2. Study of Infant Mortality TRICARE Beneficiaries Fort Riley, Kansas LTC Paul Benne, MD, MPH SPC John Makinwa, BS, MBA, DrPH Candidate September 21, 2011

3. Objectives Update of infant mortality in Kansas Update of infant mortality in Kansas Describe the Infant Mortality Rate (IMR) of the Fort Riley area Describe the Infant Mortality Rate (IMR) of the Fort Riley area Discuss contributors to IMR Discuss contributors to IMR Discuss possible community collaboration Discuss possible community collaboration

4. Definitions Two calculations methods of Infant Mortality Rate: Two calculations methods of Infant Mortality Rate: 1. Simplest, universally adopted method = Infant deaths in a given year divided by the total number of live births in the same year multiplied by 1,000 - Cross-sectional data - Data/statistics presented in the KDHE, Bureau of Epidemiology and Public Health Informatics Annual Summary and Kansas Information for Communities (KIC)

5. Definitions Cohort rate = Infants born in a given year are followed through their first birthday and the number of deaths that occur to these infants are noted and used as the numerator for the cohort IMR (linked births-deaths file) - Birth cohort – Birth for a given year are linked with infant deaths that occurred in the year of birth or the next year. - Death cohort – Deaths for a given year are linked with births that occurred in the same year or previous year. - Death cohort – Deaths for a given year are linked with births that occurred in the same year or previous year. Numbers using different methodologies will not match

6. Infant Mortality Rates 2011 2011 projected IMR in US 6.1 (CIA) 2011 projected IMR in US 6.1 (CIA) There are 46 governments that have better IMRs There are 46 governments that have better IMRs US rates are higher than many third world countries US rates are higher than many third world countries

7. Infant Mortality Trends 2000-2009 U.S. 2008, 2009 preliminary data Source: Bureau of Epidemiology and Public Health Informatics, KDHE; National Center for Health Statistics

8. Infant Mortality Rates by Race 2007 Source: National Vital Statistics Report: Volume 58, Number 19

9. Kansas Ranked Worst among States for Black Infant Mortality Rate (IMR), 2007 StatesBlack IMR Kansas18.98 Oklahoma18.03 District of Columbia16.61 Missouri16.48 Michigan16.39 Rhode Island16.00 Indiana15.99 Tennessee15.74 Virginia15.41 Wisconsin15.18 USA13.24 Source: National Vital Statistics Report: Volume 58, Number 19

10. Black non-Hispanic and White non-Hispanic Infant Mortality Rates & Ratio, 1998-2009 *NH: Non-Hispanic Source: Bureau of Epidemiology and Public Health Informatics, KDHE

11. Infant Deaths by Cause of Death Kansas, 2005-2009 Source: Bureau of Epidemiology and Public Health Informatics, KDHE

12. Births and Deaths by Gestational Age, KS 2005-2009 Average All Races Pre-term = 10% Pre-term=61% Source: Bureau of Epidemiology and Public Health Informatics, KDHE Live Births Deaths

13. How old are babies when they die? Neonatal deaths (= <28 days old) are more common than post-neonatal deaths in all races and ethnicities Neonatal deaths (= <28 days old) are more common than post-neonatal deaths in all races and ethnicities This distinction is less important today This distinction is less important today LBW and prematurity more important than the age of the baby LBW and prematurity more important than the age of the baby Source: Bureau of Epidemiology and Public Health Informatics, KDHE

14. Our Question Based on cross-sectional data, 2005 to 2009 : Geary/Riley County IMR 8.50/1,000 live births (CI95 6.69-10.66) Fort Riley (TRICARE) IMR ? Kansas IMR 7.37/1,000 live births (CI95 7.00-7.74) 92% of Fort Riley TRICARE births occur to residents of either Riley or Geary County Source: Bureau of Epidemiology and Public Health Informatics, KDHE

15. Study Subjects TRICARE beneficiaries live births in Fort Riley, Kansas area (2005- 2009) N= 4715 Beneficiaries included resident live births where TRICARE was the delivery payor (2005-2009).

16. Fort Riley Area defined as: CountyBirths Marshall7 Morris18 Ottawa7 Pottawatomie91 Riley2226 Wabaunsee22 Washington4 CountyBirths Chase0 Clay70 Cloud6 Dickinson147 Geary2101 Lyon8 Marion8 Total Live Births 4715

17. Characteristics of Fort Riley, KS TRICARE Beneficiaries (2005-2009) HospitalIrwin(%) Other (%)Total(%) Kansas 366077.6105522.44715100 Maternal Race: White NH257270.380676.4337871.671.8 Hispanic43111.8837.951410.916 Black NH41511.3938.850710.86.8 Other/Multi NH1283.5383.61663.51.7 Asian/PI NH852.3292.71142.42.7 Native Am NH280.860.6340.7 Maternal Age : <15 years20.10020 15-192827.7989.33808.110.3 20-24164544.944442.1208944.327.4 25-29111030.330428.814143030.3 30-3445012.312912.257912.320.9 35-391474.0736.92204.79 40-44240.77 310.71.9

18. Characteristics of Fort Riley, KS TRICARE Beneficiaries (2005-2009) HospitalIrwin(%) Other (%)Total(%) Kansas 366077.6105522.44715100 Maternal Education: <HS2175.9858.13026.41.3 HS104628.630629135228.718.9 >HS239765.565762.3305464.824 Unknown0070.7740.155.9 Maternal Risk: Smoking50213.720919.871115.116.1 Unmarried3228.8837.94058.637.3 Gestational Hypertension220.6424641.43.9 Gestational Diabetes260.7373.5631.33.8 Ecclampsia501.440.4541.10.2 Previous Preterm Birth40.1403.8440.92.9

19. Characteristics of Fort Riley, KS TRICARE Beneficiaries (2005-2009) HospitalIrwin(%) Other (%)Total(%) Kansas 366077.6105522.44715100 Birth Weight: <1500 kg110.3434.1541.11.4 1500-2499972.714113.423855.9 2500+35519787182.6442293.892.7 Prenatal Care: 1 st Trimester292279.878874.7371078.769.1 2 nd Trimester60316.519518.579816.919.7 3 rd Trimester11134241533.23.7 Unknown220.6191.8410.96.4 None20.1111130.31.1 Cause of Death: Other9508471748.628 Congenital6337411337.123 Respiratory0021225.7- SIDS2110025.715 Infection150012.8-

20. Analysis of Direct and Network Births Fort Riley, KS (2005-2009) DirectCareNetworkCare IrwinArmyOffPost BirthsPercentBirthsPercent Total delivery37301001119100 Vaginal delivery (w/o cc)237763.759553.2 Cesarean section (w/o cc)49213.228425.4 Complicated delivery (Vag & C-cc)86123.124021.4 Source: Medical Management Database, Irwin Army Community Hospital

21. Infant Mortality Rate: TRICARE Beneficiaries at Fort Riley Area, KS 2005-2009 Infant Mortality Rate: TRICARE Beneficiaries at Fort Riley Area, KS 2005-2009 Live births = 4715 Deaths = 35 IMR = 35 / 4715 *1000 = 7.42 CI95 (5.17 - 10.32) Infant death= Death of an infant before his or her first birthday Infant mortality rate= Number of infant deaths per 1,000 live births.

22. Average Infant Mortality Rates (IMR) for Fort Riley TRICARE Beneficiaries with Delivery on Post vs. Off-Post (2005-2009) Live Births= 4,715 Delivery Location Live Births Deaths IMR (CI95) Post (Irwin) 3,660 18 4.92 (2.91 - 7.77) Off -Post (Other) 1,055 17 16.11 (9.39 - 25.8)

23. Kansas Ranked Worst among States for Black Infant Mortality Rate (IMR), 2007 StatesBlack IMR Kansas18.98 Oklahoma18.03 District of Columbia16.61 Missouri16.48 Michigan16.39 Rhode Island16.00 Indiana15.99 Tennessee15.74 Virginia15.41 Wisconsin15.18 USA13.24 Source: National Vital Statistics Report: Volume 58, Number 19

24. Infant Mortality Rate: TRICARE beneficiaries at Fort Riley Area, KS 2005-2009 Infant Mortality Rate: TRICARE beneficiaries at Fort Riley Area, KS 2005-2009 Black NH Live births = 507 IMR = 18.98 Projected Deaths = 9 Observed Deaths = 0 Infant death = Death of an infant before his or her first birthday Infant mortality rate = Number of infant deaths per 1,000 live births.

25. Military Infant Mortality Rate Kansas military IMR (birth cohort): Kansas military IMR (birth cohort): 5.77/1,000 live births CI95 (4.25- 7.64) 5.77/1,000 live births CI95 (4.25- 7.64) Other study has had consistent finding of reduced Black NH infant deaths (rate cut in half)* Other study has had consistent finding of reduced Black NH infant deaths (rate cut in half)* Research focusing on possible sociologic effect of military culture Research focusing on possible sociologic effect of military culture * Hicks Lundquist et al, Race and Preterm Births: A Protective Effect of the Military? National Science Foundation SES 0751505, publish pending

26. Source: Kansas Annual Summary of Vital Statistics, 2009

27. Summary KS IMR is higher than in most other states KS IMR is higher than in most other states Rates are higher in KS than U.S. for all race and ethnic groups (especially Black NH) Rates are higher in KS than U.S. for all race and ethnic groups (especially Black NH) Causes of infant deaths mimic those in other states: Prematurity and LBW are key factor Causes of infant deaths mimic those in other states: Prematurity and LBW are key factor Fort Riley specific IMR lower and consistent with other study Fort Riley specific IMR lower and consistent with other study Protective effect against infant mortality particularly for Black NH in the military setting Protective effect against infant mortality particularly for Black NH in the military setting

28. Support Partner Programs Kansas Blue Ribbon Panel on Infant Mortality Kansas Blue Ribbon Panel on Infant Mortality PPOR analysis from KDHE PPOR analysis from KDHE FIMR programs in the state FIMR programs in the state March of Dimes March of Dimes Prematurity conference Prematurity conference Prematurity Coalition Prematurity Coalition SIDS Network of Kansas SIDS Network of Kansas Safe Sleep video Safe Sleep video Presentation at Conferences KAAP, KAFP Presentation at Conferences KAAP, KAFP

29. Point of Contact for Study: Paul Benne, MD, MPH Lieutenant Colonel, Medical Corps 600 Caisson Hill Rd Fort Riley, KS 66442 785 239 7323 Acknowledgements: SPC John Makinwa US Army, Fort Riley Mr. Greg Crawford Ms. Jamie Kim Ms. Carol Moyer Kansas Department of Health and Environment Dr. Dennis Cooley Kansas Blue Ribbon Panel on Infant Mortality