at the bottom, leading back to the first point. Even if there was a poor outcome in the current pregnancy (LBW, preterm), providing that mother and infant needed services may help prevent an infant death or improve the health of that woman for a subsequent pregnancy. So it does go full circle.

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

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 In the first strategy, the goal is to expand access to women’s comprehensive health and wellness services. Family planning often serves as the entry point for women into the health care system. Family planning sites in the target jurisdictions have been transitioned into Comprehensive Women’s Health Programs that provide expanded medical screening and service referrals. In the 2011 legislative session, the Family Planning Works Act was passed which will increase eligibility for FP services to women with income up to 200% FPL. It’s estimated that this will allow an additional 30,000 women in MD to access these services. Maryland also will be receiving funds from the Affordable Care Act to expand teen pregnancy prevention programs. Community-based interventions are an important part of all the strategies. Perinatal navigators and other outreach workers are being utilized in the high-risk jurisdictions to reach target populations and assist women in accessing services.

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

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 The 2nd strategy aims to increase the # of pregnant women accessing early prenatal care and receiving risk-appropriate care. Local health department sites in the target jurisdictions are implementing a Quick Start prenatal care program, an effort to identify pregnant women and provide screening, referrals and assistance in getting into prenatal care. There have been some very innovative programs developed. For example, in PG County, an important issue was a lack of prenatal care providers. Through an partnership between the local Health Department, Prince George’s Hospital Center, and the University of Maryland School of Medicine, a program was developed to provide comprehensive prenatal care services at the health department, starting in March 2010 (including high risk consultations as needed). Beginning Dec. 1, 2009, Medicaid applications for pregnant women in MD were expedited through a process called “accelerated certification of eligibility”. If a pregnant woman’s application can not be completed within 10 days, she is presumptively enrolled in Medicaid (with SSN and oral declaration of income) and provided up to 90 days of coverage while the full application is being processed. Services provided during that period will be reimbursed. This is in effect now in all jurisdictions through both LHD and DSS sites.

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

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 We are also looking at a couple other quality improvement projects that fit with this strategy. One is developing a more standardized approach to hospital discharge for mothers and infants, which the Joint Perinatal-Neonatal Collaborative has decided to work on this as their next quality improvement effort. This will include screening both mother and infant for risk factors, improving communication and discharge education, and increasing referrals for community based services. Another part of this strategy to improve quality of perinatal care is site visits to all level I and II hospitals in the state to review their compliance with the MD Perinatal System Standards. Level III hospitals are overseen by MIEMSS and the next round of site visits to monitor level III compliance has begun. Within DHMH, the Morbidity Mortality and Quality Review Committee is charged in regulation with monitoring level I and II hospital compliance. As part of this, we are reviewing every delivery of a VLBW infant occurring at level I and II facilities, looking for any barriers to transport of these mothers to level III centers prior to delivery. We know that VLBW mortality is doubled for infants delivered at lower levels of care.

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 deliveries @ level III hosp #postpartum home visits conducted

Summary of the Plan APPROACH GOALS STRATEGIES 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

Infant Mortality in Maryland & U.S. Since the newest data in 2009 showed that we had achieved the initial goal of a 10% drop in the infant mortality rate compared with 2007 and 2008, the goal had to be reset.

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 So with that improvement, the goal was reset in the fall of 2010. The goal was now to reduce both the overall rate by 10% and to reduce the Black infant mortality rate by 10% as well by 2012. The goal is maintain or hopefully further improve our the overall rate and also to reduce the Black rate to 12.6 by 2012. (If the Black IMR is reduced this much with no change in the white rate, the overall state IMR would in fact drop to 6.9.)

2010 Infant Mortality in Maryland The 2010 infant mortality data was recently released. In 2010, the overall infant mortality rate in Maryland fell another 7%, to 6.7 infant deaths per 1,000 live births.

2010 Infant Mortality in Maryland But unlike the drop in 2009 which was due to a drop in the white IMR, this decrease in 2010 was due to a 13% drop in the Black IMR. Our goal will have to be reset again, aiming for continued improvement overall and especially sustained improvement in the Black IMR.

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

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

Questions?