Infant Mortality Trends

Infant mortality is one of the most important indicators of the health of a community. It is a bellwether of maternal health, quality of and access to medical care, socio-economic conditions and public health practices.

• On average, 156 infants died each year in Franklin County from 2005 through 2008.
• In Franklin County, the average infant mortality rate for non-Hispanic blacks was 2.7 times higher than the non-Hispanic white rate for 2005-2008.

• Rate of deaths to infants under 1 year of age per 1,000 live births. Infant mortality rates for Hispanics are based on fewer than 20 deaths for each year and should be interpreted with caution.
• Sources: Franklin County and Ohio: Ohio Department of Health Information Warehouse, analyzed by Columbus Public Health Office of Assessment and Surveillance; U.S.: National Vital Statistics Reports

New Treatment to Prevent Preterm Birth Helps Couple Overcome History of Loss

Laura Pearson was vacuuming her car when her second incidence of preterm labor began. She had to endure labor and delivery knowing her baby girl would not survive.

After losing two babies, Laura and Andy Pearson are thrilled they now have two healthy children. Their story is one of the growing number of successes attributed to using the progesterone formulation “17P” to treat women at risk of giving birth preterm.

Laura had lost a son when she was 16 weeks pregnant. “When we lost our daughter at 17 weeks, I knew there was a problem,” says Laura. Her obstetrician referred her to the Prematurity Prevention Program at The Ohio State University Medical Center.

During her next pregnancy, Laura was treated with 17P injections every five days for 22 weeks. She also received biweekly cervical scans. Over the weeks, they showed her cervix shortening too early. To further help prevent preterm labor, she was put on bed rest for her last 4 months.

To the Pearson’s delight, Laura delivered a healthy daughter, Alaina, at 35 weeks and 6 days, almost to term.

Laura was treated with 17P again when pregnant with son Luke. This time, her cervix stayed thicker longer into the pregnancy. “I was able to do all my regular activities up until the last month,” Laura explains. “Then, Luke was born healthy at 35 weeks and 6 days, just like Alaina.”

Preterm Birth Trends

After increasing steadily for many years, the U.S. preterm birth rate (the birth of infants before 37 weeks gestational age) declined to 12.3 percent in 2008, marking the first 2-year decline in the preterm birth rate in nearly three decades.

• Preterm birth rates declined from 2006 to 2008 for mothers of all age groups under age 40, for the three largest race and Hispanic origin groups, and for most U.S. states.
• Franklin County experienced these declines only from 2007 to 2008.
• Non-Hispanic blacks have a higher proportion of preterm births than Hispanics and non-Hispanic whites.

• Sources: Franklin County and Ohio: Ohio Department of Health Information Warehouse, analyzed by Columbus Public Health Office of Assessment and Surveillance; U.S.: National Vital Statistics Reports

While the decreasing preterm birth rate is good news, we still have a long way to go. In 2009, the March of Dimes gave Ohio an “F” grade in its efforts to reduce preterm births, a leading cause of infant mortality nationally.

• On average from 2005 to 2008, the Franklin County infant mortality rate due to preterm birth/ low birth weight is significantly higher than Ohio and the United States.
• Disorders related to preterm birth/low birth weight were the number one cause of infant deaths in Franklin County in 2005, 2007 and 2008. They were the second leading of cause of death in 2006.

What’s Working

In response to the high numbers and personal and societal costs of preterm births, a collaborative of central Ohio hospital systems, city and county government agencies, education and not-for-profit groups is using the newest research to improve outcomes for pregnant women and their children in Franklin County. Called Ohio Better Birth Outcomes (OBBO), the collaborative has identified specific interventions known to reduce preterm morbidity and mortality, and are deploying them in a multi-faceted countywide initiative.

OBBO Initiatives

Comprising a three-component assault designed to prevent sickness and death among our smallest residents, the initiatives are:

• Progesterone Caproate Project (17P)
• Central Ohio Scheduled Births Initiative (COSBI)
• Nurse-Family Partnership

Progesterone Caproate Project (17P)

A woman who has a spontaneous preterm birth is at 20 to 50 percent greater risk of having another preterm birth. Progesterone is a normal pregnancy hormone that when given as prenatal therapy injections of 17 Alpha Hydroxyprogesterone Caproate (17P):

• Reduces recurrent preterm births by 35 percent
• Improves newborn health

Launched in June 2009, the 17P program offers treatment to low-income women who otherwise would not have access to this therapy.

Eligible women are referred to the program by Pregnancy Care Connection (PCC), which provides uninsured and underinsured pregnant women in Franklin County with a centralized system for scheduling initial prenatal care appointments and referrals to additional support services. Women with a prior preterm birth are encouraged to make an appointment at one of the special 17P program sites participating in the OBBO 17P program. These include The Ohio State University Medical Center, OhioHealth, Mount Carmel Health, Columbus Public Health, and the Columbus Neighborhood Health Centers.

At The Ohio State University Medical Center, January to May 2010, the average delivery was at 35.3 weeks for 55 women treated with 17P, compared to 30.7 weeks for their last pregnancy.

17P Programs are Improving Preterm Birth (PTB) Outcomes in Franklin County

• Source: Ohio Better Birth Outcomes (OBBO)

In addition, the 17P program seeks to help women have safe spacing between pregnancies. Mothers have a 10 to 40 percent increased risk of future preterm birth if they conceive again within 18 months of delivery. These outcomes have led experts to recommend mothers wait 18 to 24 months between pregnancies.

This “safe spacing” allows time for the mother’s body to recover from pregnancy and build up stores of essential nutrients. It allows moms time to bond with each child and takes away the stress of having two very young children to care for at the same time. As part of the 17P program, participants will have their spacing between pregnancies monitored and evaluated.

Central Ohio Scheduled Birth Initiative

The American College of Obstetricians and Gynecologists (ACOG) recommends not performing elective deliveries before 39 weeks of pregnancy¹. Unfortunately, this guideline is disregarded in at least 10 percent of all deliveries. The significant health risks to infants make it imperative to eliminate medically unnecessary preterm births. A few weeks make a big difference for the developing baby:

• Each week a baby stays in the womb between 36 and 39 weeks corresponds with a 23 percent decrease in respiratory distress, jaundice, seizures, temperature instability, brain hemorrhages, and other problems.²

The Central Ohio Scheduled Birth Initiative (COSBI) brings together central Ohio obstetricians and hospitals to increase compliance with the ACOG recommendation. Since September 2008, doctors scheduling preterm births in central Ohio’s maternity hospitals have been required to complete a form stating:

• Reason for the preterm delivery
• Term date for the baby and how that date was determined

Knowing how it was determined is important in judging the accuracy of the due date. A baby believed to be 37 weeks who may be only 35 weeks is at greater risk of complications.

Rates of nonmedical preterm births have declined in central Ohio almost every month since COSBI was initiated.

Percent of All Births Scheduled Preterm for Non-Medical Reasons July 2008 - July 2010

• *Project began September 1, 2008.
• COSBI is part of a statewide program by the Ohio Perinatal Quality Collaborative (OPQC) that has reported similar results for the whole state (see www.opqc.net).
• ¹2009 ACOG Practice Bulletin: Induction of labor. ACOG Practice Bulletin 107. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:386-97.
• ²Bastek JA, Sammel MD, Paré E, et al. Adverse neonatal outcomes: examining the risks between preterm, late preterm, and term infants. Am J Obstet Gynecol 2008;199:367.e1-367.e8.

Nurse Family Partnership

Low-income women under the age of 20 are at higher risk for preterm births. The Nurse-Family Partnership (NFP) is a national, evidence-based program that may help reduce preterm births in low-income, first-time mothers who participate in the program. These women tend to be very young and have multiple risk factors for preterm births.

We know the best chance to promote and teach positive health and development behaviors between a mother and her baby is during a first pregnancy. We also know transitioning to motherhood can be especially hard for the young, low-income, first-time mom. She may be socially isolated or facing severe hardships that threaten her own wellbeing and that of her unborn child.

• A nurse’s expertise can help reassure her and guide her to make good decisions that will benefit mother and baby.

In 2006, the Center for Child and Family Advocacy at Nationwide Children’s Hospital began an NFP program based on the national model. As of March 2010, 291 low-income, first-time mothers had enrolled. Mothers are partnered with a registered nurse before the 28th week of pregnancy and the nurse visits her at home through her child’s second birthday. The program is logging major successes. Relative to a comparison group, the local NFP:

• Preterm birth rate has been reduced by 35 percent
• NICU utilization is down by 48 percent
• NICU dollars per participant have been reduced by 48-63 percent

Teen moms have a 20 percent risk of preterm birth. But teens in the NFP program have half that rate.

Premature Infant Grows Into Typical Toddler

Paris Ellis weighed less than two pounds at birth and was kept alive by a ventilator during the 6-month hospitalization that marked the start of her tiny life.

The 2008 Full Potential report documented the fears and challenges her parents faced as they cared for a critically ill baby and looked toward a future that might include lasting problems for their daughter.

Today, Kim Ellis reports that Paris is doing very well, although she has asthma from being on a ventilator. “If Paris gets a cold, she is sicker than children who don’t have asthma; and her asthma is worse in the winter,” says Kim. “She also goes to special-needs preschool, and her teachers say she is slightly behind developmentally.”

To her mom, Paris is a typical 3-year-old girl who loves Dora the Explorer and playing outside.

Expanding on OBBO’s Success

In December 2009, the Franklin County Commissioners awarded Nationwide Children’s Hospital a $7 million grant to be provided over 5 years to fund clinical research and community outreach efforts that are part of OBBO. These funds are allowing expansion of existing programs as well as the development of new ones. New programs soon to be introduced include:

• Neonatal Abstinence Syndrome Program: Neonatal abstinence syndrome (NAS) is a term for a group of problems a baby experiences after birth when withdrawing from exposure to narcotics. When a pregnant woman uses drugs, she puts her baby at risk for a number of problems. This outpatient program is designed to help relieve the discomfort and problems of withdrawal in drug-addicted infants.
• Prenatal Smoking Cessation: Smoking increases the risk of delivering a low birth-weight baby, and may also increase risk of premature birth and stillbirth. Pregnant teens may smoke during pregnancy out of stress and fear. This program aims to help them stop smoking quickly by using the evidence-based method called “contingency management.” Participants will submit three breath samples daily over the Internet and will be rewarded financially for not smoking.

Recommendations

The following practical steps are necessary at the policy level to ensure the OBBO programs achieve their full potential to reach and serve all women who can benefit.

• Obtain a Medicaid waiver from the Centers for Medicare and Medicaid Services to extend coverage for low income women after delivery from the current six weeks to a minimum of six months. Doing so will provide access to comprehensive post partum services during a critical period for their babies. Our state partners are working with us to prepare a waiver application to the federal government.
• Implement presumptive eligibility for Medicaid among newly pregnant women. Provide coverage through Medicaid for prenatal visits before Medicaid paperwork is processed so the first visit happens as soon as possible. Early prenatal care allows for early identification of risk factors and educational needs that may prolong pregnancy and improve outcomes. The state of Ohio is committed to making this happen.
• Ensure every provider in Ohio has access to medical specialists via telemedicine, including high-speed Internet access, to improve the quality of care for pregnant women and newborns. Our preliminary work using telemedicine for isolated hospitals suggests improved care and reduced costs are achievable with commitment on both sides if we can address remaining broadband limitations in some rural hospitals.

Finally, healthy babies come from healthy mothers. Each of us has a responsibility to reach out to women in our lives and in our
communities before or very soon after they become pregnant to make sure they receive the best possible care, including:

• Vitamins and nutrition support before, during and after pregnancy
• Routine primary care medical services
• Reproductive health services of their choice
• Mental health and substance abuse services where needed
• Resources for counseling, domestic violence, transportation, housing and smoking cessation

View more infant mortality source information.