Infant Mortality Prevention: A Community and Public Health Approach CAPT Wanda D. Barfield, MD, MPH Director, Division of Reproductive Health Secretary’s Advisory Committee on Infant Mortality August 2, 2011 National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health

Outline The problem of infant mortality - It’s not just about the baby Social determinants and maternal health CDC’s public health approach through community-based prevention efforts What we can do together to address infant mortality

U.S. Infant Mortality Rate 1950-2006 Deaths per 1,000 live births 2010 Healthy People Objective: 4.5 6.7 Infant mortality is a significant indicator of the health of a nation. It is associated with maternal health, quality and access to healthcare, and socioeconomic circumstances. In this slide, we see that the U.S. infant mortality rate declined throughout the 20th century. In 2006, the U.S. infant mortality rate was 6.7 infant deaths per 1,000 live births. However, the infant mortality rate has not declined significantly since 2000. This is a big concern as we try to achieve the 2010 Healthy People Objective of 4.5 infant deaths per 1,000 live birth. Year U.S. Infant Mortality Rate: Ranks 29th in the World (2004)

The Contribution of Preterm Birth to the Infant Mortality Rate Preterm birth (< 37 weeks gestation) is the most frequent cause of infant death 37% of all infant deaths (2005) 69% of deaths due to preterm birth within the first day 2/3 of deaths due to preterm birth occurred among infants < 24 weeks gestation We cannot reduce the infant mortality rate until we figure out how to reduce the rate of preterm birth. Preterm birth, defined as births at less than 37 completed weeks of gestation, is the most frequent cause of infant death, accounting for 37% of all infant deaths in 2005. 69% of deaths due to preterm birth occur within the first day of life 2/3 occurred among infants 24 weeks gestation or younger. This last bullet brings the point home that future gains in reducing infant mortality due to preterm birth must focus on prevention. Just as an aside, the information on this slide is from Bill Callaghan’s 2003, paper, his paper showed an innovative approach to examining contribution of preterm birth to infant mortality rate and this influenced NCHS to change standard categories for annual reporting of causes of infant mortality Callaghan WM, et. al. Pediatrics 2006; 118:1566-73

Preterm Birth in U.S. by Race/Ethnicity 2006-2008 Average The 2007 preterm birth rate for non-Hispanic black infants was 59% higher than the rate for non-hispanic white infants. Source: CDC/NCHS, Retrieved April 20, 2011, from www.marchofdimes.com/peristats.

Persistent Racial Disparity in U.S. Infant Mortality Rate 1950-2005 Total Deaths per 1,000 live births Black race 13.6 White There is a persistent racial disparity in the US Infant mortality rate. The infant mortality rates for non-Hispanic black women have been consistently higher compared to non-Hispanic white women Add some discussion about what happened in terms of technology. Perinatal regionalization, obstetrical care 6.7 5.7 Year

Social Determinants of Health What are they? Conditions under which individuals are born, grow, live, work, and age What about resources? Economics, social policies, and politics impact health inequity How are they defined? WHO’s 3 recommendations: 1. Improve daily life 2. Address inequity in quality of life 3. Measure and assess impact of policies and programs and how they motivate change What are the social 'determinants' of health? The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. World Health Organization’s Commission on the Social Determinants of Health Final Report. http://www.who.int/social_determinants/en/

Social Determinants of Health (Cont’d) How do we get impact? Assessment of the true impact of policy change is necessary Evaluation of focused interventions and use of evidence-based interventions will inform states, localities, and agencies How is it measured? It is possible to examine individual-level data linked to surveillance data The life course perspective is integral to this concept

Social Determinants: The Circle of Influences - Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press

Influence on the Fetus and Infant Social Determinants : Influence on the Fetus and Infant fetus mother family community

CDC’s Safe Motherhood: Rationale Approximately six million women become pregnant in the US each year. Safeguarding the Health of Mothers by Improving women’s health before, during, and after pregnancy Identifying strategies that could reduce maternal and infant deaths in the US. Including community approaches

NCCDPHP Action Areas Public Health Infrastructure Healthy Communities Surveillance Applied research Capacity building /workforce Healthy Communities Tobacco control Nutrition and physical activity Child and adolescent health Oral health Sexual health Healthy Care Environments Promote delivery of clinical preventive services Chronic disease management Healthy schools and work environments Public Health Infrastructure Surveillance: Describe the burden Applied research: Identify best practices Capacity building - Support communities through leadership and resources We are organized so that we can continue to investigate social determinants. There is still a lot of investigation to do. The correlation may not be as strong

Factors that Affect Health Counseling and Education Clinical Interventions Long-Term Interventions Policy Socio-economic factors Smallest impact Largest impact Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

CDC Working With Communities Racial/Ethnic Approaches to Community Health ACHIEVE Communities Strategic Alliance for Health Prevention Research Centers Communities Putting Prevention to Work Community Transformation Grants Chronic Disease Consolidation Grants Racial and Ethnic Approaches to Community Health Action Communities for Health, Innovation, and EnVironmental changE

Improving Social Determinants in Maternal Health: Examples

Reaching Communities to Improve Maternal Social Determinants Reducing CVD risk among women accessing reproductive health services in Eastern North Carolina Evaluating screening for 5 risk factors (diabetes, high cholesterol, high blood pressure, obesity, smoking) at contraceptive visits Evaluating a lifestyle and weight loss intervention Healthy African American Families (HAAF) project in Los Angeles , community participatory project Target interventions to support women during pregnancy 100 Acts of Kindness The Healthy African American Families (HAAF) project in Los Angeles is a community participatory project. Information on African-american mother’s experiences during pregnancy was gathered so we could be better informed about how to target interventions. A a result of the project, a supplement for Ethnicity and Disease journal was produced that documents HAAF philosophy, history, activities, and products In addition , we provide technical assistance as needed to State Health Departments on analysis of state data to examine racial differences in preterm birth rates In collaboration with UNC UNC Center for Health Promotion and Disease Prevention Pitt County Health Department (PCHD) East Carolina University, Brody School of Medicine, Department of Public Health

B I L O A R D This is a draft of billboard that HAAF wants to put up in the community, showing family support for a pregnant woman. This is an example of a community-specific product since billboards are an important part of local LA culture but they might not be elsewhere.

Reaching Communities to Improve Maternal Social Determinants Randomized trial to evaluate a contingency management approach to weight loss and smoking cessation among American Indian women of reproductive age Evaluation of state tobacco control policies, spending, and taxes on smoking before, during and after pregnancy and on birth outcomes Assessing Medicaid coverage of smoking cessation services

These statements have been used by ACOG, by the Association of Women's Health, Obstetric and Neonatal Nurses and has been cited in high-level publications. Include how public health is coming in. This is the data

For over 40 years CDC’s Safe Motherhood program contributes to the body of evidence that changes clinical practice. For example CDC authors publications and convenes meetings on topics such as Gestational Diabetes Mellitus leading to professional organizations issuing committee opinions or committee guidelines changes to practice.

Provision of Risk-Appropriate Care Evidence: risk of death at non-level III facilities VLBW (≤1500g) infants (37 studies) OR 1.62, 95% CI 1.44-1.83 ELBW (≤1000g) infants (4 studies) OR 1.64 95% CI 1.14-2.36 Very Preterm (≤32 weeks) infants (4 studies) OR 1.55, 95% CI 1.21, 1.98 Policy: States regulate health care services and facilities License hospitals Promulgate State Health Plans/Regulations Approve facility expansion and construction Implement Title V programs ($) Lasswell JAMA 2010 ; J Perinatol 2009 21

HRSA/MCHB Performance Measure #17: Percent of VLBW Infants Delivered at Facilities for High Risk Deliveries and Neonates by State Above 2010 target Below 2010 target More than 20% below 2010 target Data not available *Goal: 90%

Measuring Impact: CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) Louisiana: Analysis of PRAMS and birth certificate data to identify associations between preterm birth and modifiable risks Implementation of “The Stork Reality” Project Military and Civilian Births*: Measuring the effect of military affiliation on preterm birth Assessed demographics, SES, health risks, stress, prenatal care, and delivery history Military affiliation reduced early preterm birth for African Americans by 41%; no difference for late preterm birth No difference in military affiliation on preterm birth for whites Program Examples: Utah’s indicators of prenatal care adequacy steadily declined from 1993 through 2000. Using PRAMS data, Utah conducted an analysis of the characteristics of women with inadequate prenatal care and implemented a program to raise awareness and promote prenatal care. Utah’s 2003 PRAMS data showed a 20% increase in prenatal care adequacy which was associated with promoting an understanding about adequate prenatal care among consumers. Louisiana recently conducted an analysis using linked PRAMS-birth certificate to identify associations between preterm birth and modifiable risks that were reported by PRAMS respondents. This included practices such as alcohol use before and during pregnancy, stressful life events, intimate partner violence, pregnancy spacing, pre-pregnancy BMI, and weight gain. The analysis found that women who were hypertensive, experienced partner abuse before or during pregnancy, had low weight gain for gestation, had inadequate or excessive prenatal care for gestational age, and less than 12 month pregnancy spacing (interval from one delivery to the next) were more likely to deliver preterm. Based on these findings, Louisiana implemented a preconception health awareness project, “The Stork Reality” targeting women who do not have regular medical homes to provide preconception and intraconception (“between pregnancy” health services. Maternal depression, including post-partum depression, can affect a woman’s ability to engage in healthy parenting behaviors, to care for herself, and to relate to others. Oregon PRAMS data indicated about 23% of women surveyed reported symptoms of depression either during or after pregnancy. The analysis was used to develop programs, activities and practice recommendations to support care for women experiencing depression or severe forms of anxiety during their reproductive years. The partnership includes stakeholders from the state’s academic, mental health, social welfare and early childhood development organizations.   www.cdc.gov/prams *Lundquist J. Under review

Data Linkage to Assess Social Determinants Pregnancy Risk Assessment Monitoring System (PELL) Vital records data Hospital discharge data PRAMS Early Intervention Program Women Infants and Children Assisted Reproductive Technology data Area resource data Healthy Start Quality Improvement Collaboratives

Quality Improvement Collaboratives Data from Ohio. Using general principles of quality improvement, The Ohio Perinatal Quality Collaborative was able to reduce elective deliveries with no indication for pregnancies 36-38 weeks. There have been other documented successes (UTAH demonstrated the same thing).

Note – over past decade – decline in SIDS has been offset by an increase in accidental suffocation in bed and deaths categorized as “unknown” When combine SIDS cases and other causes, find that there has not been a decline in cases of sudden, unexpected infant deaths Source: CDC WONDER, Mortality Files

Building Capacity in Communities: Maternal and Child Health Epidemiology Program MCHEP initiated in 1986 by the Centers for Disease Control and Prevention, and the Health Resources and Services Administration / Maternal and Child Health Bureau Request for Applications provide: Direct assistance to states Time-limited assignments Envisioned as a mechanism to promote collaboration between federal agencies and states 35+ senior MCH epidemiologists to more than 33 states and 6 other public health organizations The Maternal and Child Health Epidemiology Program (MCHEP), located within the Division of Reproductive Health (DRH), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), has been in existence for more than 25 years. In 1986, CDC and the Health Resources and Services Administration/Maternal Child Health Bureau (HRSA/MCHB) developed the Maternal Child Health Epidemiology Program (MCHEP) and released a Request for Applications (RFA) offering to provide direct epidemiologic assistance to states’ MCH programs through time-limited assignments of MCH epidemiologists. The program was originally envisioned as a mechanism to promote collaboration between federal agencies and states, and has evolved into a long-term, well-developed partnership between CDC and affiliated states. The mission of the MCHEP is to promote and improve the health and well-being of women, children and families by building capacity at state, local and tribal levels, and to use and apply sound epidemiologic research and scientific information to maternal and child health programs and policies. Since its inception, the MCHEP has assigned more than 35 senior CDC epidemiologists focused on MCH epidemiology capacity building and applied research to 33 states, and 6 other public health agencies and organizations (including Washington, D.C., Puerto Rico, US-Mexico Border Region, CityMatCH, Northwest Portland Area Indian Health Board, and the Indian Health Services). The program has also sponsored 16 national scientific conferences, numerous fellowships, and training initiatives. Assignments and activities of the MCHEP are intended to include the development, improvement and maintenance of comprehensive MCH surveillance systems; state program coordination in the areas of intervention research, health care financing, human resource and database development; data analysis for program development and implementation; training and capacity building to effectively implement surveillance and intervention research findings; and program evaluation. The foundation of these capacity-building efforts is collaboration, both with states and with other agencies.

MCHEP Sponsored Regions, States, and Public Health Agencies

SUMMARY The problem of infant mortality—Its not just about the baby Social determinants and maternal health matter to reduce infant deaths and disparities Integrative prevention research in communities is needed to assess social determinants Sustain gains made thus far Utilize broad data systems to measure impacts Increase and diversify the public health workforce

Questions? http://www.cdc.gov/reproductivehealth/ Wanda D. Barfield, MD, MPH. CAPT, U.S. Public Health Service Director, Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention (770) 488-5200 (770)488-6450 (fax) drhinfo@cdc.gov http://www.cdc.gov/reproductivehealth/ Healthy Reproduction for a Healthy Future