State Infant Mortality Toolkit

Why Focus on Infant Mortality?

Infant Mortality Seems to be a Problem for My Community This toolkit is designed to provide guidance in answering these questions whether it is for your state, county, urban area, tribal region or other population-based area. Evolving Where do I start? from the State Infant Mortality Collaborative, this toolkit l Who needs to be involved? was prepared using input from people like you who 1) care l Where do I get the data? greatly about their community, 2) are concerned about infant mortality, and 3) need assistance in gathering the l What do I do with the data? data, analyzing and interpreting it correctly, and making changes based on that information. Understanding and addressing infant mortality problems in your community may be challenging, but it is one of the most important things that can be done to improve the health of your population. ?

A Standardized Approach for Examining Infant Mortality 1 State Infant Mortality Toolkit

Why Focus on Infant Mortality? continued

A. Importance Figure 1: Infant Mortality Rate, United States, 1915-2007 Widely used as a measure of population health and the quality of health care, infant mortality is defined as the 100 death of an infant before their first birthday. Infant mortality 90 80 represents a long-standing concern of public health. The s Federal Children’s Bureau, established in 1912, focused on 70 infant mortality as its first initiative, officially recognizing its 60 importance. 50 40 The infant mortality rate is not only seen as a measure 30 of the risk of infant death but it is used more broadly as a 20

crude indicator of: Rate per 1,000 live birth 10 l Community health status 0 l Poverty and socioeconomic status levels in a community 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: NCHS - Final Mortality Data (1995-2007) l Availability and quality of health services and The annual infant mortality Figure 2: Infant Mortality Rates, United States, 1997-2007 medical rate is typically calculated technology by dividing the number of all Rate per 1,000 live births infant deaths in a given year 8 The health and 7.2 7.2 divided by the total number of 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.8 well-being of 7 6.7 live births in the same year, children and families and then multiplied by 1,000. 6 ? across the globe 5 are measured by infant mortality 4 rates. Wide acceptance and the relative ease of calculating 3 the annual rate have resulted in the infant mortality rate 2 being commonly used for comparisons across regions, populations and time periods. Such comparisons of infant 1 mortality rates are frequently used in needs assessments 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 and to evaluate the impact of public health programs. An infant death occurs within the first year of life. Source: March of Dimes, PeriStats / National Center for Health Statistics, B. National Trends in Infant Mortality final mortality data, 1990-1994 and period linked birth/infant death data, The precipitous decline in the U.S. infant mortality rate 1995-present. Retrieved September 12, 2012, from www.marchofdimes. (IMR) during the early 20th century (Figure 1) was attributed com/peristats. to improvements in milk supplies and sanitation, and to the discovery and availability of antibiotics. During the 1970s, In more recent years (as highlighted in Figure 2), progress 1980s and 1990s, infant mortality declines were mainly in reducing the infant mortality rate has slowed. Whereas the result of improvements in medical technology and between 1997 and 2007, the rate declined 5 percent, the practice in the obstetric and neonatal fields. Specifically, in overall rate has remained stagnant between 6.8 and 7.0 the area of high-risk obstetrics, antenatal corticosteroids per 1,000 live births since 2001. Further, the overall infant and intrapartum antibiotics have been linked to reductions mortality rate does not address the disparities that exist for in infant mortality. High-frequency ventilation, surfactant, many subpopulations (see sections on racial/ethnic and postnatal steroid use, thermoregulation, improved nutrition, geographic disparities). and advances in respiratory management all contributed To better understand opportunities to further reduce the infant to reductions in infant mortality during this time period. mortality rate, it is important to highlight that improvements Regionalization of perinatal services, particularly in the may stem from either: 1970s, led to improvements in infant survival by increasing l access to care in geographic areas where such services Decreases in the proportion of low birth weight (<2,500 were scarce. Increases in early and adequate use of grams) or preterm births (<37 completed weeks gestation) l prenatal care over the same period also contributed to Improvement in birth weight or gestational age specific improved perinatal health outcomes due to expansions in infant mortality rates (other cause-specific rates, such as public programs, such as Medicaid. birth defects and Sudden Infant Death Syndrome, may also play a role as discussed in other sections) A Standardized Approach for Examining Infant Mortality 2 State Infant Mortality Toolkit

Why Focus on Infant Mortality? continued As seen in Figures 3 and 4, there has been little to no mortality disparity rate ratio from 2.0 (1980) to 2.4 (2009). progress in reducing either low birth weight or preterm birth Although African American infants born with very low birth over the past decade. In recent years, the infant mortality weight (<1,500 grams) experienced a ‘survival advantage’ rate remained fairly stable, with a relative decrease of only that may have affected the disparity ratio, this ‘survival 4 percent from 2000 to 2008, from 6.9 to 6.6 per 1,000 live advantage’ began to decrease in the 1990s. births (www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf). Racial differences in access to high-risk (tertiary) perinatal Figure 3: Low Birth Weight, United States, 1999-2009 services have contributed to racial/ethnic disparities Percent of live births in adverse perinatal outcomes. Individuals, families, 10 communities, and regions that have experienced social and 8.2 8.3 8.2 8.2 8.2 economic disadvantage face greater obstacles to optimal 7.9 8.1 8 7.6 7.6 7.7 7.8 health. Race/ethnicity and a general lack of health equity are linked to exclusion or discrimination and are known 6 to influence health status (U.S. Department of Health and Human Services (HHS) Action Plan to Reduce Disparities 4 and www.nimhd.nih.gov/recovery/gosocialdeterm.asp). The landmark Institute of Medicine 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in 2 Health Care, cites lack of health insurance coverage as a significant driver of health disparities, as racial/ethnic minority 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 populations are more likely than the rest of the population to Low birth weight is less than 2,500 grams (5 1/2 pounds). be uninsured or underinsured; impacting the quality of health Source: March of Dimes, PeriStats / National Center for Health care received (HHS Action Plan to Reduce Disparities and Statistics, final mortality data. Retrieved September 12, 2012, from www.nimhd.nih.gov/recovery/gosocialdeterm.asp). However, www.marchofdimes.com/peristats. if infants are delivered at risk-appropriate facilities, regardless of race/ethnicity, survivability is increased. Figure 4: Preterm Birth, United States, 1999-2009 Additional contributors to disparities in infant deaths include Percent of live births infant age at death, cause of death, mother’s age and health, 15 multiple gestation (twins, triplets and higher order births), low 12.5 12.7 12.8 12.7 12.1 12.3 12.3 12.2 birth weight, preterm birth, assisted reproductive technology, 11.8 11.6 11.9 12 and prenatal visits.

9 Figure 5: Infant Mortality Rates by Race/Ethnicity, United States, 2005-2007 3-Year Average 6 Rate per 1,000 live births

15 13.4 3 12

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 8.8 Preterm is less than 37 completed weeks gestation. 9 Source: March of Dimes, PeriStats / National Center for Health 6.8 Statistics, final natality data. Retrieved September 12, 2012, from 5.5 5.7 6 4.8 www.marchofdimes.com/peristats. 3 C. Racial/Ethnic Disparities Infant mortality has reached historic lows, but there has been 0 Hispanic White Black Native Asian Total less success in eliminating racial and ethnic disparities in infant American mortality. Historically, infant mortality rates for infants born to All race categories exclude Hispanics. An infant death occurs within the first year of life. Source: March of Dimes, PeriStats / National African American mothers have notably been two or more times Center for Health Statistics, period linked birth/infant death data. higher than those born to white mothers (Figure 5). Since 1980, Retrieved September 12, 2012, from www.marchofdimes.com/peristats. there has been an increase in the African American/white infant

A Standardized Approach for Examining Infant Mortality 3 State Infant Mortality Toolkit

Why Focus on Infant Mortality? continued

D. Geographic Disparities There is significant variation in rates of infant mortality by state (Figure 6). State-specific rates of infant mortality are highest in the southern United States. In 2007, infant mortality rates ranged from a high of 12.9 infant deaths per 1,000 live births in the District of Columbia (not shown on map) and 10.0 in Mississippi to a low of 4.9 in both Washington state and Massachusetts. These disparities persist even after controlling for differences in the distribution of race and ethnicity among states. Potential contributors to regional differences may include access to and quality of health care, as well as health insurance access. Health care systems differ by region and should be included in an infant mortality assessment. For example, frontier state regionalized systems of care and neonatal transport may be very different from those in urban, densely populated settings. Additionally, the impact of population distribution, including nativity status, or migration, such as seasonal workers moving in and out of the area, should also be examined.

Figure 6: Infant Mortality Rates, United States 2007

WA NH VT ME MT ND

OR MN MA WI NY ID SD MI WY RI IA PA CT CA NE NV OH NJ IN DE UT IL CO WV MD KS VA MO KY NC TN AZ OK AK NM AR SC

MS AL GA TX TX LA

FL

HI

Rate per 1,000 live births Over 7.6 (15) 5.4–7.6 (19) Under 6.4 (17)

Source: National Center for Health Statistics, final mortality data, 1990-1994 and period linked birth/infant death data, 1995-present. Retrieved from www.marchofdimes.com/peristats.

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