Infant Mortality in Mecosta County Presented by: Kevin Doan, Katrina Lampman, Shelly Parker, Tina Palmer, and Carol Zinn

What factors contribute to infant mortality in Mecosta County?

Community Assessment 2011 2011: Infant mortality rate-Mecosta=8.2, MI=7.6; low birth weight-Mecosta=6.9%, MI=8.5%. Smoking during pregnancy-Mecosta=32.4%, MI=18.2%, Three year average from 2007-2009 Healthy People 2020 goal is to reach 6.0% infant mortality deaths by 2020 Healthy People 2020 goal is to reach 7.8% of low birth weight infants by 2020 Health People 2020 goal is to reach 98.6% of females delivering a live birth without smoking during pregnancy (1.4% of smoking during pregnancy)

Community Assessment 2012 2012: Infant mortality rate-Mecosta=9.1, MI=7.3; low birth rate-Mecosta=6.2%, MI=8.4%. Smoking during pregnancy-Mecosta=31.4%, MI=19.3%. Three year average from 2008-2010 Healthy People 2020 goal is to reach 6.0% infant mortality deaths by 2020 Healthy People 2020 goal is to reach 7.8% of low birth weight infants by 2020 Healthy People 2020 goal is to reach 98.6% of females delivering a live birth without smoking during pregnancy (1.4% of smoking during pregnancy)

Community Assessment 2011 2012 2011: Infant mortality rate-Mecosta=8.2, MI=7.6; low birth weight-Mecosta=6.9%, MI=8.5%. Smoking during pregnancy-Mecosta=32.4%, MI=18.2%. Three year average from 2007-2009 2012: Infant mortality rate-Mecosta=9.1, MI=7.3; low birth rate-Mecosta=6.2%, MI=8.4%. Smoking during pregnancy-Mecosta=31.4%, MI=19.3%. Three year average from 2008-2010 Infant mortality rate has increased 2012 compared to 2011 in Mecosta County, the low birth rate has declined. Healthy People 2020 goal is to reach 6.0% infant mortality deaths by 2020 Healthy People 2020 goal is to reach 7.8% of low birth weight infants by 2020 Healthy People 2020 goal is to reach 98.6% of females delivering a live birth without smoking during pregnancy (1.4% of smoking during pregnancy)

Indicator Definitions Infant mortality rate-numbers of deaths per 1,000 live births (less than 1 year of age) using a three year average Low birth weight-low weight births per 1,000 live births that are less than 2,500 grams (5 pounds, 8 ounces) using a three year average Smoking during pregnancy-smoking while pregnant are those who had a history of smoking and never quit and those who quit between conception and birth using a three year average -Infant mortality rate-numbers of deaths per 1,000 live births (less than 1 year of age) using a three year average -Low birth weight-low weight births per 1,000 live births that are less than 2,500 grams (5 pounds, 8 ounces) using a three year average -Smoking during pregnancy-smoking while pregnant are those who had a history of smoking and never quit and those who quit between conception and birth using a three year average

Analysis of Assessment Findings What is causing infant mortality rate to increase in Mecosta County? Low birth weight did not appear to be a factor Mecosta County percentage of smoking during pregnancy is higher than Michigan and DHD#10 for both 2011 and 2012 Infant mortality in Mecosta County increased in 2012 compared to 2011, but smoking has declined What is causing infant mortality rate to increase in Mecosta County? Low birth weight did not appear to be a factor Mecosta County percentage of smoking during pregnancy is higher than Michigan and DHD#10 (District Health Department # 10) for both 2011 and 2012 Infant mortality in Mecosta County increased in 2012 compared to 2011, but smoking has declined

Community Health Nursing Diagnosis Risk of infant mortality Among infants under the age of one born in Mecosta county. Related to smoking during pregnancy As demonstrated by a higher infant mortality rate in Mecosta county at 9.1 as compared to Michigan rate of 7.3. Mecosta county. In addition, the higher rate of pregnant women who smoked during pregnancy at 31.4% compared to the Michigan rate of 19.3%. According to the Michigan Department of Community Health 2012 report, the infant mortality rate for Mecosta county is 9.1 and Michigan is 7.3. Women who smoked during pregnancy for Mecosta county is 31.4% as compared to Michigan at 19.3%. Other associated areas of interest in the Michigan Department of Community Health when comparing Mecosta county to Michigan include a lower percentage of residents who are college graduates, an increased percentage of people below the poverty level as well as an increase in the number of medicaid paid births. It is also interesting to note that there is an increased percentage of people who had no access to care in the past year due to cost as well as an increase in people with no health insurance.

Smart Goal Reduce the percentage of pregnant women who smoke during pregnancy by 12% over for the next 3 years as evidenced by improved rates in Mecosta county as compared to the Michigan rate published in the District 10 community assessment reports. The 2012 rates in the District 10 report for pregnant women who smoke are 12% higher than those in Michigan. The goal is to reduce the amount of pregnant women in the community who smoke by implementing programs to provide education and collaborate with community resources and get these resources out into the community to make an impact in reaching this goal. Some of the strengths of the population in Mecosta county include a lower rate of teenage pregnancies and improved low birth rates. There are also numerous programs in the county to assist pregnant women and including immunizations, maternal-infant health services and WIC programs which are resources that can be utilized to reach out to the population of pregnant women who smoke. In addition, the community also has the Spectrum Health Big Rapids Hospital and a nursing program at Ferris State University.

Interventions (evidence based) Based on evidence, the following interventions improve maternal and infant health. Increase health awareness in importance of nutrition, prenatal care, well-child visits, immunizations, infant and maternal screenings, smoking cessation, available resources, and information on infants sleeping safe. Evaluate the community for resources Health department, schools, health center, library, churches, local pharmacy, local college. Collaborate with Ferris State University to recruit students for internships at the health department to help with home visits and screenings Collaborate with the health department and local congressman to obtain grants and subsidies for public transportation as Mecosta County is a high needs area. Assess local resources to provide transportation to prenatal and well-child visits. Collaborate with churches and workplaces to provide screenings and education. Develop and implement community wellness teams, including members from schools, hospitals, health department, local health providers, and community members. Identify those at risk in the hospital and providers offices for follow up care and education. Based on evidence, the following interventions improve maternal and infant health. Increase health awareness in importance of nutrition, prenatal care, well-child visits, immunizations, infant and maternal screenings, smoking cessation, available resources, and information on infants sleeping safe. Evaluate the community for resources Health department, schools, health center, library, churches, local pharmacy, local college. Collaborate with Ferris State University to recruit students for internships at the health department to help with home visits and screenings Collaborate with the health department and local congressman to obtain grants and subsidies for public transportation as Mecosta County is a high needs area. Assess local resources to provide transportation to prenatal and well-child visits. Collaborate with churches and workplaces to provide screenings and education. Develop and implement community wellness teams, including members from schools, hospitals, health department, local health providers, and community members. Identify those at risk in the hospital and providers offices for follow up care and education.

Interventions Cont. Improve education in schools on the importance of health screenings, regular check ups, nutrition, and importance of prenatal care, alcohol, and smoking cessation pre conception and during pregnancy. Increase local awareness by attending community meetings, collaborate with churches, schools, libraries and local representatives. Go to health fairs, health screenings, clinics, and local events. Hand out brochures on community resources and education on importance of prenatal care and smoking cessation. Collaborate with health clinics and Mecosta County hospital for free prenatal classes and education on smoking cessation. Collaborate with Mecosta County Medical Center on making Spectrum Health community wellness booklets available in physicians’ offices, clinics, pharmacies, grocery stores, and health centers. The Governor is working on legislation that would expand Medicaid coverage to low income parents I compared Montcalm County to Mecosta County as the risks and problems are similar. Their infant mortality rate went down and the women receiving prenatal care got better. Mecosta County got worse. Both counties have implemented the Maternal Infant Health program that provides education, home visits, nutritional care and education. The program is made up of a team of nurses, social workers, dieticians, and lactation consultants. The service is free based on need. Improve education in schools on the importance of health screenings, regular check ups, nutrition, and importance of prenatal care, alcohol, and smoking cessation pre conception and during pregnancy. Increase local awareness by attending community meetings, collaborate with churches, schools, libraries and local representatives. Go to health fairs, health screenings, clinics, and local events. Hand out brochures on community resources and education on importance of prenatal care and smoking cessation. Collaborate with health clinics and Mecosta County hospital for free prenatal classes and education on smoking cessation. Collaborate with Mecosta County Medical Center on making Spectrum Health community wellness booklets available in physicians’ offices, clinics, pharmacies, grocery stores, and health centers. The Governor is working on legislation that would expand Medicaid coverage to low income parents I compared Montcalm County to Mecosta County as the risks and problems are similar. Their infant mortality rate went down and the women receiving prenatal care got better. Mecosta County got worse. Both counties have implemented the Maternal Infant Health program that provides education, home visits, nutritional care and education. The program is made up of a team of nurses, social workers, dieticians, and lactation consultants. The service is free based on need.

Theoretical support Self-care Deficit In order to increase the health of the children we need to increase the health of their mothers. The high rates of smoking while pregnant indicates a Self-care Deficit. Theory was developed by Dorothea Orem in 1971, in which she states “Self-care and self-care of dependents are learned behaviors that individuals initiate and perform on their own behalf to maintain life, and well-being.” states “Self-care and self-care of dependents are learned behaviors that individuals initiate and perform on their own behalf to maintain life, and well-being.” (Theoretical Foundations of Professional Nursing, 2011) Theoretical Foundations of Professional Nursing. (2011). In K. K. Blais, & J. S. Hayes (Eds.), Professional Nursing Practice Concepts and Perspectives (6 ed., p. 102). Upper Saddle River, New Jersey: Pearson.  

Theoretical support Health Promotion Interventions are directed towards individuals who are for the most part healthy. Therefore they may have never had to actively make decisions to promote their health and well-being. Would most likely define their health status by their absence of disease. Nola Pender’s Health Promotion Model defines health as “as a positive dynamic state rather than simply the absence of disease.” Nola Pender’s Health Promotion Model defines health as “as a positive dynamic state rather than simply the absence of disease.” Pender, N., & Pender, A. R. (2001). Health promotion in nursing practice (4th ed.). Englewood Cliffs, NJ: Prentice Hall.

Theoretical support Health Promotion Cont. Assumptions used from the Health Promotion Model Health professionals constitute a part of the interpersonal environment that exerts influence on persons throughout their life span. Self-initiated reconfiguration of person-environment interactive patters is essential to behavior change. This is only two of the assumptions made by Pender. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006) Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Pearson Education.

Theoretical Support Goal-Attainment The goal of improving the health of Mecosta county by decreasing the infant mortality rate. Imogene King’s theory “highlights the importance of the participation of all individuals in decision making and deals with the choices, alternatives, and outcomes of nursing care.” The goal of lowering the infant mortality rate is great by it needs to be a mutual goal set by nursing and the expecting mothers. Theoretical Foundations of Professional Nursing. (2011). In K. K. Blais, & J. S. Hayes (Eds.), Professional Nursing Practice Concepts and Perspectives (6 ed., p. 102). Upper Saddle River, New Jersey: Pearson.  

Policies & Programs “Right Start” program in Michigan Ranking of maternal/infant well-being Expand health care coverage to low income parents Expand Medicaid eligibility Maternal Health and Wellness Plan Provides prenatal care and care after delivery up to a year for Medicaid eligible mothers The Patient Protection and Affordable Care Act Provides screenings and well-baby visits, and immunizations free of deductibles and co-pays Safe motherhood Initiative Conducted by The World Health Organization The Maternal and Infant Health Program Conducted through the CDC PRAMS The Maternal, Infant and Early Childhood Home Visiting Program Through The U.S. Department of Health and Human Services Mecosta County Medical Center Assesses community needs and implements interventions based on need. This is updated every three years. According to Healthy People.gov (2013), in spite of advances in medicine and technology, infant mortality continues to be a problem in the United States. Identification of health risks before and between pregnancies as well as prenatal care is instrumental in the prevention of possible problems. Mecosta County is reflective of this with a mortality rate that is higher than the Michigan average. According to the District Health Department # 10 pregnant women receiving prenatal care is lower than the Michigan State average and women who smoke during pregnancy is higher than the state average may be contributing to the high mortality rate. There are many programs available nationally, state wide, and through the community to help reduce the risk of health problems for the mother and infant which could ultimately reduce the infant mortality rate. Michigan is ranked 37 out of all the states for infant mortality. More than half of the births in Mecosta County are funded through Medicaid. The District Health department has been given a grant for a Maternal Health and Wellness Plan for all women on Medicaid. This program provides prenatal care from start of pregnancy and follow up care after delivery until the child reaches his or her first year. This program also provides education on risks of smoking, immunizations, family planning, and access to many other resources including helpful links, and WIC, which is a nutrition program for pregnant mothers and children who are eligible. With the passing of The Patient Protection and Affordable Care Act, Screening for gestational diabetes, breastfeeding support, and well-baby visits are covered free of charge for deductibles and co-pays as well as immunizations.. Health insurances cannot deny coverage due to pregnancy. The World Health Organization provides many programs including The Safe Motherhood Initiative which focuses on preventing complications of pregnancy and reducing infant deaths. This program partners with both government and nongovernmental programs to help insure that health needs and counseling during pregnancy are met. This program also states that skilled care should be available during childbirth and the postpartum period, family planning and community education should be readily available. The Center for Disease Control, (CDC), has many programs including a Maternal and Infant Health program which begins with prenatal care through the post-partum period, these programs offer help for tobacco cessation, education about complications of pregnancy, and post-partum period, newborn screening, detection and intervention of birth defects, and pregnancy risk assessment. The CDC has a network of perinatal care specialists and public health care workers that collaborate with physicians, hospitals, agencies, and other health care providers to improve the outcomes of pregnancies and births. This program uses evidence based practice strategies to improve and implement public health policies and practice. There is also a program called PRAMS, pregnancy risk assessment monitoring, (CDC) that works with state health departments to collect data on experiences and attitudes of mothers to help reduce adverse outcomes. (CDC, 2012). The U.S. Department of Health and Human Services has a maternal, Infant and Early Childhood Home visiting Program which works with federal, state and at community levels to identify those at risk and to improve health and outcomes of mothers and children from gestation through early childhood. This program is funded through grants and is part of the Patient Protection and Affordable Care Act (Pub.L.No.111-148).They also offer assistance to parents for health coverage, childcare, food assistance, and information on immunizations and health care providers. They also have a “sleep safe program’ which provides education and resources to help educate parents on sleep safety for infants. The Michigan Department of Community Health offers many programs to improve maternal and infant health .They have women, infants and children’s programs which provide information about breastfeeding, nutrition, and offers many resources. This is a state based epidemiology unit that helps develop and implement public health programs and policies through evidence-based research and assessment of needs to improve maternal and infant health through screenings, a pregnancy risk assessment monitoring program, and nutritional support. The Michigan League for public policy has the Right Start Program which addresses maternal health, access to and quality of health care. Also includes the Medicaid expansion program which was initiated by the governer.

Plan Michigan ranks thirty seven out of the fifty states for infant mortality We plan to decrease that rate based on the following factors: Women in Mecosta County are not getting enough prenatal care especially in the first trimester of pregnancy. Women in Mecosta County continue to smoke while pregnant These factors can result in low-birth rate, birth defects, preterm births, and complications during pregnancy Issues that may hinder access to health care are: Under insurance or no insurance, lack of transportation, single parenting, education level, socio-economic status, and high costs of co-pays and deductibles Other factors that cause infant mortality: Underlying health issues of the mother, poor maternal nutrition, lack of adequate folic acid, sudden infant death syndrome, and accidents or injuries. Plan Assess community needs based on strengths and weaknesses. Increase public awareness Improve awareness of resources Identify those most at risk Educate community Implement wellness teams Assess resources of the community Plan • Improve awareness of resources. Make brochures on programs that are available for women and infants. •Have the Spectrum Health Community Wellness booklets in physicians’ offices, clinics, pharmacies, grocery stores, and health centers where they can obtain WIC and bridge cards. • Identify needs in the hospital and provide follow up care. Home visits to high risk women and infants after go home. •Improve insurance coverage so that women with insurance can afford prenatal care without the high costs of co-pays and deductibles. Obtain grants for high need areas like Mecosta County so that women without insurance can obtain prenatal care and follow up care after birth. •Identify those at risk prior to delivery. •Educate on importance of nutrition during pregnancy and after delivery for infant and mother, immunizations, importance of smoking, alcohol cessation and prenatal care. •Provide classes at clinics.

Evaluation Short Term Long Term Students to do quarterly surveys with pregnant women who smoke during prenatal visits Survey mothers following birth at their well baby follow up Anticipate seeing an improvement within 2 years when comparing stats from the District Health Department Hope to see percentages drop when compared to Healthy People 2020 Maternal health and wellness program through the public health department; students to do quarterly survey’s and follow up education regarding smoking. We will survey smoking mothers at the pediatrician’s office at their follow up appointment. The survey will ask if the smoking cessation program was effective for them and if they were able to maintain their non smoking after the baby was born. Continue to watch the District Health Department’s Health Profile chart book for follow up data regarding smoking during pregnancy and infant mortality rates.

Questions?

References Centers for Disease Control and Prevention. Reproductive Health. Maternal and infant health. Retrieved from: http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/i ndex.htm Department of Health and Human Services. National partnership for action to end health disparities toolkit for community action. Retrieved from: http://minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Tool kit.pdf District Health Department #10 (2013). Mecosta county chartbook. Retrieved from http://dhd10.org/index.php/dhd10-community- statistics HealthyPeople.gov. (2013). Maternal, infant, and child health. Retrieved from: http://www.healthypeople.gov/2020/LHI/micHealth.aspx  

References Michigan Department of Community Health. Mecosta-Osceola ranking of maternal/infant well-being: ”Right Start” in michigan’s great start collaboratives. Retrieved from: http://www.mlpp.org/wp- content/uploads/2013/04/MecostaOsceola-RS-GSC.pdf Michigan League for Public Policy, (2013). Infant mortality in michigan 2013. Retrieved from: http://www.mlpp.org/kids- count/michigan-2/10191-2 Michigan League for Public Policy, (2012). Kids count in michigan data book 2012. Retrieved from: http://www.mlpp.org/wp- content/uploads/2012/11/KCDB12Mecosta.p MDCH Department of Community Health. Women, infants & children. Retrieved from: http://michigan.gov/mdch/0,4612,7-132-2942---,00.html

References Muecke, M. A. (1984). Community health diagnosis in nursing. Public Health Nursing, 1(1), 23-35. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006) Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Pearson Education. Pender, N., & Pender, A. R. (2001). Health promotion in nursing practice (4th ed.). Englewood Cliffs, NJ: Prentice Hall. Theoretical Foundations of Professional Nursing. (2011). In K. K. Blais, & J. S. Hayes (Eds.), Professional nursing practice concepts and perspectives (6 ed., p. 102). Upper Saddle River, New Jersey: Pearson  

References U. S. Department of Health and Human Services. (2010, July). Community health status report mecosta county michigan. Retrieved from http://www.keepingkidsalive.org/Counties/county_da ta/Mecosta.pdf U. S. Department of Health and Human Services. Health resources and services administration maternal and child health. Maternal, infant and early childhood home visiting program. Retrieved from: http://mchb.hrsa.gov/programs/homevisiting/