Best and Promising Practices to Address Infant Mortality

1. Best and Promising Practices to Address Infant Mortality Janine Lewis, PhD (c), MPH President, Lewis Health Solutions

2. Overview Methodology Best Practices: Case Studies “One Stop Shop” Smoking Cessation Regionalization of NICUs in care of PT/LBW infants Back to Sleep Campaign NY: Community Based Regionalization Model Promising Practices: Case Studies The Magnolia Project Home Visiting Promising Practices in Reduction of Preterm Birth Conclusions Acknowledgements

3. Review of Literature/Unpublished Data Focus on new/emerging strategies that show promise in reducing infant mortality National/International

4. Causes of Infant Mortality Kung HC, Hoyert DL, Xu JQ, Murphy, SL. E-stat deaths: preliminary data for 2005 health E-stats. Hyattsville, MD: US Department of Health and Human Services, CDC; 2007

5. Methodology Literature search Conducted in October-November 2009 Search Terms PubMed “reduce” (n=74), “lower” (n=127), ‘”improve” (n=46),” decrease” (n=46) infant mortality (MeSH) “infant mortality/prevention and control” (MeSH) (n=30) “interventions to reduce infant mortality” (n=433) “programs in infant mortality reduction” (n=346) “decrease infant mortality through intervention” (n=170) “best practices in infant mortality reduction” (n=4) Google Scholar (first 100 reviewed) “programs in infant mortality reduction” (n~18,100) “interventions to reduce infant mortality” (n ~101,100) “best practices in infant mortality reduction” (n~16,900) Filters (humans, English, free full text from UIC) Two reviewers (JHL/AD; final review by Dr. Arden Handler)

6. Methodology Unpublished data obtained from MCH experts/review of Google New York San Diego

7. Selection Criteria Measured decrease in infant mortality over designated time period; Clear description of intervention/program (s) developed; Applicable to national (U.S.) setting

8. Exclusion Criteria For each intervention type studied, there are additional studies with negative results - this is not a thorough evidence based review of each intervention International studies: focused on health issues unique to countries with limited health infrastructure Infectious disease Unclear description of intervention/program (description of trends without explanation) Studies without reduction of infant mortality as outcome (i.e., preterm birth, low birthweight)

9. Definitions Best Practices strategies for which there is strong evidence in reducing infant mortality Promising Practices strategies for which there is some evidence of effectiveness in reducing infant mortality, but for which evidence is limited in some way—for example, small sample size, limited to specific ethnic/geographic target population, etc Not Tested strategies for which no evidence regarding their effectiveness was found

10. Infant Mortality Strategic Template Description of Practice Source/Supporting Research Impact of Intervention (sample size, IM trends, strengths/weaknesses) Location/Duration of Implementation Typical Budget/Funding Sources What is Needed to Implement in Kansas?

11. How can you get there? "The journey of a thousand miles starts with a single step." Lao Tzu

12. 1. “One Stop Shop” (Dane County, WI) • South Madison Health and Family Center – Harambee (Swahili for “pulling together” • Collaboration of 5 entities: 3 medical clinics; Head Start; and public library • 600 patients daily • “access plus trust”

13. “One Stop Shop” • Infant Mortality Statistics: • “Apparent Disappearance of the Black-White Mortality Gap” (MMMR, 2009) – Black infant mortality dropped by 67% since 1990, from 73/1,000 live births (1991-2002) to 17/1,000 (2002-2007) • Location/Duration of Implementation: • Dane County, Wisconsin • Strengths: • Large sample size (over 97,000 births 1990-2007); multiple intervention approach • Weaknesses: • Unclear exactly what is driving decrease in Dane County

14. 2. Smoking Cessation • Women identified that had 2 singleton births between 1983-2002 • Maternal smoking during 2 pregnancies: • Never smoker • Quitter • Starter • Persistent Smoker

15. Smoking Cessation • Infant Mortality Statistics: • Hazard ratios of infant mortality in 2.0 in persistently heavy smokers in second pregnancy; among those that stopped smoking in second pregnancy HR 1.4 among those who were heavy smokers in first pregnancy, HR 1.0 among those who had been light smokers • Location/Duration of Implementation: • Sweden (1983-2002) • Strengths: • Large sample size (555,046); shows dose-response effect of smoking cessation on infant health; “natural experiment” design • Weaknesses: • Self-report of smoking status; no data on smoking status post-delivery

16. 3. Birth of high-risk infants at hospitals with subspecialty care Place of delivery examined for VLBW infants Linked birth-death records used for 1994-1996 Georgia birth cohort Levels reviewed: 0, 1,2, 2+,3,4 “Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16–23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level.”

17. Birth of high-risk infants at hospitals with subspecialty care • Infant Mortality Statistics: • Neonatal mortality was 267/1,000 at level 2 hospitals; 176/1,000 for those infants at level 4 hospitals • Location/Duration of Implementation: • Georgia linked birth-death cohort (1994-1996); N = 4770 • Strengths: • Variety of variables included in model (i.e., race, education, marital status, age, prenatal care level, type of insurance, proximity to level 3 or 4 hospital • Weaknesses: • Self-report by hospitals on their perinatal care levels, inability to control for various maternal/infant/care characteristics

18. 4. Back to Sleep Campaign • Public Awareness Campaign which included: • Promotion of recommendations from AAP in 1992 and 1993 for infants to sleep on their backs to public from health practitioners and the media; • promotes the reduction of other environmental risk factors • for SIDS.

19. Back to Sleep Campaign • Infant Mortality Statistics: • From 1990-1995, SIDS death rates in Black infants dropped from 2.63/1,000 to 1.97/1,000 (20%) • Location/Duration of Implementation: • California birth-death cohort, 1990-1995 • Strengths: • Large sample size; reduction in SIDS rates not due to new classification of SIDS deaths to other causes • Weaknesses: • Smoking cessation effort occurred around the same time period; unclear whether decrease in SIDS deaths due to reduction in tobacco use or Back to Sleep Campaign; possible race misclassification

20. 5. NY Community Based Regionalization Model • Selected components include: • Newborn home visiting program, targeting high-risk communities; • Nurse-Family Partnership; • state and city perinatal depression initiatives, • several adolescent reproductive health programs • that work with health care providers and school based health centers to deliver accessible, • comprehensive sexual and reproductive health care; • Citywide Coalition to End Infant Mortality

21. NY Community Based Regionalization Model • Infant Mortality Statistics: • Among states with more than 10% of births to AA women in 2007; NY had lowest IM rate (11.7/1,000, 2003-2005); lowest white IM rate (4.65/1,000), lowest neonatal/postneonatal rates in 2007 • Location/Duration of Implementation: • New York State Births, 2003-2005 • Strengths: • Collaboration between community-based organizations and health professionals; organization of regional perinatal partnerships (beyond strictly medical model) • Weaknesses: • Program areas for expansion include increase of first trimester prenatal care, smoking cessation programs

22. 6. The Magnolia Project • Intensive holistic health program – targets high-risk non-pregnant women (outreach, CM, support, well-woman prenatal care, health education, and community development) • Infant Mortality Statistics: • Infant mortality rate in Magnolia Project Clients decreased from 81.3 to 35.7 following case management, while the infant mortality rate increased from 27.2 to 37.5 in the comparison group • Location/Duration of Implementation: • Women in targeted high-risk zip codes in Jacksonville, FL (2000-2005)

23. 7. Home Visiting Interventions • (Bangladesh) Community health workers identified pregnant women, provided education/nutritional supplements, provided 2 antenatal and 3 postnatal home visits, referred high-risk clients to hospitals • Infant Mortality Statistics: • Neonatal mortality was reduced in home care arm by 34% during the last 6 months of the 30 month intervention. • Location/Duration of Implementation: • Project effectiveness may be unique to location; clusters, not individuals, were randomly assigned; possible recall bias of behavior changes

24. Prevention of Preterm Birth Centering Pregnancy Parkland Memorial Hospital: A case study 17α-hydroxyprogesterone

25. Conclusions “One Stop Shop”/Lifecourse approach Regionalization Community/Medical Hybrid Approaches

26. Acknowledgements Arden Handler, DrPH Professor Community Health Sciences University of Illinois at Chicago Allison Dahlke MPH Student Community Health Sciences University of Illinois at Chicago

27. Questions? Comments? Janine Lewis (708) 250-2212 jlewis6@gmail.com