Where We Stand CAPT Wanda D. Barfield, MD, MPH, FAAP Director, - PowerPoint PPT Presentation

Infant Mortality in the US: Where We Stand CAPT Wanda D. Barfield, MD, MPH, FAAP Director, Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Accessible version: https://youtu.be/MM_G0MPdCJM 1 1 1

A Tale of Two Babies 1963 2001 2 2

What is Infant Mortality?  The death of a live-born infant before his/her first birthday  Neonatal period: 0 - 27 days  Postneonatal period: 28 - 364 days  The largest component of childhood mortality  A major indicator of societal health and well-being 3 3 3

Timing of U.S. Infant Death, 2011 Neonatal 33% 67% Postneonatal Neonatal (<28 days) Postneonatal (28-364 days)  Drivers :  Drivers:  Preterm  Sudden unexpected infant death (SUID)/Sudden infant  Birth defects death syndrome (SIDS)  Maternal health conditions  Injury  Lack of access to risk-  Infection appropriate care National Center for Health Statistics, National Vital Statistics Reports, 2011 4 4

U.S. Infant Mortality Rates, 1960-2011 Percent of Deaths per 1,000 live births 50 45 40 35 30 25 Total Black, Non-Hispanic 20 15 11.42 10 6.05 5 White, Non-Hispanic 5.11 0 1960 1970 1980 1990 1995 2000 2004 2007 2008 2009 2010 2011 Year National Center for Health Statistics, National Vital Statistics Reports 5 5

Trends: Birth Weight-Specific Neonatal Mortality 100 90 1950 80 1985 70 2008 60 50 Percent mortality 40 30 20 10 0 National Center for Health Statistics 6 6

Trends: Birth Weight Distribution 45 40 35 30 25 Percent of live births 1950 20 1985 15 2009 10 5 0 National Center for Health Statistics 7 7

Infant Mortality Rates, OECD Countries, 2008 Iceland 2.5 Sweden 2.5 Finland 2.6 Japan 2.6 Greece 2.7 Norway 2.7 Czech Republic 2.8 Italy 3.3 Portugal 3.3 Spain 3.3 Germany 3.5 Republic of Korea 3.5 Austria 3.7 Belgium 3.7 France 3.8 Ireland 3.8 Israel 3.8 Netherlands 3.8 Denmark 4.0 Switzerland 4.0 Australia 4.1 United Kingdom 4.7 New Zealand 5.0 Canada 5.1 Hungary 5.6 Poland 5.6 Slovak Republic 5.9 United States 6.6 0 1 2 3 4 5 6 7 Rate per 1,000 live births Health, United States, 2011 OECD: Organization for Economic Cooperation and Development 8

Infant Mortality Rate, 2006-2008 4.94 – 5.98 5.99 – 6.57 6.58 – 7.65 7.66 – 11.97 National Center for Health Statistics 9 9

Underlying Causes of Infant Death in the US, 2008 NEONATAL POSTNEONATAL Percentage of total Mortality rate (per Percentage of total Mortality rate (per Cause of death deaths (in specified 100,000 live births in Cause of death deaths (in specified 100,000 live births group) specified group) group) in specified group) Disorders related to short Sudden infant death gestation and low birth syndrome 21.7% 50.4 weight, not elsewhere 25.4% 109.0 Congenital classified malformations, deformations and 15.6% 39.6 Congenital malformations, chromosomal anomalies deformations and 21.7% 93.1 chromosomal anomalies Unintentional injuries 12.0% 27.9 Maternal complications of Diseases of the pregnancy 9.6% 41.0 circulatory system 4.9% 11.5 Complications of placenta, Gastritis, duodenitis, and cord and membranes 5.9% 25.1 non-infective enteritis and 3.4% 7.9 colitis Bacterial sepsis 3.7% 15.9 *ICD-10 codes grouped by modified Dolfus classification scheme http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_06.pdf 10

Contribution of Preterm Birth to U.S. Infant Mortality Percent of Live Births and Infant Deaths by Weeks of Gestation, US, 2007 Infant Deaths Births ≥ 37 <32 32-33 34-36 ≥37 <32 32-33 34-36 9% 32% 54% 10% 87% National Center for Health Statistics, linked birth/infant death data set 11 11

U.S. Infant Mortality Rates for Selected Causes of Death for Non-Hispanic Black and Non-Hispanic White Women 600 Non-Hispanic black Non-Hispanic white 599 Infant mortality rate per 500 100,000 live births 400 300 200 178 165 100 124 108 30 58 61 0 Preterm-related Congenital SIDS Unintentional causes malformations injuries CDC/National Center for Health Statistics, linked birth/infant death data set, 2007 12 12

Contribution of Preterm Birth to the U.S. Infant Mortality Rate  The tiniest babies bear the biggest burden  More than 50% of infant deaths occur among infants 32 weeks gestation or younger  Annual societal economic burden  $26.2 billion (2005)  Major contributor to poor international rankings  US ranks 130 of 184 in preterm births 13 13 13

Maintaining the Gains: Provision of Risk-Appropriate Care  Meta-analysis of 30 years of data on perinatal regionalization (104, 944 VLBW infants)  Odds of death at non-level III facilities  Infants weighing ≤1500g • OR 1.62 (95% CI 1.44 - 1.83)  Infants weighing ≤1000g • OR 1.64 (95% CI 1.14 - 2.36)  Infants born ≤32 weeks • OR 1.55 (95% CI 1.21 - 1.98)  In the US, many of these infants are not delivered in level III facilities Lasswell SM, Barfield WD, Rochat RW. Perinatal regionalization for very low-birthweight and very preterm infants: a meta-analysis. JAMA 2010 Sept 1;304(9) VLBW: very low birthweight 14 14 14

Contribution of Cigarette Smoking to Infant Mortality  Prenatal smoking occurs in 11.5% of all U.S. live births  Smoking in pregnancy accounts for  5%-8% of preterm deliveries  13%-19% of low birth weight among term infants  23%-34% of deaths due to SIDS  5%-7% of deaths from preterm-related causes  Potentially preventable Dietz PM, England LJ, Shapiro-Mendoza CK, et al. Infant morbidity and mortality attributable to prenatal smoking in the U.S. Am J Prev Med 2010 Jul .38(1) 15

Five Current National Strategies for Infant Mortality Reduction  Prevention of Elective Deliveries < 39 weeks  SIDS/SUID Risk Reduction  Perinatal Regionalization  Smoking Cessation in Pregnancy  Preconception and Interconception Care ASTHO President’s Challenge: www.astho.org ASTHO: Association of State and Territorial Health Officials 16

Circle of Influences on Fetal and Infant Health community family mother fetus 17

Pregnancy Risk Assessment Monitoring System (PRAMS): Using Data to Reduce Infant Deaths Denise D’Angelo , MPH Health Scientist, Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention 18 18

PRAMS Overview  Population-based surveillance system  Self-reported maternal behaviors and experiences around the time of pregnancy  Supplements birth certificate information  State and near-national estimates 19

PRAMS Background and Goals  Established in 1987 as part of an Infant Health Initiative  Congressional funding provided to CDC to establish state-based programs  Reduce maternal and infant morbidity and mortality  Maternal and infant health programs  Health policies  Maternal behaviors 20 20

Who Participates in the PRAMS Surveys?  Women who recently delivered a live infant  Random sample from birth certificate records  Women are sampled when infants are 2 - 6 months old  State sample ~1500 – 3000 women per year  40 states and NYC (combined annual sample ~ 77,000) 21

Representative Sample Coverage Weight Sampling Weight Response Weight Sample Respondents Population Frame 22 22

PRAMS Participation, 2012 WA NH ME VT MN OR MA WI NY CT WY MI RI IA PA NYC NE NJ OH IL DE UT WV CO MD VA MO NC TN NM OK AR SC MS AL GA LA TX AK FL HI PRAMS represents approximately 78% of all U.S. live births 23 23

PRAMS Surveys  Data collection primarily by mailed paper survey  Survey booklets are 14 pages and around 85 questions in length  Telephone follow-up  Takes 20 - 30 minutes to complete 24

Selected PRAMS Survey Topics  Breastfeeding  Cigarette smoking and alcohol use Cigarette smoking during pregnancy  Contraceptive use  HIV counseling and testing  Infant sleep position Infant Sleep Position  Influenza vaccination  Medicaid and WIC participation  Multivitamin use  Physical abuse  Preconception health  Prenatal care  Unintended pregnancy 25 25

Smoking During Pregnancy, 26 PRAMS Sites 35 30 25 20 Percent 15 10 5 0 Overall AK AR CO DE GA HI ME MD MA MN MO NE NJ NY NYC OH OK OR PA RI TX UT VT WA WV WY States Pregnancy Risk Assessment Monitoring System, 2010 26 26

Smoking During Pregnancy, by Race and Age Race Age White <=19 Black 20-34 Hispanic ≥35 Other 0 5 10 15 0 5 10 15 Percent Pregnancy Risk Assessment Monitoring System, 2010 27

Behind the Numbers “ I smoked a lot while pregnant with my daughter. As a result, she was born 6 weeks premature and weighed 3 lbs 6 oz. She stayed in the hospital for a month. People really don’t think smoking effects pregnancy, but it does (in) so many ways. I wish there was a way to stress to people the importance of NOT SMOKING!!” » PRAMS respondent 28 28

Infants Placed to Sleep on Back 90 80 70 60 Percent 50 40 30 20 10 0 Pregnancy Risk Assessment Monitoring System, 2010 29 29

Back Sleep Position, by Race and Age Race Age White <=19 Black 20-34 Hispanic ≥35 Other 0 50 100 0 50 100 Percent Pregnancy Risk Assessment Monitoring System, 2010 30