National Center for Chronic Disease Prevention and Health Promotion

1. Preventing Infant Mortality and Preterm Birth: Looking Beyond the Baby CAPT Wanda D. Barfield, MD, MPH Director, Division of Reproductive Health Region IV & Region VI Infant Mortality Summit January 12, 2012 National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health

2. Outline • The problem of infant mortality • What are some things for region IV and VI to consider? • Maternal health, community health, and social determinants for infant mortality • A public health framework for impact through community-based prevention efforts

3. U.S. Infant Mortality Rates1950-2007 Black, Non-Hispanic (NH) Total Deaths per 1,000 live births 13.3 6.75 5.63 Year NCHS National Vital Statistics Reports

4. State Infant Mortality Rates, 2004-2006 NCHS; prepared by Ashley Schempf, HRSA

5. What should region IV and VI consider? • Region IV and VI have excess deaths and racial disparities due to: • Extreme preterm neonates who die soon after birth • Infants (preterm and term) who die after the first month of life in their beds

6. Very Preterm Birth (<32 weeks) by State, 2004-2006

7. Source: CDC WONDER, Mortality Files

8. Tackling Infant Mortality: Frameworks/Resources • Life Course Perspective • Social Determinants • Impact Pyramid

9. CDC’s Division of Reproductive Health: Priority Areas Strategic Partnerships Science To Practice Optimal Reproductive Health for a Healthy Future

10. Public Health Infrastructure Surveillance Applied research Capacity building /workforce Healthy Communities Tobacco control Nutrition and physical activity Child and adolescent health Oral health Reproductive health Healthy Care Environments Promote delivery of clinical preventive services Chronic disease management Healthy schools and work environments CDC’s National Center for Chronic Disease Prevention and Health Promotion: Action Areas

11. Social Determinants: Influence on the Fetus and Infant community family mother fetus

12. Factors that Affect Health Smallest impact Largest impact Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

13. Potential Prevention Strategies • Improving Women’s Health • Preventing chronic disease, obesity • Smoking cessation • Preconception/ inter-conception care • Treatment of diabetes in pregnancy and postpartum • Long acting reversible contraception (birth spacing) • Safe infant sleep, injury prevention • New models of care (e.g. Centering) • Preventing non-indicated late preterm/early term births • Perinatal regionalization, Antenatal transport • Health insurance , Employment

14. Illustration: Impact Pyramid for Infant Mortality Prevention Smallest impact Largest impact Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

15. Reducing Infant MortalityExamples to Consider

16. Using Data in Communities to Assess Social Determinants • PRAMS (40 states and NYC) –All Region IV and IV states!! • State data linkages (FL, MA, MI) • Pregnancy Mortality Surveillance System (PMSS) (all states) • Perinatal Periods of Risk Assessments (any state) • Fetal-Infant Mortality Reviews • SUID Case Registry (CO, GA, MI, MN, NH, NJ, NM) • PerinatalCollaboratives (CA, NY, OH)

17. Improving Maternal Health

19. Changing the Context in Communities to Improve Social Determinants • Evaluation of state tobacco control policies, spending, and taxes on smoking before, during and after pregnancy and on birth outcomes (PRAMS) • Assessing Medicaid coverage of smoking • cessation services • Investigatingcauses of Sudden Unexpected Infant Death (SUID) to informpolicy for safe infant sleep environments

20. Improving SUID Surveillance

21. Evidence: risk of death for very-low birth weight/very preterm infants at non-level III facilities Review of 30 years of evidence on perinatal regionalization 104, 944 VLBW infants VLBW (≤1500g) infants (37 studies) OR 1.62, 95% CI 1.44-1.83 ELBW (≤1000g) infants (4 studies) OR 1.64 95% CI 1.14-2.36 Very Preterm (≤32 weeks) infants (4 studies) OR 1.55, 95% CI 1.21, 1.98 Interventions Available Now!Provision of Risk Appropriate Care Lasswell, Barfield, Rochat, Blackmon. JAMA 2010

22. Meta-Analysis of High Quality Publications on VLBW Infants Lasswell, Barfield, Rochat, Blackmon. JAMA 2010

23. Policy: States regulate health care services and facilities License hospitals Promulgate State Health Plans/Regulations Approve facility expansion and construction Implement Title V programs ($) Pay for provision of care (e.g. ICUs, transport) Many States have not meet Healthy People/MCHB Performance Measure goal of 90% VLBW infants delivered in level III facilities Provision of Risk Appropriate Care Blackmon et al, J Perinatol, 2009; Nowakowski et al, MCHJ 2009

24. Percent of LVBW Infants Delivered in Level III NICUs MCHB, Title V Information System

25. Proportion by State of Women of reproductive age living within 50 miles of a hospital with a subspecialty Neonatal Intensive Care (NICU) Unit, HHS regions IV and VI, 2008

26. SUMMARY • The problem of infant mortality in region IV and VI is driven by extreme preterm birth and SUID/SIDS • Maternal health, community health, and social determinants matter to reduce infant deaths and racial/geographic disparities • A public health framework for impact provides a practical approach for community-based prevention efforts

27. B I L L B O A R D

28. Questions? Centers for Disease Control and Prevention (770) 488-5200 (770)488-6450 (fax) drhinfo@cdc.gov The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. http://www.cdc.gov/reproductivehealth/ Optimal Reproductive Health for a Healthy Future