1. Reducing Infant Mortality in Maryland S. Lee Woods, M.D., Ph.D. Medical Director, Center for Maternal and Child Health Maryland Department of Health & Mental Hygiene April 21, 2010

2. 2 Reducing Infant Mortality Partners include …. Office of Minority Health and Health Disparities Medicaid Behavioral Health  Mental Hygiene Administration  Alcohol and Drug Abuse Administration WIC Local Health Departments Department of Human Resources Governor’s Office for Children

3. 3 Infant Mortality in Maryland & U.S.

4. 4 Leading Causes of Infant Mortality

5. 5 Maryland Rankings  Infant Mortality39 th  Preterm Birth34 th  Low Birth Weight43 rd  SIDS / SUID35 th

6. 6 Racial Disparity in Infant Mortality Black:White ratio of 3:1

7. 7 Racial Disparity in Leading Causes of Infant Mortality In Maryland, a Black infant …. is 1 ½ times as likely to be born prematurely, almost twice as likely to be born at low birth weight, almost 2 ½ times as likely to die of SIDS/SUID as a white infant.

8. 8 Baltimore City Anne Arundel Howard Baltimore Caroline Queen Anne’s Prince George’s St. Mary's Charles Allegany Carroll Harford Cecil Kent Wicomico Dorchester Worcester Washington Garrett Frederick Montgomery Talbot Calvert Somerset Geographic Disparity in Maryland Average Infant Mortality Rate, By Jurisdiction, 2003-07 Legend Rate per 1000 live births 3.6 – 5.0 5.1 – 10.0 10.1 -14.8 Data Source: MD Vital Statistics Administration

9. 9 (1) Health and Health Care Risks – Lack of Early Prenatal Care – Associated with Increased Infant Mortality

10. 10 (1) Health and Health Care Risks – Lack of Early Prenatal Care – Associated with Increased Infant Mortality

11. 11 (2) Socio-demographic Risks – Racial Disparities Go Beyond Socio-Economic Factors From NCHS 1998-2000 data, Preterm Birth, IOM, 2007

12. 12 (3) Behavioral Risks – Unintended Pregnancy – Associated with Increased Neonatal Mortality * * Bustan et al, AJPH, March 1994

13. 13 (3) Behavioral Risks – Substance Abuse

14. 14 (3) Behavioral Risks – Substance Abuse  Non-pregnant women in treatment 48% White 49% Black 1.6% Hispanic  Pregnant women in treatment 45% White 52% Black 1.5% Hispanic

15. 15 (3) Behavioral Risks – Substance Abuse Data Source: Maryland PRAMS

16. 16 (3) Behavioral Risks – Substance Abuse Data Source: Maryland PRAMS

17. 17 Reducing Infant Mortality Governor’s Strategic Goal: Reduce infant mortality in Maryland by 10% by 2012 ************************* 2007 Baseline – 622 deaths, rate of 8.0/1,000 births 2012 Goal – 60 fewer deaths, rate of 7.2/1,000 births

18. 18 Reducing Infant Mortality – Targeting High-Risk Jurisdictions – 2007 Baseline Baltimore City Prince George’s Somerset 112 Infant Deaths Rate 11.3/1000 150 Infant Deaths Rate 11.7/1000 6 Infant Deaths Rate 24.0/1000

19. 19 Reducing Infant Mortality – Intervention Points Across the Life Span PRECONCEPTION (Before pregnancy) Healthier women at time of conception, planned pregnancies Earlier entry into prenatal care Comprehensive, high quality perinatal and neonatal care Healthier Children and Adults PRENATAL (During pregnancy) PERINATAL/N EONATAL (After delivery)

20. 20 Reducing Infant Mortality – Strategy 1 – Before Pregnancy Expand access to women’s comprehensive health and wellness services Transition 3 family planning sites into Comprehensive Women’s Health Programs. Transition 3 sexually transmitted disease program sites and 3 behavioral health program sites to implement expanded referral services. Include screening/referral for Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, smoking cessation, weight management services. Promote culturally-competent outreach and education efforts in the community.

21. 21 Reducing Infant Mortality – Strategy 2 – During Pregnancy Increase the # of women accessing early prenatal care Transition 3 local health department sites as pilot programs for implementing a Quick Start prenatal care program. Include screening/referral for Medicaid eligibility, WIC, substance abuse, mental health, domestic violence, and smoking cessation. Reduce the # of days between request for prenatal care and enrollment into Medicaid. Reduce the # of days between enrollment into Medicaid and first prenatal care visit.

22. 22 Reducing Infant Mortality – Strategy 3 – During and Following Delivery Expand access to more comprehensive, high quality perinatal and neonatal care Ensure that pregnant women identified through these programs receive timely perinatal care and appropriate follow up referrals for substance abuse, mental health, domestic violence, and smoking cessation. Develop a standardized hospital postpartum discharge process that ensures risk-appropriate follow-up care for mother and infant. Assure linkages to culturally-competent, community-based prevention services. Future data - Electronic Birth Certificate

23. 23 Reducing Infant Mortality in Maryland – Summary of the Plan APPROACH Assessing the Data & Targeting Disparities Building on Strengths & Partnerships Comprehensive Systems Approach GOALS Healthier Women/ Planned Pregnancies Earlier Entry into Prenatal Care Improve Quality of Perinatal and Post- Delivery Care STRATEGIES Comprehensive Women’s Health Centers Expediting Medicaid eligibility / Quick Start Prenatal Care Standardized hospital discharge protocols