1. North Carolina’s Recent Infant Mortality Experience and Women’s Health Joe Holliday, MD, MPH Belinda Pettiford, MPH October 28, 2009 December 10, 2008 May/June 2004 Issue

2. Source: NC Center for Health Statistics www.schs.nc.us/SCHS/data/ Recent Infant Mortality in North Carolina  1988 was a landmark year - NC was 49th in among 50 states in the infant mortality rate.  The NC infant mortality rate has declined by over one-third since 1988.  More recently, the downward trend in the NC infant mortality rates has slowed and NC ranks 45th among 50 states.

3. Recent Infant Mortality in North Carolina (cont.)  Since 1988 infant death rates have declined less among African Americans and American Indians than among whites, leading to increasing racial disparities over time.  With prenatal care participation rates improving, maternal smoking and teen birth rates declining, and other key indicators generally moving in a favorable direction, the lack of recent progress in infant mortality reduction is perplexing.

4. Infant Mortality Rate North Carolina, 1988-2008 Rate Per 1,000 Live Births Year

5. Infant Mortality Rate North Carolina, 1988-2008

6. Infant Mortality An issue of great magnitude  Accounts for 68% of all deaths to children  Has multiple causes – serves as a proxy measure for the broader issue  Also associated with childhood morbidity  Increasingly associated with origins of some chronic diseases

7. Major Determinants of Infant Mortality Major Determinants of Infant Mortality  Preterm Birth / Low Birth Weight  Birth Defects  Sudden Infant Death Syndrome  Other Conditions During Pregnancy

8. Birth Weight Trends  The percent of live births that are low birth weight has increased steadily.  The percent of increase of low birth weight by weight category ranges from 5% to 35.1% with the greatest increase in the under 500 gram birth weight category for minorities.

9. Percentage of White and Minority Low-Birthweight Live Births, North Carolina, 1987-2008 Percent Of Live Births

10. Birth-Weight-Specific Infant Mortality Rates  Most of the decrease in the IMR in recent years is due to improved survival at each level of birth weight. Survival now at a plateau?  The fetal death rate decreased 22% over this time period (8.6 to 6.7). This suggests that real improvement in both fetal and neonatal survival has taken place.

12. Racial Disparity in Infant Mortality  The racial disparity in infant mortality has increased 1.95 in 1988 to 2.45 in 2008, although the minority infant mortality rate fell to an all-time low in 2008 to 13.5 per 1,000 live births.  The neonatal survival advantage of low birth weight African American babies has decreased over time. This could be contributing to the increasing racial disparity in infant mortality.  In 2008, nearly 17% of live births in the state were among Hispanics, compared to only about 2% in the early 1990s.

13. Racial Disparity in Infant Mortality Role of Women’s Health  Racial disparities in birth outcomes correlate with disparities in measures of women’s health.  These disparities increase with maternal / female age.  Increased education reduces but doesn’t eliminate disparities.

14. Racial Disparities in Health Outcomes Increase with Age NC BRFSS SURVEY RESULTS 18-2425-3435-44 2008 - % Obese (BMI>=30) African American27.943.546.4 White 21.029.828.3 Ratio1.331.461.64 2008 - % Who Report Their Health as Fair or Poor African American4.011.215.8 White 7.16.68.3 Ratio0.561.701.90 2007 - % With High Blood Pressure African American8.915.626.9 White 4.57.416.3 Ratio1.982.111.65

15. Racial Disparity in Birth Outcomes Increase with Age Birth Outcome Measures by Maternal Race & Age, NC Residents, 2004-2008 15-1920-3435+ % Very Low Birthweight African American3.13.54.8 White 1.61.21.6 Ratio1.92.82.9 Neonatal Deaths per 1,000 Live Births African American10.610.311.8 White 5.93.74.8 Ratio1.82.82.5

16. Socio-Economic Disparities Associated with Unintended Pregnancies  29% women are more careful about using contraception every time  12% women considering switching to long-term contraceptive  18% women inconsistently used the pill as a means of saving money  25% women put off gynecology or birth control visit to save money Source: Guttmacher Institute, September 2009

17. What North Carolina Women Say About Their Health? What North Carolina Women Say About Their Health?  Quantitative Data Not Sufficient to Tell the Story  Qualitative Research Project Provides Real Insights Why do (or do not) women adopt preventive health behaviors? Why do (or do not) women use preventive health services? Source: www.nchealthystart.org Source: www.nchealthystart.org

18. What North Carolina Women Say About ….

19. North Carolina’s Recent Infant Mortality Experience  Decline in birth weight specific mortality until recently  Increase in low birth weight births  Racial disparities not improved  Importance of women’s health throughout the lifespan increasingly recognized Need a cultural shift Need a cultural shift

20. Feto-Infant Mortality: Birthweight Distribution Mortality by Birthweight Risk Factors Interventions Access Socio-Economic Smoking Race Medical Conditions Gender Gestational age Race Medical Conditions Prenatal Care Smoking Cessation Tocolytics Perinatal Care Quality Care Referrals Health Insurance Primary Care Content Availability Referral Systems Transport Systems Expertise

21. Infant Mortality - Recent Directions: Improve Access to Healthcare  Primary Healthcare for Women Extend Medicaid for women for 2 yrs postpartum. Extend Medicaid for women for 2 yrs postpartum. Extend health insurance to parents Extend health insurance to parents  High Risk Maternity Care Regionalization of perinatal care challenged Regionalization of perinatal care challenged CCNC adding high risk initiative CCNC adding high risk initiative Preterm birth prevention and PQCNC projects Preterm birth prevention and PQCNC projects NC IOM Substance Abuse Study NC IOM Substance Abuse Study  New Electronic Birth Certificate

22. Infant Mortality - Recent Directions: Reduce Unintended Pregnancies  Approximately half of live births in NC are unintended  Associated with late prenatal care, low birth weight, poor maternal nutrition and smoking, and less likely to breastfeed  Expanded Medicaid income eligibility up to 185% FPL for family planning services for men & women >18yrs age

23. Infant Mortality - Recent Directions: Reduce Unintended Pregnancies (cont.) Infant Mortality - Recent Directions: Reduce Unintended Pregnancies (cont.)  In Year 2 with very limited participation, an estimated 1,139 births were averted and $12 million saved  ACOG Supports Increased Access to Long- Acting Reversible Contraceptives (Implants & Intrauterine devices) as safe, long-acting, convenient & highly effective  More Medicaid $$ to support these methods through Family Planning Waiver Program

24. Infant Mortality - Recent Directions: Education and Support  Folic Acid Awareness & Multivitamin Distribution  Educational Resources Resource Line and Healthy Start Foundation Resource Line and Healthy Start Foundation  Case Management & Home Visitation MCC-CSC, Baby Love Plus, Nurse Family Partnership, Teen Pregnancy Prevention Initiatives MCC-CSC, Baby Love Plus, Nurse Family Partnership, Teen Pregnancy Prevention Initiatives

25. Infant Mortality - Recent Directions: Education and Support  Baby Love Plus Model Consortium comprised of consumers, community leaders, providers Consortium comprised of consumers, community leaders, providers Case Management/Care Coordination Case Management/Care Coordination Prenatal (Maternity Care Coordination)Prenatal (Maternity Care Coordination) Outreach and Client Recruitment Outreach and Client Recruitment Community Health AdvocatesCommunity Health Advocates Education and Training Education and Training Providers, Faith EntitiesProviders, Faith Entities Interconceptional Care Interconceptional Care Working with mom and baby for 2 yearsWorking with mom and baby for 2 years Depression Screening and Referral Depression Screening and Referral

26. Infant Mortality – Recent Directions: Improve Maternal Health

27. North Carolina’s Infant Mortality and Women’s Health Our Success and Future Tchernavia “T” Ranesfore Receives National Recognition 2009 Healthy Teen Network Outstanding Teen Parent Award