Jackson County Fetal and Infant Mortality Review Report 2017 Prepared by Aimee Fors, FIMR Health Educator Mary Kops, BSN FIMR Abstractor

What Is Fetal Infant Mortality Review (FIMR)? The Jackson County FIMR case review team consists of a diverse group of health professionals, social service professionals and community members. This team reviews the life and death circumstances of infants who died in Jackson County. The team identifies factors contributing directly or indirectly to the infants death. The goal is to identify ways to improve our community’s service systems for pregnant women, infants and families with young children.

Why is FIMR important Infant Mortality is often used as an indicator to measure the health and well-being of a community, because factors affecting the health of entire populations can also impact the mortality rate of infants. FIMR is a surveillance methodology used nationally to monitor and understand infant death. Evaluating these deaths is a window into the communities health, which allows us to identify gaps and improve birth outcomes in Jackson County.

Two Tiered Process FIMR Case Review Team Community Action Team Or Maternal Child Health Action Team Identifies social, economic, cultural, health, and safety system issues Takes recommendations to action to improve community resources and service delivery systems FIMR is a 2 tiered process involving a Case Review Team (FIMR Team) and a Community Action Team (Jackson County Prenatal Task Force). Data is gathered from record abstraction and home interview. It is summarized and de-identified and presented to the CRT. CRT identifies social, cultural, economic, health, safety and system factors that contribute to infant death and makes recommendations to the Community Action Team. CAT takes recommendations to action in order to improve community resources and service delivery systems.

The FIMR Process Cycle of Improvement Changes in Community Systems Data Gathering Cycle of Improvement FIMR is a comprehensive community approach to decreasing infant mortality. It is a continuous cycle of improvement involving data gathering, case review, community action, and changes in community service systems. While the long term goal is a reduction in infant mortality; it is the intermediate (steps) of making improvements in community resources and service systems for women, infants and families that drive the reduction in infant mortality. Community Action Case Review

Number of Infant Deaths 1999-2015 * FIMR began in 2003

Jackson County Infant Mortality Rate 2005-2015 Rates are per 1,000 life births * 2015 rate is Provisional

Jackson County; 3 year average IMR Compared to Michigan and US, 2004-2015

Percent of Jackson Co. Infant Deaths by Cause, 2013-2015 (n=30) Other =2014, undertermined (possibly sleep), 2013 (Broncho-pneumonia), 2012 (respiratory Failure/Sepsis) .

JC Infant Death by Leading Causes 2002-2015 2008 2009 2010 2011 2012 2013 2014 2015 Prematurity 5 4 4 6 2 5 2 5 Congenital 4 3 4 1 1 5 4 1 Positional 2 3 0 1 2 3 0 2

Jackson County: Black/White IMR (3 year moving average) 2003-2015 Deaths per 1,000 live births African American or black rate is both Mother and Father are listed as African American on birth certificate

Jackson County compared to Michigan risk ratio for Black/White IMR disparities 3 year moving average (2004-2015) In 2013-2015 African American babies were 3.1 times more likely to die before their 1st birthday than Caucasian babies

Jackson County IMR by race 3 year moving average (2004-2015)

% Deaths by Race and Cause of Death, 2013-2015 n=32 *Multi racial infants are considered ‘other’ * Other includes Bronchopneumonia, Undetermined, and Accidental (fire)

Sleep Related Deaths (Jackson County) For Sleep related deaths between 2013-2015 In 80% of the sleep related deaths babies were co-sleeping 40% of the babies were in an adult bed 80% of babies were put to bed with blankets In 60% of the cases parent used drugs or alcohol just prior to the death 60% of babies were put to bed with a pillow

Natality and Pregnancy Data The following slides look at prenatal care trends and live births in Jackson County compared to Michigan

2000-2015 Teen Pregnancy Rates Rates per 1000 females, aged 15-19)

2014/2015 Teen Birth Rates (Rates per 1000 females, aged 15-19)

Jackson County Compared to MI Percent of Preterm Live Births and LBW 2000-2015 11.1 9.8 9.5 % 8.5 2009 2010 2011 2012 2013 2014 2015 Mi PT 9.8 9.8 12.3 12.2 12 12.3 9.8 Jxn PT 8.5 8.2 11.2 11.1 10.6 10.1 11.1 MI LBW 8.4 8.4 8.4 8.5 8.3 8.4 8.5 Jxn LBW 8.2 9 9 9.3 7.9 7.3 9.5

Adequate(*Kessner index) & Entry into care(1st trimester) Prenatal Care Adequate(*Kessner index) & Entry into care(1st trimester) % The dotted line looks at Michigan compared to Jackson on “The percent of women that received prenatal care during the first trimester” * The Kessner Index is a classification of prenatal care based on the month of pregnancy in which prenatal care began, the number of prenatal visits and the length of pregnancy (i.e. for shorter pregnancies, fewer prenatal visits constitute adequate care). Adequacy of prenatal care (Kessner index) 2009 2010 2011 2012 2013 2014 2015 Jackson 66.7 66.5 71.4 71.9 68.3 65.9 66.7 Michigan 68 68.1 68.9 68.8 66.9 66.8 67.2 Entry to care Jackson 72.4 70.8 75.6 77.7 74 72.2 72.3 MI 73.5 74.3 74.6 74.3 73.1 72.7 72.3 *The Kessner index classifies care based on entry into care, the number of prenatal visits and the length of pregnancy

Live Births using Medicaid Payment, Jackson County, 2000-2015 (MDHHS, Vital statistics)

Pregnancy Intention of infant deaths 2013-2015 (n=30)

Jackson County infant deaths/live births Maternal Characteristics 2013-2015 (3 year average) % Infant Deaths (n=30) 2015 % infant Deaths (n=9) % live births Jackson % live births Michigan 13% Teen Mom 0% 7.3% 5.7% 53% 1st pregnancy as teen 11% 33% < 12th grade education 12.7% 12.1% 73% Mother Unmarried 67% 50.1% 42.7%

Maternal/Prenatal Characteristics 2013-2015 3 year average % Infant Deaths (n=30) 2015 % infant Deaths (n=9) % live births Jackson % live births Michigan 63% Adequate Prenatal Care 78% 66.7 67.2 73% Entered Prenatal care 1st trimester 89% 72.3% 77% Low Birth weight baby (<2500grams) 9.5% 8.5% 70% Kept 6 Week postpartum visit 56% 53% Obese (BMI > 29) 44%

Social/Economic Characteristics 2013-2015 3 year average % Infant Deaths (n=30) 2015 % infant Deaths (n=9) % live births Jackson % live births MICHIGAN 60% Multiple Stressors / Social Chaos 44% 20% Drug Use 0% 40% Smoking 11% 28% 17% 43% Mental Health / Depression Issues 56% 67% Medicaid 47.5%

Systems Issues and Recommendations The following slides look at recurring systems issues and team recommendations from the reviewed infant death cases

Identified System Issues (2013-2015 cases n=30) Lack of PNV/folic acid prior to conception (15) Lack of preconception and interconception care/education (14) Lack of dental care assessment. Referral and follow-up (14) Smoked during pregnancy (12) Did not keep postpartum visit (8)

Top Recommendations 2013 Improve assessment, referral process and follow up on high Edinburgh score, to include pediatricians, hospital, OB office and postpartum Improve communication and increase referrals between available resources (i.e. hospital, high risk clinic, OB office, ultrasound, mental health/depression, smoking cessation and substance abuse) Provide Inter-conception care including folic acid, obesity and dental care Improved assessment and referral for substance use / alcohol and the effects on the pregnancy

Top Recommendations 2014 Gather accurate birth abstract information Improve post-partum care follow up in the areas of depression, immunizations & contraception education. Conduct follow up on referrals during pregnancy for smoking cessation, mental health and substance abuse

Top Recommendations 2015 Provide drug screen testing on all preterm deliveries Institute standard safe sleep training module for hospital and community staff Provide complete communication between tertiary care and local OB’s, and ensure local bereavement services know when a baby from Jackson area has passed Provide prenatal vitamin for all women of childbearing age

Recommendations to Action Possible strategies to turn recommendations to action Example: Meet with birth abstract person at HFAH by 12/2017 to determine potential roadblocks in gathering accurate birth certificate information. Gather accurate birth abstract information

Maternal Child Health Action Team

Maternal Child Health Action (MCHAT) Team Accomplishments Community Navigation Specialist (pathways program/MHEF) promoting community linkages 37 referrals, 116 pathways completed Most commonly used pathways have been: housing, financial, transportation, clothing, and childcare 43% of referrals were currently pregnant Worked to update the local PRAMS survey to include more social determinates of health / equity questions Continued safe sleep presentations to colleges, non-profits, DHHS, adoption services, rehabilitation organizations etc.

Emerging concepts Opioid use in pregnancy and the burden of Neonatal Abstinence Syndrome Using an equity lens to addressing racial disparities Impact of trauma experiences on birth outcomes The impact of changes in health care coverage

Summary As the leading causes of infant mortality in Michigan our primary goal is reduce the number of preterm births, congenital anomalies and positional asphyxia deaths of our infants. Infant mortality remains a complex, multi-factorial issue that must be challenged on multiple fronts with emphasis on addressing the top causes of infant death through some of the following: Interconception Care Folic acid, chronic disease management, depression screening, pregnancy planning, dental care and weight management Inter-agency referrals Substance abuse assessment and treatment Focus on social determinates of health and the impact on birth outcomes

Summary (cont.) Our community action team (MCHAT) must address these issues in a collaborative way looking at root causes and implementing system changes for long term effects. Improved maternal and infant outcomes require strategies that focus on specific factors across the life course. In order to support better health status of women and girls, communities must ensure access to health care, health information, and health education, in ways that empower individuals and families to become active participants in healthy lifestyles and behavioral choices.

Questions? Aimee Fors & Mary Kops Jackson County Health Department www.co.jackson.mi.us/hd (517)768-2123 / 517-768-1672 afors@co.jackson.mi.us / Mkops@co.jackson.mi.us