Our Babies Are Dying

Our Babies Are Dying

Our Babies Are Dying From Data to Action: A Review of All 2018 Infant Deaths in Northeast Florida Northeast Florida Healthy Start Coalition October 31, 2019 Sulzbacher Village Welcome & Introducti ons Overview Impetus and Purpose of the Review Approach Summary of Findings Moving from Data to Action Next Steps Impetus &

Purpose of Review NEF exceeds state and national infant mortality rates. Why? To identify key medical, system, social and environmental risk factors and policy impacting birth outcomes in NEF and implement action to address them. Approac h Analysis of fetal & infant deaths (linked vital stats records) Identify specific periods of risk Examine contribution of birthweight Pinpoint contributing factors, issues in NEF (case abstractions) Identify evidence-based strategies for improving outcomes Take action! Infant Deaths/1000 Live Births

18 15.6 16 14.1 14 12.8 13.2 7.1 7.4 7.3 4.8 4.9 5.2 2015 2016

2017 12.5 12 Infant Mortality 2014-2018 10 8 8 7.9 6 4.9 4 4.3 2 0 2014 Total

White Black 2018 Leading Causes of Infant Death 2018 Cause Prematurity/Low Birthweight Other Perinatal Conditions Congenital Anomalies Sudden Unexpected Infant Deaths Infections Injuries Other Causes TOTAL Number 30 45 27 31 4

4 6 147 More than half: Prematurity/LBW & Other Perinatal Conditions Fetal Deaths/1000 Deliveries 14 12.1 Fetal Deaths 20142018 11.3 12 10.1 10 8.3 8 7.1 6

6.2 4 5.4 9.9 10.1 6.8 7.2 4.8 5.1 2017 2018 8 6 2 0 2014 2015

Total 2016 White Black & Other Fetal Deaths 2018 70% unknown or unspecified cause 30% 24+ weeks gestation & 1500+ grams Periods of Risk BIRTHWEIGHT AGE AT DEATH Fetal Deaths >=24 wks gestation 5001499 gram

s 1500 + gram s Neonatal Deaths 0-27 days Postneonatal Deaths 28-364 days MATERNAL HEALTH & PREMATURITY MATERN AL CARE NEWBOR N CARE INFANT CARE Each period of risk is associated with its own set of risks and prevention factors MATERNAL CARE &

PREMATURIT Y MATERNAL CARE NEWBORN CARE INFANT CARE Chronic disease, health behaviors, preconception care Prenatal care, High risk referrals, OB care Perinatal management , NICU care Sleep-related deaths, injuries, infection Summary of Findings Largest

proportion of fetal-infant deaths & Most significant disparities MATERNAL HEALTH & PREMATURITY MATERN AL CARE NEWBOR N CARE INFANT CARE 2016-2018 linked birth, death & fetal death files PPOR Results 2016-2018 12 % 18 %

30% 40 % All Races Maternal Health & Prematurity Newborn Care Maternal Care Infant Care 15 % PPOR Results by Race 2016-2018 24 % 33% White 29 %

Maternal Health & Prematurity Maternal Care Newborn Care 17% Infant Care 11% Black 26% 46% MH/Prematurity: Contribution of Birthweight Difference in Outcomes (Groups with Best vs. Poor Outcomes) Root causes Birth weight advantage? (Birth weight distribution)

Behavioral, social, health, economic disparities + Survival advantage? (Birthweight specific mortality) Perinatal or medical care Too many babies born too soon and too small (90% of excess deaths) Findings Social determinants of health 10% due to medical/health care Access, service delivery, quality improvement opportunities Two periods of risk Maternal health &

account for largest prematurity proportion of poor birth Maternal care outcomes in NEF: These periods of risk reflect the greatest disparities in birth outcomes. Infant care also contributes to poor outcomes among white babies (sleeprelated deaths, accidents, abuse/neglect) Difference in mortality between groups with best and worst outcomes too many babies are born in NEF too soon and too small What we learned. . . Next Step: NEF Case Reviews Prenatal, hospital, other medical records abstracted using NFIMR tool for 147 infant deaths (2018) 12 Maternal interviews completed Healthy Start prenatal screens (2018) Findings: Summary information on key issues, with particular focus on Maternal

Health & Maternal Care Challenges & limitations of review Missing data, inconsistent documentation No fetal cases Risk NEF Scan: Healthy Start Prenatal Screen 2018 At Risk Moms (6 or more) %Whit e (n= 988) %Black (n=289 5) Not Married 41.4

75.2 Education

11.9 Prior LBW birth 4.7 10.0 Needs Ongoing Medical Care 16.2 17.9 2nd Trimester PNC Entry 20.0 32.6 First pregnancy 36.6 30.6 7.8

17.8 18.0 21.3 Unwanted pregnancy Birth interval < 18 mos Maternal Health/Prematurity Case #2 Un em p loy ed Partner erm t e r 2p s* e

i r e deliv Housing Poverty Transportati on Home Visitation : N o Po st pa rt um F/ U ss e

cc d a i e Lat edica M No HS Diploma Low Po de stp pr a r es tu si m on BM I-no WIC Maternal Health/Prematurity Case #3 Po v ert pre d

re u s cy n Uni egnan pr y Medicaid Housing Un stable WIC Home Visitation An xi et y/ D ep re s HTN/Obesity si

on ctim i v lt u a Ass : ucation d e e d a r g 8 th No Tran spo rtat i on H

is t Ad ory di O ct pi io o i n d Maternal Care Summary #1 6 th pre gn ye ancy ars / tal a n pre d ite re m i L ca 7 Medicaid

WIC 5 living children Chronic Hypertension High School l th a e al h r o r Poo Social Support Multiple STIs : Ne igh bo

rho od Maternal Care Summary #2 N on sp Engl ea kin ish g rty e v Po Unfunded Clinic Uncontrolled Diabetes Social Support Healthy Start l

D is tr us t of sy st em ata n e pr d e it e Lim car : Self Pay Fina

ncia l Di stre ss Tr an s is por s u ta es tio n Social determinants of health Key issues: prepregnancy 61% unmarried (single, divorced, separated) 12% < 18 years old at first pregnancy 77% high school or less education 55% low income 41% employed Dads had similar profiles (although lots of missing info) Lack of insurance prior to pregnancy Disproportionate impact on black moms

Prior poor outcome 27% previous pre-term of LBW birth More likely among black moms Lack of family planning Key issues: prepregnancy 40% had < 18 months between pregnancies About 30% not using birth control 50% of these moms report pregnancy as unintended or mistimed Substance use (prescription & illegal) 43% self-report 20% used tobacco during pregnancy (white moms at higher rates) 10% documented MAT Poor pre-pregnancy health 59% overweight or obese Chronic hypertension, diabetes One-third with STIs Prenatal care

Key issues: Prenatal 82% received some prenatal care One third entered care late or not at all 50% covered by Medicaid 45% received < 5 visits prior to delivery Access or compliance issues were documented in nearly half of the cases Transportation Medicaid, other insurance problems Pregnancy complications Most common: gestational hypertension, diabetes, pre-eclampsia Multiple births in 11 cases Stressors during pregnancy One-third of cases with documented stressors Financial problems, IPV, depression Key

issues: Prenatal Use of services, support Most cases (72%) documented receipt of social services About half received referral to case management Lack of follow-up by mom Lack of engagement, follow-up by provider 40% of cases had documented home visit, BUT Low intensity, short duration of services across programs Medical complications Key issues: Delivery One-third documented pre-term labor One in five cases experienced PROM, PPROM Chorioamnionitis, placental abruption Cord problems UTI, HELLP syndrome

Prematurity & very low birthweight Key issues: Baby, Postpartu m 36% of babies lived < 1 day 59% of babies born VLBW lived < 1 day 52% of babies lived < 1 week Disproportionate impact on Black babies Nursery & NICU 40% with documented morbidity during nursery stay RDS, neonatal sepsis, jaundice, other most common 40% with NICU stay > 1 day Substance use 11% documented with substance exposure Preventable post-discharge deaths Sleep-related, accidents Postpartum visit Only 23 of 147 cases included some documentation of a postpartum visit by mom What we

learned. . . Prepregnancy health of mother is a key factor contributing toLack poor of outcomes insurance coverage (before & after pregnancy) Chronic health conditions, especially among black moms Lack of family planning Social determinant s of health Siloed,

fragmented care Birth intervals <18 months Poverty, lack of education, transportation, violence = STRESS Disconnect between clinical/medical /hospital and community support services Non-use Postpartum visit? Screening, documentation by providers? Culturally sensitive/traum

a informed care? Lack of awareness among policymakers, Lack of followthrough, engagement, retention in home visiting, other care coordination Increase Provider Screening Rates Develop Medical Home Model Medical and Social Needs Model Action!! Centering Pregnancy Group Care Models -Chronic Disease and Stress Model Universal Home Visitation Improve Quality of Care In Florida, state law requires every prenatal care provider to offer a Healthy Start Risk Screen to all pregnant women to assess risk for preterm birth. The Universal Screen is voluntary and women can choose not to be

referred for services. Screen and treat women at risk for preterm births State Screening Rate 70.1% NEFL Rate 53.8%. Strengthen screening for SDOH. Create NEF SDOH Consortium of stakeholders to address. In addition to screening women for risk factors, also screen for cervical shortening. Enhance supports for families before Nurse and after birth Universal Healthy Start Home Visitation Healthy Families Family Partnershi p

Home Visitation Improve identification, engagement and retention of families (CQI) Medical One Stop - Social Determinan ts of Health Investment Invest in medical provider hospitals/hubs/ clinics/offices that offer one-stop comprehensive services in addition to medical care. Families looking for additional support face a fragmented system, begin with where services are located. Research: one-stop approach can promote healthy behaviors and reduce negative outcomes associated with maternal and infant mortality. Medical home and Episode based Payments Medical Home

Model Successful models: Strong Start for Healthy Mothers & Babies Medical Home Model in Tampa Bay area (successful three-year demonstration project). Wisconsins Obstetric Medical Home Program (part of state Medicaid program) Access to Medical Care Before, During & After Pregnancy Expansion of health care coverage, use of Expand knowledge, utilization postpartum Continue Medicaidfamily eligibilityplanning & primary care of Family Planning Medicaid for one year post-birth waiver Provide Medical Home for all women of childbearing age

Centering Group Care Model Pregnancy Pediatric/Parenting & Interconception Improve Quality of Care The Cultural Humility Model: An effective approach to addressing bias and racism key aspect of the cultural humility model. Results can be used as part of broader efforts to align payment with quality, such as rewarding providers that successfully reduce racial disparities in maternal and infant mortality. Take advantage of opportunities to participate in Florida Perinatal Quality Collaborative. Incorporate CQI in ongoing medical, community service delivery. Community voice Engagemen t of community is key Families, community residents &

leaders, faith-based orgs MCH providers, stakeholders Doctors, hospitals, midwives, other MCH providers Hospitals Family planning, public health social service providers Healthy Start, home visiting programs Public & private payers (insurers, MCOs) Policymakers Business Others How do we make this happen? Thank you & last word

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