Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities Impact of Perinatal Health Issues on Infant Mortality and Morbidity in the Bronx

Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities Impact of Perinatal Health Issues on Infant Mortality and Morbidity in the Bronx

• Deborah Campbell, MD, FAAP

• Division of Neonatology

• June 15, 2007

Faculty Disclosure Form

• In the past 12 months, I have not had any significant financial interest or relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation.

• This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA.

Bronx Health Center and Community Districts

Overview Perinatal Health in the Bronx

• Rates for infant and maternal mortality, low birth weight, teen pregnancy, late or no prenatal care exceed city, state and US averages

• Large racial disparities for black and Hispanic women and infants

Overview of Bronx Perinatal Health

• Highest IMR are in Morrisania, Williamsbridge and East Tremont sections of the Bronx

• > 10% infants are born LBW

• 12% of Bronx births are to teen mothers

• Mott Haven, Hunts Point, East Tremont, Morrisania

• ~ 66% Bronx births are to women on MA – NYS rate is 20%

• Mott haven, Hunts Point, Unionport/Soundview, Concourse/Highbridge, Fordham, Williamsbridge

• 25% pregnant women have late/no PNC

• Additional 41% inadequate PNC
• Fordham, Bronx Park, Central Bronx, Highbridge, Morrisania, Mott Haven and Hunts Point

Overview of Bronx Perinatal Health

• > 50% delivering women in the Bronx are immigrants

• Primarily from Latin America

• > 50% Spanish speaking

• Highest rates of asthma in NYC

• Breastfeeding rates

Live Births, Induced Terminations and Spontaneous Terminations

Live Births, Induced Terminations and Spontaneous Terminations, NYC 1986-2005

2005 Live Births, Spontaneous and Induced Terminations of Pregnancy

Live Births, Induced Terminations NYC, 2005

Live Births by Maternal Ethnicity

Live Births by Race/Ethnicity & Borough 2005

Bronx Live Births 2005: 20,766

NYC Live Birth Characteristics

Distribution of Births By Gestational Age

Ancestry of Mother in 2005

• NYC - 122,725 LB

• Puerto Rican 9922
• Dominican 9907
• Mexican 7986
• African-Am. 16448
• Chinese 7426
• Jewish/Hebrew 7632
• Other Hispanic 6769

Teen Childbearing

• Preliminary data for 2005

• Decline in birth rate by 2% to 40.4/1000 women 15-19 yrs.
• Greatest decline among 15-17 yr olds. to 21.4/1000
• Rate for 18-19 yr olds. stable at 69.9/1000
• Rate for 10-14 yr olds. unchanged: 0.7/1000
• 3% decline for non-Hispanic white and non-Hispanic black teens 15-19 yrs old, between 2004-2005
• 6% for non-Hispanic black teens 15-17 yrs old

Teen Birth Rate for 15-19 year olds: 1991 v. 2005

Teen Live Births: 2003-2005

Infant, Neonatal and Post-Neonatal Mortality Rates, NYC 1988-2005

Citywide Infant Mortality

• 2005

• 6.0/1000 LB v. 6.8/1000 LB for the entire US
• Decline in births by 1.1 % from 2004
• Decline in infant mortality by 3.8%

• Since 1990 there has been a 48% decrease in NYC’s IMR

• Infant mortality is influenced by multiple factors

• Maternal health, SES over the perinatal care continuum, substance use, access to and utilization of quality service, levels of stress and social support
• Knowledge about safe sleep position and other risk factors for SIDS

2005 IMR by Borough

Infant Mortality Rate/1000 LB: Bronx Health Districts 2001-2005

2005 Infant Mortality Rate by Ethnicity

Distribution of Deaths: Fetal-Neonatal-Infant Mortality

Components of Perinatal Period of Risk

The Role of Maternal Morbidity and Mortality

Maternal Mortality Ratios for White Women:1987-1996

Findings of the SMI Causes of Death (n=33) August 2003 – June 2005

• Embolism 24.2%

• PIH 24.2 %

• Hemorrhage 15.2 %

• Infection 15.2 %

• Cardiomyopathy 6.1 %

• Anesthesia None

• Other/Unknown 15.2 %

SMI: A Look at Chronic Disease

• 54% of the pregnancy-related deaths had a history of chronic disease

• Hypertension
• Cardiac Disease
• DVT
• Diabetes
• Scleroderma
• Sickle Cell Disease

• Obesity was the most commonly identified (66%)

Issues Identified

• Coordination of Care – coverage and vacations

• Embolism – prophylaxis or treatment

• Blood bank – Policy and Procedures

• EMS protocols & ED process

• Availability of Diagnostic studies

• Translation Services

• Prenatal care – Accessible and Acceptable

• Medical Care – recognition and transfer policy

• Consultation issues – willingness and adequacy

• Grief Counseling for Family and Staff

New York City Initiative

• Leadership – Gina Brown, MD

• Multi-disciplinary Committee on Maternal Mortality

• Enhanced Surveillance and Case Reviews

• Bureau of Maternal Infant Reproductive Health

BMIRH MMR Enhanced Surveillance Methods

• Case ascertainment

• Vital Statistics, Medical Examiner, SPARCS

• Case Review

• Medical records, ME reports, maternal death certificates, infant birth certificates

• Data entry and analysis

NYC MMR Review 1998-2000: BMIRH Enhanced Surveillance

Location of Death: BMIRH 1998-2000

Percent of Live Births and Maternal Deaths By Race/Ethnicity: BMIRH 1998-2000

MMR and Race/ Ethnicity BMIRH 1998-2003

US Historical Perspective: Racial Disparities

MMR by Birth Place BMIRH 1998-2003

Comparing Leading Causes of Death (%)

Hemorrhage Related Deaths BMIRH 1998-2000

• Black 64 %

• Hispanic 21 %

• White 8 %

• Asian/Pacific Isl. 8 %

• In hospital 97%

Obesity: Maternal Mortality Risk From Hemorrhage BMIRH 1998-2000

Hemorrhage Initiative

• Hemorrhage alert – Commissioner of Health, NYC

• Hemorrhage protocols

• Hemorrhage Poster

• Unusual collaboration between the NYC DOH, NYS DOH and ACOG

What About the Bronx?

MMR by Borough BMIRH 1998-2003

Predictors of Maternal Mortality and Near Miss Mortality

• Weiler Hospital – Jan. 95 – June 2001

• Cases of MM and NM identified

• ICD-9 codes
• QI records
• ICU logs

• 3 Controls from same delivery day

• Charts reviewed

• Collaborators:

• C. Chazotte, MD D. Goffman, MD J. Choi, MD R. Madden, PhD

• E. A. Harrison, MD I. R. Merkatz, MD

Maternal Mortality and Near Miss

• Model containing all recognized risk factors: race, maternal age, obesity, past medical history, prior cesarean, and gravidity

• Multiple logistic regression

• Black race remained a significant factor -OR 5.0 (CI 1.5-17.0)

Where Do We Go From Here

• Preconception Care

• Medical Conditions
• Obesity
• Family planning
• Maternal age, number of children
• IVF and multiples

• Systems Issues

• SMI, NYC
• Hemorrhage Initiative

Newborn and Infant Care Issues

Leading Causes Infant Death: 2004

• Congenital malformations (20.1%)

• Disorders related to short gestation and LBW

• 16.6% deaths in 1st year life due to preterm birth

• SIDS (8%)

• Newborn affected by maternal complications of pregnancy (6.1%)

• Accidents (unintentional injuries) (3.8%)

• Newborn affected by complications of placenta, cord and membranes (3.7%)

Birth Weight Categories

• Normal BW > 2500 g (5.5 lbs)

• Low BW < 2500 g (5.5 lbs)

• Very Low BW < 1500 g (3.3 lbs)

• Extremely LBW < 1000 g (2.2 lbs)

Infant Mortality Rate for Birth Weight Categories, NYC: 1994-2004

Central Bronx: LBW and IMR

South East Bronx

Hunts Point – Mott Haven

2005 US Breastfeeding Rate: Ever Breastfed (Annual Summary VS, Pediatrics 2007)

Bronx Initiative to Improve Perinatal Health

• Nurse Family Partnership

• Newborn Home Visiting Program

• Healthy Women/Healthy Baby Initiative

• Healthy Teens Initiative

• Breastfeeding Initiative

• Bronx Strategic Action Committee

• Citywide Infant Mortality Case Review Committee

• Infant Mortality Reduction Initiative funded by the City Council