Transcript Center for Maternal & Infant Health

Preventing Infant Mortality:
What We Know, What We Don’t,
and What You Can Do
Tom Ivester, MD, MPH
UNC School of Medicine
Division of Maternal Fetal Medicine
UNC Center for Maternal and Infant Health
June 12, 2007
Overview
 Snap shot of infant death in North Carolina
 What providers know and don’t know about
preventing infant death
 Items to study when reviewing cases
 The importance of obstetricians in the review
process
Infant Deaths in North Carolina
 Each week 19 babies die
before their first birthday
 Half of “excess” infant death
occurs in 13 counties
 29% of infant deaths occur in
the first hour of life
 The percent of multiple births
has increased
 22% of postnatal deaths
were to babies weighing less
than 1,500 grams
Causes of Infant Mortality in NC
All leading causes of infant death are higher in North Carolina
compared to the U.S. mean in 2004
Infant Deaths in NC

Infant deaths accounted
for 65% of all child deaths
from 2000 to 2004
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Birth defects and other
birth-related conditions
make up almost 50% of all
child deaths
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Your case reviews can
shape how North Carolina
addresses infant mortality
and reduces future risk
Source: NC Division of Public Health
Child Death by Cause in NC
Ages Birth through 17 years
Cause of
Death
Average
Annual
Number
20002004
Number
in 2003
Number
in 2004
%
change
from
last year
Birth Defects
207
209
219
5%
Other birthrelated
conditions
557
520
575
11%
SIDS
96
100
103
3%
Illnesses
283
285
286
0%
Unintentional
injuries
279
271
313
15%
Homicide
48
46
51
11%
Suicide
26
23
23
0%
All other
50
49
37
-24%
TOTAL
1546
1503
1607
6.9%
Infant Mortality Disparities in NC
 African American infants are 2.3 times more likely to
die than Caucasian infants.
 Between 2002 and 2004, preterm births were highest
among African American infants, at 18.7% of all live
births, compared with 11.9% of live births for
Caucasian infants
 Racial disparities increase with maternal
age
 The neonatal survival advantage of
AA babies has decreased over time.
Birth Defects: Causes & Related Factors
 Genetics
 Teratogenic medications
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Isotretinoin (e.g., Accutane)
Anti-epileptic drugs (e.g., valproic acid)
Levothyroxine (for hypothyroidism)
Oral anticoagulants (e.g., Warfarin)
 Inadequate folate consumption
 Alcohol and tobacco
 Obesity and Diabetes
 Toxic exposures at work and at home
 Many unanswered questions
Preterm Birth in NC
In 2004, 1 out of every 7 babies was born preterm.
The rate increased 8% in the past decade.
Premature Birth Facts
 Preterm births are defined as live births
occurring at <37 completed weeks gestation.
 Preterm births are the leading cause of
newborn death.
 The best known risk indicator is a previous
preterm birth.
Premature Birth Facts
The main routes leading to preterm labor are
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Maternal or fetal stress
Trauma
Preeclampsia (high blood pressure)
Infections
Bleeding
Uterine stretching
Drug intoxication
What we know
 Infant mortality rates are stagnant
 Premature birth is rising
 Birth defect rates have stayed
about the same
 Health disparities persist
What we don’t know
 All the triggers for early birth - the causes of
preterm birth are complex and multi-factorial
 The causes of many birth defects
 How to stop preterm labor once it has started
Where can we intervene?
The Socio-ecological Model
(Source: Gebbie, 2003 #174)
What to consider in a review
 Where was the baby born?
 Were the mother and baby cared for at appropriate
facilities by the right providers?
 What were the details leading up to the birth?
 Were steroids given prior to delivery to improve lung
development for preterm babies?
 Prenatal care

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Did she have it? When?
Cultural and/or physical access issues
 How does this case fit in with local mortality?
Consider…
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Family violence & stress
Tobacco, Alcohol and illicit substance use
Chronic disease management
Access to health care
Exposures (teratogenic drugs, environmental,
infections)
Nutrition (folate, overweight, underweight)
Closely spaced pregnancies
Maternal health conditions
Maternal age
Consanguineous pregnancies
What to recommend
 17 P in subsequent pregnancies to prevent
preterm birth
 Early prenatal care in next pregnancy
 Policy advocacy: improved preconception,
prenatal, and interconception health care
funding
What to recommend
Interconception Health
 Folic Acid
 Optimal control of maternal medical conditions
 Health education
Obstetricians are Key Resources
 Encourage medical facilities to conduct their
own internal infant death reviews and share
findings with the team
 Ask for periodic in-services by local
obstetricians
 If you have a health care provider vacancy –
consider inviting an obstetrician
Professional Resources
Resources available on www.mombaby.org:
 Preconception Health Resources
 Public Health Maternal Child Health Links
 OB Management Algorithms
 Patient / Provider Resources
 Infant Mortality data
 And More!
Questions?