2. What is B’more for Healthy Babies?
A new bold & exciting initiative in Baltimore
Designed to decrease our high infant mortality rate
Will work on different levels to affect change – policy, services, community and individual levels

3. African American: 14.3 per 1,000 (2008) White: 7.3 per 1,000 (2008)
A Public Health Crisis
In 2009, an estimated 123 infants died in Baltimore City – a rate of 12.3 per 1,000 live births … an average of over 10 babies per month
African American: 14.3 per 1,000 (2008)
White: 7.3 per 1,000 (2008)
Baltimore City has the highest rate of infant death in Maryland and the 4th worst infant mortality rate in the U.S.
The rate of infant death in Baltimore (12.1 deaths per 1,000 live births in 2008) is extremely troubling. Maryland’s infant mortality rate is 8 per 1,000 live births, for some comparison.
The disparity between African American and White infants is particularly important to note..
Healthy People 2010, which is a statement of national health objectives and establishes national goals. In the US the infant mortality goals is 4.5 per 1,000 lives births. We are triple that rate in this city. 3

4. Unexpected Infant Deaths that Occurred During Sleep 2002-2009
The infant was bed sharing in 75% of these cases
Baltimore City Health Department analysis of data from cases reviewed by the Baltimore City Child Fatality Review data is still tentative.
In 2009, 82% of deaths were African American, 18% White, 0% Hispanic

5. What is B’more for Healthy Babies?
Our vision is to ensure that all of Baltimore’s babies are born healthy weight, full term, and ready to thrive in healthy families.
This will be done by:
mobilizing communities, families, and individuals around reducing the disparities of infant mortality
improving access to and quality of medical and social services
inspiring a collaborative spirit among policy advocates, health and social service organizations, and community members to actively reduce Baltimore’s infant mortality

6. Intended Outcomes Reduce:
Rate of pre-term births by at least 10% (283 fewer preterm babies)
Rate of low birth weight infants by at least 10% (259 fewer low birth weight babies)
Number of deaths from unsafe sleep by at least 30%
(12 infants)
The strategy has three primary outcome measures that relate to the most common preventable causes of excess infant death.
What you see here are the goals and cumulative targets for the end of the three-year period.
The goals are to achieve:
a 10% decline in pre-term births, representing 283 fewer preterm babies,
a 10% decline in low birth weight births, representing 259 fewer low birth weight babies,
and a 30% decline in deaths from unsafe sleep, representing 12 fewer sleep-related tragedies.
The success of community programs in linking residents to the high-impact services will also be closely tracked, and local agencies will be held accountable for efforts on capacity and quality.
Because of year-to-year variability in the infant mortality rate, this statistic is not the best measure of success over a three-year period.

7. Factors Affecting Poor Birth Outcomes
Health of the mother and father before conception
Medical and social support during pregnancy
Access to critical knowledge and services after birth
After examining these data, the partners developing the strategy looked at the factors that contribute to pre-term, low birth weight, and unsafe sleep and noted that they can be summed into three basic categories including: the health of the mother and father before conception, medical and social support during pregnancy, and access to critical knowledge and services after birth.

8. Factors Affecting Poor Birth Outcomes
Stage
Pre-Pregnancy
Pregnancy
Post-Pregnancy
Care
Preconception
Prenatal & Obstetric
Postpartum & Neonatal
Modifiable Determinants of Adverse Outcomes
Smoking
Substance abuse
Poor nutrition/obesity
Psychosocial stress
Domestic violence
Infection/ Sexually Transmitted Infections
Underlying Chronic Illness
Lack of Health Insurance Coverage
Underlying Determinants of Poor Reproductive Health
Poverty
Environmental exposures
Poor housing
Racism
Genetic factors
Interventions Specific to Stages
Planned pregnancies:
- Wanted & timed
- Spaced
Good nutrition
- Adequate folate
High quality primary care
STD treatment
High quality prenatal care
Access to high-risk obstetrics
Home visiting for high-risk pregnancies
Breastfeeding
Safe sleep
Adequate nutrition
Immunizations
Dr. Bernie Guyer from Johns Hopkins School of Public Health helped us look at the factors in more depth and this slide summarizes in more detail the factors that guided the recommended strategies.
The columns represent life stages related to pregnancy: Pre-pregnancy, Pregnancy, and Post pregnancy
The first row shows what kind of care would be offered in each of these stages: preconception care, prenatal and obstetric care in pregnancy, and postpartum and neonatal care post-pregnancy. The second row shows the modifiable factors related to poor birth outcomes such as smoking, substance abuse, poor nutrition, domestic violence, etc., the next row identifies the underlying determinants of poor reproductive health such as poverty, environmental exposures, poor housing, and racism, and the last row show interventions that could be implemented in each stage that would address the modifiable factors. This framework guided our strategy.
The health of the mother well before conception is a critical factor in the health of the baby. Research demonstrates that stress, chronic illness, substance abuse, and poor nutrition all are associated with poor birth outcomes.
The risks are especially high with early, unplanned pregnancies. In Baltimore, nearly 20% of high school students are obese, 12% teenagers smoke, and 18% of babies are born to teen parents.
In Baltimore, 25% of women initiate prenatal care after the first trimester. As many as one in five women experience domestic violence during the vulnerable period of pregnancy.
Finally, unsafe sleep practices put babies at risk of dying at home. From 2002 to 2006, the deaths of eighty-one infants were associated with newborns not sleeping alone, on their back, and in a crib. Having another baby quickly also raises the chance of an adverse outcome, with the recommended interval being at least eighteen months between pregnancies. Mothers whose babies have suffered complications or death are often at high risk for repeat tragedies.
No “quick fix” solution for poor birth outcomes
Evidence-based research indicates certain high-impact service areas lead to improved birth outcomes

9. High-Impact Service Areas
(1) Primary health care in a medical home
(7) Smoking cessation
(2) Obstetric care
(8) Family planning
(3) Home visiting
(9) Nutrition support
(4) Drug and alcohol treatment
(10) Breastfeeding promotion
(5) Domestic violence
Interventions
(11) Safe sleep education
(6) Mental health care
Based on the framework of factors discussed on the previous slide, the strategy identifies eleven high impact areas that we believe addressed in combination will have an impact on the poor birth outcomes in Baltimore City.
Primary health care/preconception care
High quality care can improve the health of the mother and father long before conception, ultimately improving birth outcomes. Need a seamless transition of care from preconception to prenatal to inter-conception health.
High quality obstetric care
can help manage chronic illness in pregnancy, and obstetric complications, including infections, hemorrhage, and eclampsia.
Home Visiting Effective home visiting interventions have been associated with reductions in low birth weight and increases in the intervals between pregnancies.
Drug and alcohol treatment Substance use treatment improves not only the health of the mother, but also the health of the unborn baby.
Intervention for domestic violence Violence during pregnancy has been linked with poor birth outcomes, including low birth weight and preterm births, as well as maternal morbidity.
Mental health careUntreated depression and anxiety lead to increased rates of prematurity and more low birth weight infants.
Smoking cessation
Smoking by the mother during pregnancy, as well as second-hand smoke from caregivers after delivery, have negative effects on the infant’s health before and after birth.Smoking cessation programs for pregnant women are effective and can improve birth outcomes.
Family planning
Appropriate spacing between pregnancies is associated with better birth outcomes.
Breastfeeding promotion
Breastfeeding improves the immune strength delivered to a newborn infant and can improve the chances of an infant’s survival.
Safe sleep education
Changing the sleeping arrangements for newborns can dramatically reduce mortality after birth. 9

10. Gaps in Current Efforts to Improve Birth Outcomes
Individual initiatives are funded inadequately and separately
Poor coordination of services
Lack of adequate primary health care
Lack of health insurance
Lack of minimum standard of care
Limited community mobilization to promote healthy behaviors prior to or between pregnancies
As part of developing this plan, the health department and other partners reviewed the current services offered in Baltimore and concluded that services are funded inadequately and are fragmented.
Some of the key gaps include – a poor coordination of service. In what is becoming a tighter and tighter funding environment the problem of poor coordination of services is extremely critical.
Lack of adequate primary health care
Lack of health insurance leading to late prenatal care. The complexity of just getting enrolled into an MCO can take women well into their second and third trimesters.
Other gaps included noting a lack of a minimum standard of care for young women and men in the city. For example, some adolescent care providers may offer reproductive health care, substance abuse assessment and referral and comprehensive medical care; others may just fill out school physicals.
Finally, while there are community outreach programs that are targeting poor birth outcomes, the programs cover a very small proportion of the population. The limited individual and community attention to promoting healthy behaviors is a critical component of these poor birth outcomes. Most of these outcomes are preventable with greater utilization of existing services and healthy behaviors before, during, and after pregnancy

11. Support Continuum for Improved Birth Outcomes
Professional Case Management for Selected Individuals at Risk
High-Impact Service Areas
Primary health care/ preconception care
Obstetric care
Homevisiting
Drug and alcohol treatment
Intervention for domestic violence
Mental health care
Smoking cessation
Family planning
Nutrition support
Breastfeeding promotion
Safe sleep education
Paraprofessional Home/Community-Based Services for Selected Communities at Risk
Targeted Health Education and Support Services
Referrals and Coordination
Community Mobilization and Health Education
The community programs will be modeled on a Support Continuum for Birth Outcomes as shown on this slide. The pyramid depicts the core interventions that will be offered by each of the community programs. Interventions will aim to engage persons between the ages of 11 and 49 in each community statistical area prior to, during, and between pregnancies. More intensive services will be offered during pregnancy and through an infant’s first year, depending on need.
At the top of the continuum, professional home and/or community-based case management will be offered to the highest risk women in the pregnancy and post-partum periods; these include victims of domestic violence, women with poor birth outcomes in a previous pregnancy, those with HIV/AIDS or syphilis, and women with chronic hypertension and diabetes.
At the next level of the continuum, programs will offer paraprofessional care management. Minimally, all women in the targeted geographic areas will receive one home visit upon discharge from the hospital following delivery. In some cases, the post partum visit will be the only home visit the woman receives.
On the third level of the continuum, programs will offer targeted outreach, health education, and support services, such as transportation. The largest role of the community programs will be mobilization, advocacy, and resource development as represented on the fourth level of the continuum.
 Community programs will have access to a web-based toolkit that will include appropriate best practice interventions and materials, including messages for each of the high-impact areas developed in the citywide campaign.
Citywide Infrastructure and Education 11

12. Excess Number of Infant Deaths by
Census Tract, Baltimore City,
This map shows the excess number of infant deaths by census tracts in Baltimore City. It depicts where infant deaths are clustered in Baltimore city neighborhoods. The darkest areas of the map are census tracts with four or more excess infant deaths. When we use the term “excess infant deaths” we mean the number of infant deaths occurring in a particular census tract over the years that are in excess of what would be expected if the infant mortality rate in that census tract were the same as the rate for Maryland for that time period. 
The birth outcomes strategy identifies 12 of the city’s 55 neighborhoods for initial targeting. From 2002 to 2006, these neighborhoods had approximately 60% of the city’s total number of excess infant deaths and only 27% of Baltimore’s births. Just a quarter of the births and more than half the deaths. The strategy proposes that a targeted community-based program in each of these areas take responsibility for the birth outcomes of the entire community.
There are fifty-five Community Statistical Areas. Clusters of Baltimore neighborhoods were created along census tract boundaries to form fifty-five CSA's. This clustering was necessary for the creation of statistical areas since most of the 270+ neighborhoods in Baltimore City do not have boundaries that fall along census tracts. This clustering represents the work of the Baltimore City Planning Department and the Family League of Baltimore City.
Using the Maryland rate, which is higher than the U.S. rate and the Healthy People 2010 goal, provides us with a relatively conservative measure of high-need areas in Baltimore City.

13. Fetal/Infant Mortality Core Implementation Team
SIBO Organizational System
Donors
STEERING COMMITTEE
COMMUNITY ACTION TEAM
State IM Plan
BabyStat
Medicaid/MCOs
Fetal/Infant Mortality
Review
Hospital Team(s)
Child Fatality Review
FQHCs
Core Implementation Team
Ad Hoc
Committees
We are organized by a steering committee that is made up of city cabinet leaders (Health Commissioner, Head of Housing, Director of Department of Social Services, Chief Executive Officer of the Family League to name a few agencies) that meets quarterly and by a core implementation team of operations people from the Health Department, the Family League, and Johns Hopkins Center for Communications program that meets weekly. The core implementation team guides all of the day to day work of the strategy. Key organizational networks are linked into the strategy through the steering committee including donors, the BabyStat committee of home visiting programs, the fetal, infant, and child fatality review boards, the state, Medicaid offices, hospitals, and federally qualified health centers. Key to everything, however, are our neighborhood based programs that are led by neighborhood consortiums.
Neighborhood
Action Team
Neighborhood
Action Team
Neighborhood
Action Team

14. Implementation Timeline: 10 years (3 Years of initial funding)
4 Results Areas: Policy, Services/Systems, Communities, Families/Individuals
Entry Point: Pregnancy/Postpartum
3 Phases of Communication: Healthy and Safe Parenting, Healthy Pregnancies, Healthy Baltimore
12 Communities – starting with 3

15. Results Area 1: Policy/Systems
Implementation
Results Area 1: Policy/Systems
Policy for coordinating risk assessment and referral is in place
Citywide triage system for home visiting services and integrated database
Prenatal Risk Assessments – making system more efficient
Linking families to community-based services and BHB messages at discharge from labor and delivery
Fetal and Infant Mortality Review Team – Community Action Team – Neighborhood Action Teams
Selecting home visiting models for the city
Each of our results areas are supported by an objective and then specific activities. I will go through a few of these examples.

16. Results Area 2: Services
Implementation
Results Area 2: Services
Agencies and partners providing services adhere to policies and guidelines for risk assessment and referral with goal of increasing access
Service Availability Profile—leading to agency work plans
Nurse home visiting adoption of Partners for a Healthy Baby curriculum.
Cadre of trainers trained as change agents and disseminators of BHB messages
Provider outreach on PRAs
Hospital outreach at postpartum (video)

17. Results Area 3: Communities
Implementation
Results Area 3: Communities
Communities know their role in supporting improved birth outcomes and buy into strategy
Communities selected and funded
Introduction of Baby Basics and Mom’s groups
Text4Baby
Specific strategy for no prenatal care/unable to locate under development

18. Upton/ Druid Hts— University of Maryland Medical System Greenmount
East – People’s Community Health Center
Patterson Park
North and East – Baltimore Medical System

19. Results Area 4: Families and Individuals
Implementation
Results Area 4: Families and Individuals
Families and individuals at risk use available services and practice behaviors that improve birth outcomes
Branding/safe sleep focus groups
Home visiting programs
Provider outreach

20. Next Steps? Design and implement baseline evaluation for the strategy
Finalize citywide triage criteria
Work with State and hospitals to identify high risk women at discharge from labor and delivery
Develop provider and community-based toolkit for high impact areas
Implement phase I of citywide communications campaign:
Healthy and Safe Parenting: SAFE SLEEP
Develop website
Begin community program interventions

21. Imperative: A City-wide Coordinated Effort
Citizens and leaders
Mayor’s Office
Health Department
The Family League of Baltimore City, Inc.
Baltimore HealthCare Access, Inc.
Baltimore Substance Abuse Systems, Inc.
Managed Care
Organizations
Housing
Dept of Social Services
Baltimore Mental Health Systems, Inc.
Pediatricians/Adolescent physicians/Obstetricians
Home visiting and community outreach programs
Schools
Faith-based organizations
Businesses
Public Safety Departments
Hospitals
These outline just a few of the partners that need to be involved in improving birth outcomes for Baltimore city. This must be a coordinated effort among public and private institutions --- from health providers to business leaders – from the department of social services to the school teacher. Messages related to preconception health, early prenatal care, safe sleep habits and so forth must be consistent across institutions and should come from multiple disciplines. We also must rally together to find the highest risk women in Baltimore city who are still falling between the cracks. Many of the deaths discussed in the fetal and infant mortality review board involve women who have had little or no prenatal care. Finally, all partners must start addressing how to ensure the issue of payment for services. I recently learned about a pregnant woman who requested to participate in a birthing class was turned down by two hospitals because her MCO did not pay for birthing classes. We need to provide services to support improved birth outcomes.