In observation of National Infant Mortality Awareness Month, here’s an article from the Fall 2019 issue of Northeast Ohio Medical University’s Ignite magazine.
At any given moment, millions of people depend upon data to prescribe what they should do in a certain situation.
Data optimizes traffic lights and driving patterns. It guides business decisions. When we search for information on the web, Google’s algorithms crunch the data and delivers the best possible results.
Data can also be used to disseminate information for best practices in health care.
A nonprofit called Better Health Partnership collects data from health care providers and other stakeholders as a way “to share best practices and to accelerate data-informed improvements,” says Rita Horwitz, President & CEO of the Northeast Ohio organization, which was established in 2007 with support from the Robert Wood Johnson Foundation. One focus? Learning what issues are contributing to premature births.
Many people are aware of deaths from violence in the U.S. – there were nearly 20,000 victims of homicide in 2017 – and recognize the impact that public policy strategies can have in addressing prevention at a population-based level.
Yet the rate of infant mortality is not nearly as well known.
According to the Centers for Disease Control and Prevention (CDC), in the year 2017 alone, 22,335 babies died before their first birthday. We don’t receive news notifications on our phones about these babies and the stories are rarely shared via social media. It is as if these deaths had not even occurred.
Yet many of those 20,000 infant deaths could have been prevented, had the families been aware of some simple practices. Those practices might have enabled their babies to live and utter those first “googoo, ga-ga” sounds that we take for granted until they go silent.
“Maternal and Child Health” is among the 33 health concerns listed on the American Public Health Association (APHA) website, which provides great resources and education – including a focus on ending preventable deaths among all women, children and adolescents.
But since the rate of infant mortality is not well known by the general public, it could be argued that the Infant Mortality Rate (IMR) should also be listed and highlighted separately, as it is highly preventable and needs more public education and awareness than it receives
Thousands of Babies Dying Before Their First Birthday Should Not Be “A Thing”
Yet, available preventative and healing strategies are not being used, and thousands of babies are dying not long after they are born. Infant mortality is defined as the death of a live-born baby before their first birthday. The IMR is the number of infant deaths per 1,000 live births. In 2017, the IMR in the United States was 5.8 deaths per 1,000 live births, meeting the Healthy People 2020 target of 6.0 infant deaths per 1,000 live births. Healthy People provides science-based, 10-year national objectives for improving the health of all Americans.
If the IMR goal is being met and the infant mortality rate is supposed to serve as an important marker of the overall health of a society, something’s amiss in this formula. The 2019 edition of the Bloomberg Healthiest Country Index, which ranks 169 economies according to factors that contribute to overall health, lists the U.S. as number 35. Thirty-fifth!
We can’t be doing too well.
Progesterone Prevents Some Premature Births
“Twenty years ago, two-thirds of infant deaths before age one was due to prematurity. Now, it’s at about 35%,” notes Elena M. Rossi, M.D, FAAP, associate medical director for special projects at Akron Children’s Hospital’s Boardman, Ohio location. “That’s thanks to neonatology, obstetric care and the use of progesterone.”
Progesterone is a hormone that helps the uterus grow during pregnancy and keeps it from having contractions. Treatment with progesterone may reduce the risk for premature births; it also prevents premature birth recurrence, says Dr. Rossi, a neonatologist who also serves as clinical professor of pediatrics at Northeast Ohio Medical University. “If a woman who has a premature birth becomes pregnant again, by taking progesterone she has a 40% chance of carrying the pregnancy further.” But locally, for example, only half the women who are eligible receive it, Dr. Rossi notes.
A pregnant woman can qualify for progesterone in one of two ways: She must have had a previous premature birth or she must have a short cervix. Ohio’s Go When You Know campaign stresses the importance for a woman to seek prenatal care as soon as she knows she is pregnant and to talk to her provider about progesterone. This allows them to be evaluated for progesterone and get a cervical length ultrasound, which lets them know that they have a short cervix. Even if the pregnant woman hasn’t had a premature birth before, this would let them know that they could still benefit from progesterone, which they might be eligible to receive once a week, starting at 16 weeks. If they don’t get the cervical length ultrasound when they see their prenatal care provider, then they won’t be offered the progesterone to potentially prevent a premature birth.
But prematurity is just one of many contributors to infant mortality. And progesterone is just one of several best practices that would prevent thousands of these deaths from occurring.
A Before and After Checklist
With Ohio’s infant mortality rate (in 2011) nearly 30 percent higher than the national average, the Ohio Equity Institute was formed in 2013. The data-driven and evidence-based initiative consists of nine Ohio communities and the Ohio Department of Health partnering to focus on improving birth outcomes and reducing racial disparities in infant mortality.
The nine communities are Butler County, Canton-Stark County, Lucas County/Toledo, Cincinnati, Mahoning County/Youngstown, Columbus, Montgomery County/Dayton, Cuyahoga County/Cleveland, and Summit County.
There are some things that are known to increase the likelihood of having a healthier baby and to reduce the infant mortality rate. And “we have a checklist,” says Dr. Rossi. Safe sleep. Birth-spacing. Tobacco. Progesterone eligibility.
“In Mahoning County/Youngstown they already had the MY Babies First Infant Mortality Coalition,” says Dr. Rossi. “And they were ahead of some of the other communities — already thinking about safe sleep; breastfeeding (they found they couldn’t impact that change); birth spacing; and progesterone. But in 2016, they added tobacco – a huge, potentially preventable factor for infant mortality.
“They did a huge awareness campaign to educate people. Although they reached their overall goal in Mahoning County with IMR of less than six per thousand, the impact of poverty, stress and lack of prenatal care remained. The IMR is still three times higher for blacks, with black women having higher risks – even when educated — of IMR, low birth rate and their own maternal death.
“This is devastating to parents. And so, many choose to get pregnant again quickly. We’re all in this together, we all want healthier outcomes; but we need to educate the entire family,” adds Dr. Rossi.
According to the passionate physician, many don’t want to hear advice. When she expressed her concern about a TV show storyline in which a character on “The Big Bang Theory” was sleeping in the crib with her baby, the backlash was huge.
Evidence-based practices on Dr. Rossi’s checklist
For safe sleep, mothers shouldn’t fall asleep with their babies while breast-feeding. And babies must sleep on their back for a least a year in an empty crib. Everyone can get a cribette and car seat for free. Promote the ABCs — Alone, Back, Crib — of safe sleeping. [See sidebar.]
For birth spacing, if you get pregnant within 12 months of a previous delivery, low birth weight and prematurity goes way up. The recommendation is to wait at least 18 months before becoming pregnant again.
Regarding progesterone, six years ago, agencies didn’t know much about it — only obstetricians did, but they were seeing patients too late in their pregnancies to help.
And tobacco? In 2017, 33% of mothers with babies in the NICU used tobacco. The number was 25% in the ’90s. “Recent data says that people want to stop but they just don’t have a lot of success.
Unfortunately, no one thinks there’s harm in e-cigarettes, so many of Ohio’s cities are working on age 21 and over laws to buy them,” says Dr. Rossi. [Gov. Mike DeWine recently signed a bill which states that all Ohioans must be at least age 21 to legally buy cigarettes, cigars, vape pens and other tobacco products. The law takes effect October 1, 2019.]
So, the coalition changed its education from “Do you smoke”? to “Are you interested in stopping?” and “Here are the effects that smoking has on your baby … secondhand and thirdhand.” Free resources, such as 26 weeks of nicotine replacement products, are available, too.
Follow the Leaders
By 2017, Ohio had the ninth-highest IMR in the country, at 7.2. But, while the state’s infant mortality rate for Hispanic and white infants was lower in 2017 than in 2016, the rate for black infants — at 15.6 in 2017 — increased, with black infants dying at three times the rate as white infants. That’s bad news, but it’s worth noting that best practices are making a difference in counties such as Butler, Franklin, Stark and Summit, which saw fewer black infant deaths in 2017.
Local groups within all nine counties in the Ohio Equity Institute are pursuing evidence-based strategies and promising practices to reduce infant mortality and address racial disparities in birth outcomes. State and federal funding is supporting these eff orts. During the past eight years, Ohio has invested more than $137 million to help more babies reach their first birthdays. One new strategy that began last year involves the use of “neighborhood navigators” to identify pregnant women in their community who may be at risk for a poor birth outcome and connect them with needed health care, social and other services.
In Cuyahoga County, where significant disparities in birth outcomes exist based on race, ethnicity and location, First Year Cleveland is working on a unified strategy centered on reducing racial disparities, addressing extreme prematurity and eliminating sleep-related deaths.
“In 2018, the infant mortality rate in Cuyahoga County was 8.5 — reduced by 20% from 2015’s 10.5. The goal is to get to 6.0 by 2020. We’ve impacted sleep-related deaths — reducing them from 27 in 2015 to 19 in 2018 through increasing public awareness, education and addressing cultural practices related to safe sleep,” says Horwitz. “But the leading contributing factor to infant deaths in our region has been prematurity which we have only reduced from 14.9% in 2015 to 11.9% in 2018. Our goal is reduce prematurity as a factor to less than 10% by 2020.”
A Community Responds
In December 2015, First Year Cleveland (FYC) was formed by the CEOs of health systems in Cuyahoga County and other leaders in the city of Cleveland, Cuyahoga County and the state of Ohio who came together to call for an eff ort to help save “our babies and make sure that they celebrate their first birthdays.”
They also needed an organization like Better Health Partnership, which could respond quickly to the issue, given their well-established infrastructure and process for leading collaboration, getting and collecting data and getting consensus around modifiable interventions that could have the greatest impact on reducing extreme premature birth.
By taking an overall systems view, First Year Cleveland assembled 11 action teams to take part on different issues. For example, the racial disparities team works with employees in workplaces to look for any potential biases that might be negatively impacting maternal and child health outcomes. The families team focuses on those who have experienced a loss, helping them to gain perspective on losses that occur in the prenatal period, in the hospital or after the mother has gone home following giving birth.
Then there’s the extreme prematurity team. This group aims to get at the root causes of prematurity by working with hospital systems and researchers. Called Action Team No. 4, Better Health Partnership works with four major health systems — MetroHealth, Cleveland Clinic, University Hospitals, and Southwest General — to collect 2018-2019 data to identify and replicate best practices of modifiable interventions that can prevent or delay premature births and optimize outcomes of periviable births.
Better Health Partnership is looking at zip codes and their related demographics in Cuyahoga County, where infant mortality and preterm birth rates are the highest. Of those with the highest rates, most families are living below the poverty level and most are African American.
As Simple as it Seems
There’s a tendency by some to make assumptions about the demographic makeup of the grieving families. While poverty is a factor, many misconceptions have come to light. [See “Misconception vs. Reality” sidebar.]
The work continues. Better Health is connecting its clinical and demographic data with other First Year Cleveland Action Teams, which are working on research to better understand the roles that race and maternal stress play in infant deaths. They will also look for things that may beg a question or two, such as, “When there’s appropriate access to care, is there some unconscious bias in the plan of care that may be impacting outcomes?”
How to help more babies live past their first birthday?
“There’s no silver bullet to the issue of infant mortality. It’s multi-layered and complex. Whereas public health concerns like opioids may touch everyone, infant mortality may not,” says Horwitz. “We need to keep raising awareness and to educate the entire community on the causes of infant mortality and interventions that can help save our babies and ensure they celebrate their first birthdays. And we need to continue to look for best practices through the data supplied by the participating health systems; conduct learning circles; and disseminate what works with all providers of care.”