1. Preliminary Findings 2004 Infant Deaths TFIMR is a collaborative effort of the Tulsa Health Department, the Oklahoma State Department of Health, the Tulsa Healthy Start Initiative and the Tulsa Family Health Coalition.

2. Case Selection Criteria Infant <365 days old Resident of Tulsa County at birth and death Born and died in Tulsa County Died from causes other than an accident (infant deaths with unsafe sleeping environment are eligible for case review) Formal legal proceedings beyond initial investigations, not initiated Mother must have obtained PNC in Tulsa County

4. Hospital Abstractions

5. Case Review Team TFIMR 2004 Infant Deaths N=46

6. Home Interviews TFIMR 2004 Infant Deaths

7. Infant Characteristics and Risk Factors

8. Infant Deaths by Month of Occurrence

14. Hispanic Ethnicity 3 (6.8%) Hispanic ethnicity unknown 7 (17.1%) Hispanic ethnicity 34 (82.9%) Non-Hispanic ethnicity

15. Gestational Age (weeks) Term Births 37+ weeks10 (25%) Preterm <37 weeks30 (75%) Birth Weight VLBW <1,500g 22 (55.0%) LBW 1,500-2,499g 8 (20.0%) Normal 2,500g-3,90010 (25.0%)

18. 4

19. Grief/Loss Support 12 (26%) No clear documentation on who if any gave grief support to the mother after the infant died. 13 (28.3%) More than one person listed as providing grief support. 21 (45.7%) One person listed as providing grief support Grief support provided by Social Workers, Clergy, Nurses, volunteer pregnancy loss support group.

20. Father’s Information

21. Of the 44 fathers there is no information for 4 fathers Of the data collected, unknown values range from 22.5% to 40.0% making data reliability very low.

22. Mother Maternal Characteristics and Risk Factors

25. Mother’s Educational Attainment Of the 44 mothers who lost infants during 2004  Educational attainment is unknown for 6 (13.6%)  6 were over the age of 19 and had less than a high school education  4 mothers were under the age of 20 and were below their expected grade level

26. Mother’s Educational Attainment Age of Mother Grade Completed151617181920-2425-2930-3435-3940-44 <7th.1....1... 7th.1........ 8th.......... 9th11...1.... 10th...11.... 11th..1..4... High School Grad or GED...21522. 1st year of College & above.....21432 Total13132124632 Shaded area is below expected grade level.

27. Mother’s Employment Employed20  Employed, hours worked unknown 14  Employed full-time 6 Incarcerated 1 Student 6 Unemployed 16 Unknown 1

28. Mother’s Primary Language English40 (90.9%) Spanish 3 (6.8%)  PNC interpreter available for 1 mother, unknown if services were available for 2 mothers  L&D interpreter available for 2 mothers, 1 is unknown if services were available Vietnamese 1 (2.3%)  PNC mother provided her own interpreter part of the time, unknown if one was available at any PNC visit  L&D hospital provided an interpreter part of the time

31. Was nutrition discussed and documented in mother’s medical record? Yes 18 (26 mothers were under or over ideal body weight. Of those nutrition was discussed and documented for 12 (46%)) Nutritional risk factors identified and documented  1 folate deficiency  1 calcium, protein deficiency  1 caloric deficiency  1 PICA (eating non-food items)

33. Marital Status Married23 (52.3%)  16 living with FOB  6 unknown living situation  1 living with other relatives Single21 (47.7%)  5 living with FOB  3 living with her parent(s)  6 living alone or alone with siblings of infant  1 other relatives  1 incarcerated  5 unknown living situation

34. Mother’s Living Arrangement Unknown 11(25%) Father of the baby21  9 FOB alone  12 FOB and siblings Significant other 0 Mother’s parents 3  2 parents alone  1 parents and infant’s siblings Alone 6  2 alone  4 alone with infant siblings Other family 2  1 other only  1 other and infant’s siblings Incarcerated 1

35. Mother’s Health Insurance Medicaid24 (54.6%)  91.7% of the black mothers had Medicaid as their primary insurance  33.3% of the white mothers had Medicaid as their primary insurance Private 16 (36.4%)  Only 1 black mother had her private insurance as her primary insurance  51.9 % of the white mothers had private insurance as their primary insurance Self-pay 3 (6.8%)  100% of the self-pay mothers were of Hispanic ethnicity, 2 were not born in the U.S., 1 birthplace was unknown, all had Spanish as their primary language Medicaid & private 1 (2.3%)

36. Mother’s Tobacco Use Unknown tobacco use 3 (6.8%) No tobacco use24 (58.5%) Smoked during pregnancy17 (41.5%)  8 smoked 10 or fewer cigarettes per day  6 smoked 1 pack of cigarettes per day  2 smoked, unknown amount  1 smoked cigars

37. Mother’s Alcohol Use Three mothers admitted to alcohol use at PNC visits or at the hospital yet there was no documentation that they received a referral or education on the dangers of drinking during pregnancy Alcohol use unknown 7 (15.9%)

38. Mother’s Drug Use Marijuana use was unknown for 6 (13.6%) mothers. 5 mothers admitted marijuana use at either PNC visits or at the hospital but only 1 referral was documented. Of these 5 mothers, 3 were given drug screens, all were negative. No documentation was found for drug screens for 32 mothers Of the 12 drug screens administered:  8 were negative  4 were positive 3 were positive for marijuana (1 positive for THC, opiates, barbiturates) 1 positive for cocaine and opiates No referrals were noted in the medical records for any of these positive drug screens.

39. Prenatal Care 31 (70.5%) mothers began PNC during their 1 st trimester of pregnancy 11 (25%) mothers began PNC during their 2 nd trimester of pregnancy 1 (2.3%) attended PNC but it is unknown the week gestation she began PNC 1 (2.3%) mother did not receive PNC

40. Missed PNC Appointments

41. Method of Delivery Spontaneous vaginal27 (58.7%) Primary C-section13 (28.3%) Repeat C-section 3 (6.5%) Vaginal breech 2 (4.3%) Forceps 1 (2.2%)

42. Indications for C-Section Fetal Indications6  3 Footling breech  3 Fetal indications unspecified Maternal Indications9  3 Hemorrhage  2 Previous C-section  2 Chorioamnionitis  1 Pre-eclampsia  1 Failure to progress Unknown Indications1

43. Conditions Noted at Birth Amniotic fluid 7  3 Bloody  3 Foul odor  1 Bloody and foul odor  1 Cloudy  1 Meconium stained Abruptions Placental infection 1

44. Placental Exams No placental exams9 (20.%) Placental exams35 (79.5%)  23 (65.7%) Chorioamnionitis, Funisitis, Villitis 20 (57.1%) Chorioamnionitis 8 (22.9%) Funisitis 5 (14.3%) Villitis

45. Maternal Infections Infection Present 19 (43.2%)  Sexually Transmitted Infection present 15 (34.1%)  Other Infection Present 10 (22.7%) Group B Strep11 (25%) Chlamydia 7 (15.9%) Bacteriodes fragilis 4 (9.1%) Trichomonas 2 (4.6%) E. coli 2 (4.6%) One each of the following: 7 (15.9%)  Herpes, syphilis, gonorrhea, bacterial vaginosis, yeast, diptheriodes and prevotella, coccal UTI-organism not specified

46. Maternal Infections con’t. No Placental exams - 9  2 GBS positive Placental Exams - 35  No Chorio/funisitis/villitis present - 13 2 Chlamydia present 1 E.coli 1 GBS, Trichomonas, Yeast 1 E. coli, Chlamydia  Chorio/funisitis/villitis present - 22 1 GBS, bacteriods, Chlamydia 1 GBS, syphilis 3 GBS 2 Bacteroides 1 GBS, gonorrhea 1 diptheroides, prevotella 1 GBS, bacteroides 1 GBS, herpes, trichomonias

47. Did a Social Worker contact the mother during the hospital stay? Yes25 (56.8%) Documentation was found in the medical record of a Social Worker contacting the mother during the hospital stay.

48. Were any of the following problems identified during the mother’s hospital stay? None Depression Inadequate support system Inadequate housing Need for public assistance, Medicaid, food stamps, WIC Drug/alcohol abuse Crime/legal problems other

49. Discharge Instructions* Nothing noted in chart 2 (4.5%) Follow-up in __ weeks35 (79.5%)  1-2 weeks13  3-4 weeks 9  5-6 weeks13 Standard discharge instructions 29 (65.9%) Other discharge instructions 8 (18.2%) Mothers could be given more than one discharge instructions. Percents do not add up to 100.

50. How was the mother instructed to make her post partum follow-up appointment? Call for an appointment 24 (54.5%) Not mentioned 19 (43.2%) Appointment made before leaving the hospital 1 (2.3%)

51. Did the mother attend her post partum visit? Yes20 No 8 Unknown16 (36.4%)