2018 Infant Mortality Annual Report 2 Ohio Infant Mortality Report 2018 TABLE of CONTENTS

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2018 Infant Mortality Annual Report

  • 2
  • Ohio Infant Mortality Report 2018

TABLE OF CONTENTS

  • EXECUTIVE SUMMARY
  • 4

  • SECTION 1: GENERAL FINDINGS
  • 5-10

  • 5
  • Ohio Infant Mortality Rate by Race and Ethnicity (2016-2018)

Trends in Ohio Infant Mortality (2009-2018) Ohio Five-Year Average Infant Mortality Rates by County Neonatal and Postneonatal Mortality Rates
68
9-10

  • SECTION 2: A DEEPER LOOK
  • 11-19

11-12 13-14 15-16
17
Infant Mortality by Duration of Gestation and Birthweight Risk Factors among Ohio Infant Deaths Leading Causes of Infant Deaths Prematurity-Related Infant Deaths External Injury-Related Infant Deaths Deaths to Infants Less Than 24 Weeks Gestation
18 19

DATA SOURCES AND METHODS DEFINITIONS
20
21-22

  • 23
  • REFERENCES

  • APPENDICES
  • 24-45

24-25 26-29 30-45 30-36 37-45
Appendix A: The Ohio Equity Institute (OEI) Appendix B: Sleep-Related Deaths Appendix C: Supplementary Data Tables
Section 1: County-Level Infant Mortality Data Section 2: A Deeper Look

3

EXECUTIVE SUMMARY

Ohio has identified infant mortality as a priority in its 2017-2019 State Health Improvement Plan (SHIP)1. Infant mortality is the death of an infant before his or her first birthday. The Infant Mortality Rate is the number of infant deaths per 1,000 live births. The Infant Mortality Rate not only serves as a key indicator of maternal and infant health but is also an important measure of the health status of a community.

In 2018, the infant mortality rate fell to 6.9 from 7.2 in 2017 for all races. The rate among black infants fell to 13.9 in 2018 from 15.6 in 2017. However, the Ohio and national goal is 6.0 or fewer infant deaths per 1,000 live births in every racial and ethnic group. Additionally, racial and socio-economic inequities persist.

ODH continues to examine vital statistics and other data sources to monitor our progress and to better understand infant deaths so they may be prevented.

The following report presents results of analyses performed on infant deaths that occurred in 2018.

Key Findings

Section 1: General Findings

In 2018, Ohio’s infant mortality rate was 6.9 per 1,000 live births compared with 7.2 in 2017. From 2009 through 2018, Ohio’s infant mortality rate decreased at an average of 1.1% per year. After a five-year increase, the black infant mortality rate went from 15.6 per 1,000 live births in 2017 to 13.9 in 2018. Black infants still die at a rate 2.5 to 3 times higher than white infants.

Section 2: A Deeper Look

Prematurity-related conditions remain the leading cause of infant death in Ohio, comprising almost one-third of deaths.

Infant deaths attributable to external injuries increased from 79 deaths (8%) in 2017 to 95 (10%) in 2018. Almost a third (32%) of all infants who died were born prior to 24 weeks gestation. A full-term pregnancy is at least 37 weeks.

Preventable risk factors and opportunities for intervening were identified among infants who died.

  • 4
  • Ohio Infant Mortality Report 2018

SECTION 1: GENERAL FINDINGS

Ohio Infant Mortality Rate by Race and Ethnicity (2016-2018)

In 2018, 938 Ohio infants died before their first birthday, 44 fewer than in 2017 (Table 1, Figure 1). In 2017, Ohio registered 982 deaths. Ohio’s infant mortality rate for all races was 7.2 in 2017 and 6.9 in 2018 (Table 1). The black infant mortality rate was 15.6 in 2017 and 13.9 in 2018 (Table 1). Black infants were still more than 2.5 times more likely to die than white infants.

From 2009 through 2018, the infant mortality rate for all races decreased at an average of 1.1% per year while the white infant mortality rate decreased an average of 2.4% per year (Figure 2). The black infant mortality rate has not changed significantly since 2009.

Table 1: Ohio Infant Mortality by Race and Ethnicity (2016-2018)

2016
Infant Deaths
2017
Infant Deaths

982

2018
Infant Deaths

938

IMR*

7.4

IMR*

7.2

IMR*

  • 6.9
  • All Races**

Race
1,024
White Black American Indian Asian/Pacific Islander Ethnicity
610 369
2
5.8
15.2 **** 3.8^
550 384
0
5.3
15.6 ****
4.2
553 339
4
5.4
13.9 ****

  • 3.2^
  • 18
  • 20
  • 15

Hispanic Non-Hispanic***
54
970
7.3 7.4
54
928
7.2 7.2
45
893
6.1 7.0

Data Source: Ohio Department of Health, Bureau of Vital Statistics * Infant mortality rate per 1,000 live births. ** The total for all races includes 26 infant deaths of unknown race. *** Non-Hispanic deaths include those of unknown or missing ethnicity. **** Rates based on fewer than 10 deaths do not meet standards of reliability or precision and are suppressed. ^ Rates based on fewer than 20 infant deaths should be interpreted with caution.

5

Trends in Ohio Infant Mortality (2009-2018)

Figure 1: Trends in the Number of Ohio Infant Deaths, by Race (2009 – 2018)

1,200 1,100 1,000
900 800 700
1,109 738
1,086
1,064

687
1,047
675
1,024
641

  • 1,005
  • 1,024

982
955

938

553
672
610

369
580 367
568
550
600

500
384
371

  • 362
  • 363

  • 330
  • 338

  • 339
  • 344

400

300

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018

—— Overall —— Black —— White

Data Source: Ohio Department of Health, Bureau of Vital Statistics

Figure 2: Trends in Ohio Infant Mortality Rate (per 1,000 live births), by Race (2009 – 2018)

18.0
16.0
15.5
15.6

  • 15.1
  • 15.2

14.3

16.0

14.0 12.0 10.0
8.0

  • 14.0
  • 13.9

  • 14.2
  • 13.9

  • 7.7
  • 7.9

6.4
7.7
7.4 5.8
7.6
7.4

6.1
6.9 5.4
7.2 5.5
7.2 5.3
6.8 5.3
6.0

  • 6.4
  • 6.4
  • 6.4

4.0

2.0 0.0

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018

—— Overall —— Black —— White

Data Source: Ohio Department of Health, Bureau of Vital Statistics

  • 6
  • Ohio Infant Mortality Report 2018

Racial Disparity in Infant Mortality

Despite seeing gains in the overall and white infant mortality rates, there has been no significant improvement in the black infant mortality rate in the past 10 years. After five years of steady increase, the black infant mortality rate went from 15.6 per 1,000 live births in 2017 to 13.9 in 2018. This is an encouraging sign. However, there is still much work that needs to be done as black infants continue to die at a rate 2.5 to 3 times that of white infants (Figure 3).

Figure 3: Black/White Infant Mortality Ratio*, Ohio (2009-2018)

3.5 3.0
2.9
2.7
2.7
2.5

2.0 1.5

  • 2.6
  • 2.6

2.5
2.4
2.3
2.2
2.2

1.0

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018

Data Source: Ohio Department of Health, Bureau of Vital Statistics *Black Infant Mortality Rate divided by the White Infant Mortality Rate

7

Ohio Five-Year Average Infant Mortality Rates by County

Figure 4: Ohio Five-Year Infant Mortality Rate (per 1,000 live births), by County (2014-2018)

Lake
Ashtabula

Trumbull
Lucas
Williams
Fulton

Ottawa
Geauga
Cuyahoga
Wood
Sandusky
Erie
Defiance

Paulding
Lorain
Henry

Portage
Huron
Summit

  • Seneca
  • Medina

  • Mahoning
  • Hancock

Hardin
Putnam Allen

Ashland

Van Wert Mercer

  • Crawford
  • Wyandot

Stark

  • Columbiana
  • Wayne

Holmes
Richland
Carroll
Marion
Auglaize
Morrow

Jefferson
Tuscarawas
Knox

Logan
Harrison
Shelby

Miami

  • Union
  • Coshocton

Delaware

Darke
Champaign

Clark
Licking
Guernsey

Noble
Belmont
Muskingum
Franklin

Madison

Fayette

  • Montgomery
  • Monroe

Preble

Butler
Fairfield
Perry

Pickaway
Greene

Clinton
Morgan
Hocking

Vinton
Washington
Warren
Athens

Meigs
Ross
Highland
Hamilton

Infant Mortality Rate Per 1,000 Live Births

Pike

Clermont
Jackson

Gallia
Brown
Adams
Scioto

3.1 - 4.9 5.0 - 6.1 6.2 - 7.1 7.2 - 8.2

Lawrence

8.3 - 10.1 Rate not reported (<10 infant deaths)

N

  • Miles
  • 0
  • 15 30
  • 60

Data Source: Ohio Department of Health, Bureau of Vital Statistics

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  • Ohio Infant Mortality Report 2018

Neonatal and Postneonatal Mortality Rates

Neonatal deaths occur during the first 27 days of life while postneonatal deaths occur at 28 through 364 days of life. Neonatal deaths are the largest contributor to the overall infant death rate, accounting for about two-thirds of all infant deaths (Table 2). The difference in the overall infant mortality rate from 2017 to 2018 can be largely attributed to fewer neonatal deaths in 2018 compared with 2017. This is especially true in the black population. This is likely due to a drop in premature births, especially those born prior to 23 weeks gestation. The neonatal mortality rate for all races was 5.0 in 2017 and 4.7 in 2018. The black neonatal mortality rate was 11.3 in 2017 and 8.5 in 2018.

Table 2: Ohio Neonatal, Postneonatal, and Overall Infant Mortality
(per 1,000 live births), by Race and Ethnicity (2014-2018)

Neonatal Deaths

  • Neonatal
  • Postneonatal

Deaths
Postneonatal Mortality Rate
Total Infant Deaths
Infant

  • Race/Ethnicity
  • Year
  • Births

106,371

  • Mortality Rate
  • Mortality Rate

2014 2015 2016 2017 2018 2014 2015 2016 2017 2018 2014 2015 2016 2017 2018 2014 2015 2016 2017 2018

  • 406
  • 3.8

3.6 4.1

  • 162
  • 1.5
  • 568

580 610 550 553 344 367 369 384 339 955
1,005 1,024
982 938
43
5.3 5.5 5.8 5.3 5.4
14.3 15.1 15.2 15.6 13.9
6.8 7.2 7.4 7.2 6.9 6.2 6.0 7.3
379 429 375 393 252 252 255 278 208 692 667 713 684 632
32
201 181 175 160
92 115 114 106 131 263 338 311
298 306
11
1.9 1.7 1.7
106,028 104,957 103,709 102,570
24,133 24,288 24,316 24,542 24,359 139,514 139,312 138,198 136,895 135,226
6,885
White
3.6 3.8
10.4 10.4 10.5 11.3 8.5 5.0 4.8 5.2 5.0 4.7 4.6 4.3 5.1
1.6 3.8 4.7 4.7 4.3 5.4 1.9 2.4 2.3 2.2 2.3
1.6* 1.7* 2.2* 1.6* 1.3*
Black All Races
30 38 42 35
12 16 12 10
42 54 54 45
6,974 7,425 7,473 7,434
Hispanic Ethnicity (Any Race)
5.6

4.7
7.2 6.1

Data Source: Ohio Department of Health, Bureau of Vital Statistics * Rates based on fewer than 20 infant deaths should be interpreted with caution.

9

Neonatal mortality is associated with prematurity (preterm birth before 37 weeks gestation), low birth weight, congenital anomalies, and health problems originating in the perinatal period, such as infections or birth trauma. Between 2009 and 2018, the overall neonatal mortality rate decreased by an average of about 1% per year. The white neonatal mortality rate decreased an average of about 2% per year during the same time period. The black neonatal mortality rate has not changed significantly over the past 10 years (Figure 5).

Figure 5: Trends in Ohio Neonatal Mortality (per 1,000 live births), by Race (2009-2018)

11.3
12.0
11.0
10.4

  • 10.4
  • 10.5

10.1

  • 9.8
  • 9.9

9.3
10.0

8.0 6.0 4.0 2.0 0.0
8.5
5.2 4.3
5.2 4.2
5.2 4.3

  • 5.2
  • 5.0

3.8
5.2 4.5
5.2 4.1
4.7 3.8
4.8 3.6
5.0 3.6
4.4

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018

—— Overall —— Black —— White —— SHIP Target 4.3

Data Source: Ohio Department of Health, Bureau of Vital Statistics

Common causes of death in the postneonatal period include Sudden Infant Death Syndrome (SIDS), congenital anomalies, and unintentional injuries. Ohio’s overall and black postneonatal mortality rate did not change significantly between 2009 and 2018. The white postneonatal mortality rate decreased an average of 3.2% per year (Figure 6).

Figure 6: Trends in Ohio Postneonatal Mortality (per 1,000 live births), by Race (2009-2018)

6.0
5.5
5.4

4.9
4.7

  • 4.7
  • 4.6

5.0

4.0 3.0 2.0 1.0

  • 4.4
  • 4.3

3.8
3.8

2.6

2.2
2.5
2.1
2.5 1.9
2.4 1.9
2.4 1.9
2.3 1.6
2.3 1.7
2.1 1.8
2.2 1.7
1.9 1.5
0.0

  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018

—— Overall —— Black —— White —— SHIP Target 2.0

Data Source: Ohio Department of Health, Bureau of Vital Statistics

  • 10
  • Ohio Infant Mortality Report 2018

SECTION 2: A DEEPER LOOK

Infant Mortality by Duration of Gestation and Birthweight

Infant survival is highly associated with gestational age.

Although infants born less than 24 weeks accounted for 0.3% of total infants born, they accounted for about one-third of all infant deaths (Figure 7).

Despite the same proportion of babies born at full term (37 or more weeks gestation) in 2018 and 2017 (90%), the proportion of term babies dying was 35% in 2018 compared with 30% in 2017.

Figure 7. Proportion of Ohio Infant Births and Deaths by Gestational Age (2018)
Ohio Infant Deaths, 2018
Ohio Infant Births, 2018

20-23 weeks 0.2%

24-27 weeks 0.4%

28-33 weeks 2.2%

<20 weeks 0.1%

<20 weeks
9.9%

34-36 weeks 7.4%

20-23 weeks

  • 21.9%
  • 37 weeks or more

34.7%

37 weeks or more 89.8%

24-27 weeks

  • 12.4%
  • 34-36

weeks 10.4%
28-33 weeks 10.8%

Data Source: Ohio Department of Health, Bureau of Vital Statistics
11

Forty percent of the infants who died did not survive their first day of life (Figure 8).

Among infants who died (Figure 8):
Twelve percent occurred within the first hour of life.

Twenty-eight percent more died by the end of the first day of life. Thirty-three percent died after the first month of life, but before the first birthday (called post-neonatal death).

Most of the infants who died were born early or small.

Among infants who died:
Almost half (48%) were very low birth weight (<1,500g or 3 lbs 5 oz).

Almost half (44%) were born before 28 weeks gestation (called very preterm). Over a quarter (28%) were small for their gestational age [among singletons born at greater than 21 weeks of gestation].

Figure 8. Age at Death Among Ohio Infants who Died (2018)

33%
28%

  • 14%
  • 13%

12%

  • First Hour
  • First Day
  • First Week
  • First Month
  • First Year

Data Source: Ohio Department of Health, Bureau of Vital Statistics

  • 12
  • Ohio Infant Mortality Report 2018

Risk Factors Among Ohio Infant Deaths

Preventable Risk Factors for Infant Death were Common (Table 3).

Among infants who died:
Two in five whose mothers had a prior birth were conceived earlier than recommended (less than 18 months after the prior birth).

More than one-third were born to mothers who received no first trimester prenatal care. Twenty percent had a mother who smoked at the beginning of pregnancy. About one in 10 were born to a teenage mother. Almost forty percent (36%) of infant deaths were born to first-time mothers (first live birth), indicating the need for prevention efforts to target both first-time and non-first-time mothers.

Table 3. Common Risk Factors Among Ohio Infant Deaths (2018)

  • Risk Factor
  • %
  • #

Conceived <18 months after prior birth1 Mother smoked during first trimester of pregnancy Low income (presumed Medicaid) Father not named on birth certificate Mother’s education < high school Teen mother (<20 years of age)
42 20 57 31 18
9
160 188 524 288 144
72
Behavioral Social

  • No first trimester prenatal care2
  • 40

9
325
77
Healthcare
Born at inadequate level hospital3

1among infants whose mothers had a previous live birth 212.4% unknown 3An infant born in a hospital without the appropriate level of care given the infant’s gestational age and/or birth weight. Denominator includes infants born in a facility.

Data Source: Ohio Department of Health, Bureau of Vital Statistics

Many women whose infants died had health concerns prior to pregnancy.

Of the infants’ mothers:

One in three (38%) was obese. One in four (24%) smoked within three months of becoming pregnant. Pre-pregnancy hypertension (7%) and diabetes (2%) were relatively uncommon. However, these factors pose a high risk to pregnancy.

13

Infant deaths were not evenly distributed among the Ohio population.

Among infants who died:

More than 33% had a non-Hispanic black mother. Almost two-thirds (60%) lived in an urban county targeted through the Ohio Equity Institute in Birth Outcomes (OEI): Cuyahoga, Franklin, Hamilton, Summit, Butler, Lucas, Montgomery, Stark, and Mahoning.

Forty-one percent of white infant deaths and 88% of black infant deaths occurred in OEI counties.

Of the infants’ mothers:

One-third (33%) participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy, a program that reduces infant mortality by reducing the incidence of babies born at low birth weights and provides support services necessary for full-term pregnancies.

About a third (30%) of mothers were not participating in WIC, but on Medicaid and therefore were likely eligible for WIC.

Most (74%) mothers had a previous pregnancy (including live births and pregnancy losses) and some may have benefited from care between pregnancies.

About 40% of the women did not receive first trimester prenatal care.

Preventable Preconception Risk Factors related to the leading causes of Ohio infant deaths

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