issue brief INFANT MORTALITY IN MISSISSIPPI Health Potential Strategies to Improve Infant PUBLISHED JANUARY 2014 Mississippi’s high infant death and illness rates are significant public health problems. This issue brief reviews health and economic impacts of poor birth outcomes in Mississippi and examines potential strategies for improvement. VERY LOW BIRTH WEIGHT Mississippi’s infant mortality rate remains the highest in the nation at 8.8 deaths Below 3 pounds, 5 ounces at birth per 1,000 live births compared to 6.0 deaths per 1,000 live births for the U.S. Although 14 percent of all births in Mississippi are low or very low birth weight, LOW BIRTH WEIGHT 67 percent of infant deaths are below normal birth weight. Babies born at the Around 3 pounds, 5 ounces very lowest birth weights accounted for over half (52%) of the infant deaths in to 5 pounds, 8 ounces at birth Mississippi during 2012 (Figure 1). FIGURE 1. INFANT DEATHS BY BIRTH WEIGHT, MISSISSIPPI, 2012 THE FIVE LEADING CAUSES OF INFANT DEATH IN MISSISSIPPI, 2012 Unknown, 2% RANK CAUSE OF DEATH 1 Birth Defects Low Birth Weight Normal Birth Very Low 2 & Preterm Birth Weight, Birth Weight, 31% 52% Sudden Infant Death 3 Syndrome (SIDS) 4 Accidents Low Birth Weight, 15% 5 Maternal Complications Source: Mississippi State Department of Health, Office of Vital Statistics. (2012). Source: Mississippi State Department of Health, . Vital Statistics. (2013). The infant mortality rate is also ten times higher for preterm births compared PRETERM BIRTH to term births (33.6 per 1,000 versus 3.4 per 1,000) in the state. In a March Birth before completing of Dimes report highlighting preterm birth rates, Mississippi was one of the at least 37 weeks of pregnancy three states graded the poorest in terms of preterm birth rates (Figure 2). . FIGURE 2. PRETERM BIRTH NATIONAL REPORT CARD, UNITED STATES, 2011 INFANT MORTALITY RATES PER 1,000 LIVE BIRTHS IN MISSISSIPPI, BY RACE, 2008-2012 White Black All Races 0 5 10 15 Grade A Preterm Birth Rate Grade B Preterm Birth Rate Source: Mississippi State Department of Health, Vital Statistics. (2013). Grade C Preterm Birth Rate Grade D Preterm Birth Rate Source: National Center for Health Statistics. (2012). Grade F Preterm Birth Rate 1 of 4 Center for Mississippi Health Policy � Brief: INFANT MORTALITY IN MISSISSIPPI—Potential Strategies to Improve Infant Health JANUARY 2014 Why Poor Birth Outcomes Matter POOR BIRTH OUTCOMES Infant death is the ultimate poor birth outcome. Premature or immature babies who COST ESTIMATES, MISSISSIPPI survive are likely to require immediate specialized medical care and can face long- ECONOMIC BURDEN COSTS IN term health and development problems. In addition to the financial and emotional MILLIONS* burdens placed on families, these poor outcomes also affect state budgets. Medical Care $241.05 Services Most (85%) medical care costs associated with poor birth outcomes accrue during Lost Productivity the first few weeks of life. Based on data from a 2005 economic study by the $72.97 Institutes of Medicine, medical care costs alone associated with premature births (parents) in Mississippi are estimated at $241 million annually. Since over half of the births in Special Education $14.33 Mississippi are covered by the state Medicaid program, improving birth outcomes Early Intervention could return substantial cost savings to the state. $7.82 Services Underdeveloped babies are also at higher risk for developmental problems and are TOTAL COST PER YEAR: $336.17 MILLION *Note: based on Mississippi premature births in 2012 and cost more likely to require early intervention services and special education. Annual estimates from the Institutes of Medicine (IOM) in 2005 dollars. costs in Mississippi for these services are estimated at $22 million. Causes of Poor Birth Outcomes Poor birth outcomes can occur due to a variety of factors. Certain medical conditions, genetics, exposure to toxic substances, and inadequate access to medical care have all been linked to poor birth outcomes and infant deaths. Evidence also points to the following risk factors as major contributors to poor birth outcomes in Mississippi, which can be impacted by preventive efforts: ADEQUATE PRENATAL CARE INDEX BY GEOGRAPHIC LOCATION Poor health status before pregnancy PRENATAL CARE LOCATION Many women have limited access to health care and enter pregnancy in poor INDEX health. More than a third (36%) of Mississippi mothers report having no health 74.7% U.S. insurance before pregnancy. Medicaid is available for low-income pregnant women, which faciliates access to prenatal care, but is too late to improve chronic 75.5% Southern States health problems, and Medicaid coverage ends 60 days after delivery. 81.7% Mississippi Source: Centers for Disease Control, National Center for Health Tobacco use during pregnancy Statistics. (2012). The rate of smoking during pregnancy in Mississippi was 40 percent higher than the national rate in 2010. High rates of early elective deliveries Mississippi had rates of early deliveries for non-medical reasons that were 38 percent higher than the nation in 2011. High risk births in hospitals with an inappropriate level of care Mississippi has one of the lowest rates reported in the U.S. for low birth weight babies born in hospitals equipped to handle their complex care. Sleep-related deaths SLEEP RELATED INFANT DEATHS A combination of all sleep related deaths The state Child Death Review Panel found nearly three-fourths (73%) of infants including Sudden Infant Death Syndrome dying from sleep-related causes did not sleep in a crib, more than half (62%) slept (SIDS), suffocation, and other causes. with other people, and over one-third (39%) did not sleep on their backs. 2 of 4 Center for Mississippi Health Policy � Brief: INFANT MORTALITY IN MISSISSIPPI—Potential Strategies to Improve Infant Health JANUARY 2014 Potential Strategies to Improve Birth Outcomes The Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality, a multi-state public/private partnership to improve birth outcomes, has CoIIN to Reduce Infant Mortality is a multi-state examined available evidence and identified five priority areas for states to focus their infant public/private partnership to improve birth outcomes. mortality reduction efforts. An additional strategy is described to address Mississippi’s very high prematurity rate. INTERCONCEPTION CARE MEDICAID WAIVERS Georgia & Louisiana cover interconception care for Evidence suggests that ensuring women have access to regular health care before certain high risk women via 1115 Waivers. and between pregnancies can ensure health problems are addressed earlier and reduce poor birth outcomes. Some states have accomplished this goal by extending Medicaid coverage beyond 60 days after delivery. SMOKING CESSATION IN PREGNANCY Smoking during pregnancy is a major risk factor for many poor birth outcomes. Providing education and support to help mothers quit smoking during pregnancy can help reduce the smoking rates of pregnant women. EARLY ELECTIVE DELIVERIES REDUCTION OF EARLY ELECTIVE DELIVERIES For more information about early elective deliveries see the issue brief Delaying elective deliveries until at least 39 weeks of pregnancy is associated on this topic at www.mshealthpolicy.com with lower infant death rates and intensive care unit hospital admissions at birth. Policies have been established recently by other states which resulted in declines in early elective deliveries, including those among Medicaid beneficiaries. These states project millions of dollars in cost savings as a result. PERINATAL REGIONALIZATION IMPLEMENTATION OF A SYSTEM OF PERINATAL HOSPITAL CARE An organized system of care in which hospitals are categorized by the Research shows that high risk babies delivered in hospitals equipped to handle scope of perinatal services provided. their complex medical needs have better chances of survival. A well-developed system of maternal and newborn hospital care can strengthen access to appropriate care for those at highest risk. This goal can be accomplished by the implementation of an organized system of hospital care similar to the state’s organized system of trauma care. SAFE SLEEP EDUCATION Evidence suggests that raising awareness about the safest ways to position infants during sleep helps reduce the rates of sleep-related deaths. Teaching caregivers about infant sleep safety can help reduce infant deaths from sleep-related causes. ACCESS TO 17- ALPHA-HYDROXYPROGESTERONE CAPROATE (17-P) Clinical trials show the drug 17-alpha-hydroxyprogesterone caproate (17-P) can reduce preterm births in women at highest risk. Injections of 17-P must be given Early and consistent access to 17-P has been proven to weekly for up to 20 weeks from weeks 16 through 36 weeks of pregnancy. Early and consistent prevent preterm births in high risk women. access to the drug has been proven key to successfully preventing preterm births in high risk women who have a history of a previous preterm birth. 3 of 4 Center for Mississippi Health Policy � Brief: INFANT MORTALITY IN MISSISSIPPI—Potential Strategies to Improve Infant Health JANUARY 2014 Summary Mississippi has the highest infant death rate in the nation as well as high incidence of other negative birth outcomes. In addition to the impact on families, poor birth outcomes result in significant costs to the state in terms of medical care, special education, reduced productivity, and lost human potential. Many of the causes of poor birth outcomes are amenable to preventive measures. Evidence-based strategies designed to improve the health of pregnant women, delay birth until the baby has adequately matured, ensure delivery at a hospital that can provide the appropriate level of care, and help babies sleep safely can target these key factors contributing to infant illness and death to improve the health of Mississippi’s youngest citizens. Sources American Academy of Pediatrics. (2011). SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics, 128(5): e1341-e1367. American College of Obstetricians & Gynecologists. (2013). Nonmedically indicated early-term deliveries. Committee Opinion, No. 561. Obstetrics & Gynecology, 21:911–915. Applegate, M. (2012). Improving care and proving it. 2nd Annual CMS Medicaid/CHIP Quality Conference, Baltimore, MD. Association of State and Territorial Health Officials. (2013). Improving birth outcomes position statement. Policy and position statement as approved on March 15, 2012. http://www.astho.org. Behrman, R.E. & Butler, A.S. (2006). Preterm birth: causes, consequences, and prevention. Institue of Medicine of the National Academies. Washington, D.C. National Academies Press. Berg, C.J., Callaghan, W.M., Syverson, C., & Henderson, Z. (2010). Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics & Gynecology, 116(6): 1302-1309. Blackmon, L.R., Barfield, W.D., & Stark, A.R.(2009). Hospital neonatal services in the United States: variation in definitions, criteria, and regulatory status, variation of neonatal services definitions. Journal of Perinatology. Vol.29:788-794. Clark, S., Miller, D., Belford, M., Dildy, G., Frye, D., & Myers, J. (2009). Neonatal and maternal outcomes associated with elective term delivery. Obstetrics & Gynecology, 200: 156.e1-156.e4. Center for Mississippi Health Policy. (2013). Early elective deliveries in Mississippi: impact on health and medical care costs. Issue Brief. http://www.mshealthpolicy.com/early-elective-deliveries. Centers for Disease Control & Prevention. (2010). Pregnancy risk assessment monitoring system. Cuevas, K.D., Silver, D.R., Brooten, D., Youngblut, J.M., & Bobo, C.M. (2005). The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visitis over the first year of life. American Journal of Nursing, 105(7): 56-64. Gee, R.E., Alletto, M.M., & Keck, A.E. ( 2012). A window of opportunity: the Louisiana birth outcome initiative. Journal of Health Politics, Policy, and Law, Vol. 37(3): 551-557. Graham, J., Wesley, M.M., Zhang, L., Johnson, D., Bish, C.L., & Currier, M. (2012). Mississippi infant mortality report. Mississippi State Department of Health. Health Services and Resources Administration. (2013). National performance measures. Maternal and Child Health Bureau Title V information system. Mississippi State Department of Health. (2013). Vital birth and death statistics. Heron, M. (2013). Deaths: leading causes for 2010. National vital statistics reports, Vol. 62(6).National Center for Health Statistics. Centers for Disease Control and Prevention. Hyattsville,MD. Lasswell, S.M., Barefield, W.D., Rochat, W.R., Blackmon, L. (2010). Perinatal regionalization for very low-birth-weight and very preterm infants, a meta-analysis. Journal of the American Medical Association. Vol.304(9):992-1000. Lawler, M. (2012). State title V infant mortality initiative. Health Resources & Services Administration. Department of Health and Human Services. Lu, M.C. (2012). Off to a good start: state efforts to promote healthy babies. National Conference of State Legislatures Fall Forum, Washington, D.C. March of Dimes National Foundation. (1976). Toward improving the outcome of pregnancy: recommendations for the regional Plaza Building, Suite 700 development of maternal and perinatal health services. Committee on Perinatal Health. White Plains, NY. 120 N. Congress Street Meis, P.J., Klebanoff, M., & Thom, E. et al. (2003). Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone Jackson, MS 39201 caproate. New England Journal of Medicine. 348(24): 2379-2385. Mississippi State Department of Health. (2011). Mississippi child health review panel annual report, 2011. http://msdh.ms.gov/ msdhsite/_static/resources/4959.pdf. Phone 601.709.2133 Fax 601.709.2134 National Governor’s Association. (2012). Case study: Louisiana birth outcomes initiative. http://statepolicyoptions.nga.org. Reddy, U.M, Ko, C.W., Raju, T.N., Willinger, M. (2009). Delivery indications at late-term gestations and infant mortality rates in t0he United States. Pediatrics, 124:234-240. 600. www.mshealthpolicy.com Ranji, U. & Salganicoff, A. (2009). State medicaid coverage of family planning services: summary of state survey findings. The Henry J. Kaiser Family Foundation & The George Washington University Medical Center. 4 of 4 Center for Mississippi Health Policy � Brief: INFANT MORTALITY IN MISSISSIPPI—Potential Strategies to Improve Infant Health JANUARY 2014