1. Infant Mortality: An Overview of Determinants and Prevention Opportunities for Regions IV and VI Ashley H. Schempf, PhD Office of Epidemiology, Policy and Evaluation Maternal and Child Health Bureau Health Resources and Services Administration, DHHS

2. Outline Basic epidemiology Background Data from 2004-2006 Period Linked Live Birth / Infant Death File Timing and Causes of Death Contribution of Preterm Birth Contribution of Racial Disparities Promising avenues for intervention

3. Background Infant mortality is a sentinel population health indicator Health of babies depends on the health of the population—not only mothers but fathers, families, and society US infant mortality rate (6.7 per 1,000 births) 28 th among industrialized countries Recent plateau after long decline

4. Period of Death Neonatal (<28 days) Comprise 2/3 of all deaths Driven by PTB/LBW, maternal/newborn health, risk-appropriate care Moderately preventable given current knowledge Postneonatal (28-364 days) Comprise 1/3 of all deaths Driven by SIDS, injury, infection Highly preventable with current knowledge

5. Infant Mortality by Period of Death Difference between Region IV and Other Regions is equally apportioned to excess neonatal and postneonatal mortality Difference between Region VI and the other regions is mostly postneonatal 6.8 7.0 6.3

7. Leading Causes of Death Underlying Cause*Death Rate Per 100,000 % of Deaths Prematurity and related conditions 206.330.5% Congenital anomalies 136.320.1% SIDS/SUID 81.012.0% Obstetric conditions 47.47.0% External causes 36.55.4% Perinatal infections 33.75.0% Other infections 21.03.1% Birth Asphyxia 11.11.6% All other causes 103.915.3% U.S. 2004-2006 *ICD-10 codes grouped by modified Dolfus classification scheme

8. What are the causes of excess infant death in Regions IV and VI? Underlying CauseRegion IV Rate Ratio* % of excess deaths Region VI Rate Ratio* % of excess deaths Prematurity and related conditions 1.3435%0.97-8% Congenital anomalies 1.107%1.1631% SIDS/SUID 1.5320%1.5252% External causes 1.498%1.199% Perinatal infections 1.396%1.146% Other infections 1.525%1.308% *Compared to all other regions; only causes contributing ≥5% shown

9. Preterm Birth Gestational Age% of Births% of DeathsIMR <28 weeks0.8%46.2%406.9 28-31 weeks1.3%8.5%44.7 32,33 weeks1.6%3.9%16.3 34-36 weeks9.0%9.8%7.2 All preterm, <37 weeks12.7%68.3%36.1 All term, 37+ weeks87.3%31.7%2.4 U.S. 2004-2006 About 2/3 of all deaths occur among preterm births Almost half occur among those born <28 weeks

13. Late Preterm Birth Accounts for ~10% of infant deaths May be highly preventable Largest component of PTB increase in 90’s Preliminary data indicate 5%↓ 2006-2009 IMR also has begun to decline again Promising Interventions Physician/patient/hospital education to reduce non-indicated late preterm / early term births Ohio Perinatal Quality Collaborative March of Dimes Tool Kit

14. Racial Disparities U.S.Region IVRegion VIOther Regions White IMR5.76.36.45.4 Black IMR13.514.013.113.3 Black-White Risk Ratio 2.42.22.02.5 Black-White Risk Difference 7.97.66.78.0 % Black Births14%25%14%11% Racial disparities are persistent and striking in every region Somewhat lower in Regions IV and VI because of higher rates among Whites (higher poverty is a key factor) Excess infant mortality would remain even if disparity were eliminated

15. What would happen if disparities were eliminated? Current LevelsBlack IMR = White IMR Deaths per 1,000 =1.9 =0.8 Disparities explain 56% of the gap between Region IV and Other Regions

16. Determinants of Black-White Disparity 2/3 neonatal, 1/3 postneonatal Neonatal contribution is driven by excess PTB, particularly <28 weeks Postneonatal contribution driven by SIDS, injury, and infection; prematurity also increases vulnerability Excess PTB accounts for 80% of disparity, ~60% from 3 fold disparity at <28 weeks * Proximate causes: infection, vascular disorders Distal determinants include lifecourse SES, environment, stress/discrimination, intergenerational factors * Schempf A, Branum A, Lukacs S, Schoendorf K. The Contribution of Preterm Birth to the Black-White Infant Mortality Gap: US, 1990 and 2000. American Journal of Public Health, 2007;97(7):1255-1260.

17. Guiding Frameworks/Resources Lifecourse/Multiple Determinants Perinatal Periods of Risk (PPOR) AMCHP State Infant Mortality Collaborative toolkit

18. Potential Avenues Maternal health Chronic conditions, obesity Smoking Unintended pregnancy, birth spacing Paternal involvement SIDS/SUID prevention Health Care Factors Regionalization (Title V Indicator) Health insurance (mothers and children) Preventing non-indicated late preterm/early term births Preconception care, new models of care

19. CDC, Behavioral Risk Factor Surveillance System

20. Current Population Survey, Annual Social and Economic Supplement

22. MCHB, Title V Information System

23. Acknowledgements Michael D. Kogan, PhD Director, Office of Epidemiology, Policy and Evaluation Cassie Lauver, ACSW Director, Division of State and Community Health Peter C. van Dyck, MD, MS, MPH Director, Maternal and Child Health Bureau