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


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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

  • 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
  • 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



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