Infant Mortality

1. Infant Mortality Melanie & Tracy

2. Focus Group African American Women

3. Community Problem Diagnosis African American Women experience higher infant loss due to death within the first year of life, at a rate of 2-3 times the National average in Kent County as evidenced by the rate of deaths recorded.

4. Leading Causes of Infant Mortality • Low Birth-Weight • Sudden Infant Death Syndrome • Congenital Malformation • Prematurity and Low Birth Weight • Perinatal Conditions • Infection • Congenital Anomalies • Injury • Sudden Infant Death Syndrome • Undetermined Nationally Kent County

5. Social Learning Theory • Social learning or social cognitive theory is a behavior change approach affected by environmental influences, personal factors, and attributes of the behavior itself. • Most importantly, a person must believe in their own capability to perform the behavior as well as perceive an incentive to do so. • The immediate or longer-term benefits must be valued.

6. Risk Factors in Kent County • Poor nutrition prior to and during pregnancy • Unsafe Neighborhood • Infant in a Non-Infant Bed • Lack of Family Support/Lack of Support From Father • Homeless or Frequently Moves • Father in Prison, Parole or Probation • Illness or Death in Family • Stress (especially racial stress) • Financial Trouble • History of Abuse

7. National Statistics In 2009 the National average was 6.7% deaths per 1,000. In Michigan the average was 5.4% deaths per 1,000, while African Americans averaged as many as 15.5% deaths per 1,000.

8. Is Kent County Falling Behind? • Regardless of socio-economic status and age African American women have more than double the infant deaths than Caucasian women. • Michigan infant mortality has been above the National average for more than 20 years.

9. Michigan Statistics

10. Kent County Statistics

11. Health Disparities: Infant Mortality Rates Higher for African American Women Compared to Caucasian Women

12. Analysis of Disparity • The disparity seen in infant death rates of African American women and Caucasian women remains a medical mystery. There are many hypothesized theories, but no definite causative factor. • Overall health of the women and the time interval between pregnancies are factors that can be changed, which have proven to improve infant outcomes.

13. African American Women’s Health Determinant: risk for infant deaths • Poor nutritional and health prior to and during pregnancy. • Broader acceptance of being young, unmarried and less education when becoming pregnant. • Lack of health insurance and therefore lack of access to pre-pregnancy care. • Low socio-economic status. • Unsafe neighborhoods. • Single family homes with absent father, no family support. • Risky sexual behaviors that lead to unplanned pregnancy. • Lack of education in general health care for themselves and their infant.

14. The Relapse Prevention Model • Relapse often occurs because of: • Lack of or limited coping skills • Negative emotional states • Decreased motivation • Stress • High-risk experiences

15. What is Being Done in Kent County • One of Kent County Health Initiative (KCIHI) for 2010 is to reduce infant mortality. • Implementing a variety of projects aimed at reducing infant mortality and eliminating racial and ethnic health disparities. • Inter-Conception Care Program (ICP), Brush Up for Baby and Family Planning Program have been implemented to help all families and infants. • Strong Beginnings is an African American based program that addresses health concerns for pregnant women, their partner and children from age 0-24 months.

16. Pre-Term Births (PTB) • Approximately 80% of the disparity seen between African American and Caucasian women is related to the different rates of pre-term births (PTB) experienced by each group. • Activation of the inflammation pathway is theorized as a cause of PTB. • Nutritional deficiencies play an important role in the activation of the inflammation pathway. • Deficiencies in iron, folic acid, zinc, vitamin D, calcium and magnesium are more widely seen in African American women versus Caucasian women. • Approximately 25% of pregnant African American adolescents are iron deficient in their first trimester. • 79-95% of all pregnant AAW are deficient in Vitamin D compared to 46-62% of Caucasians women.

17. Primary Community Nursing Interventions to Enhance Nutrition in Pre-Pregnant AAW • Identify social and cultural roles of nutritional intake. • Assess overall ability to access and afford healthy food choices. • Encourage participation in the YMCA’s Veggie Van which makes daily and weekly stops in urban neighborhoods to provide families with discounted fruits and vegetable choices. • Provide a list of pharmacies that will provide free prenatal vitamins. • Address and educate women onissues associated with low-birth weight including smoking and substance abuse.

18. Secondary Nursing Interventions to Promote Nutrition • Provide information to pregnant women regarding increased intake in folic acid, vitamin D and other nutrients. • Involve mothers to be in a nutritional care program and assess her ability to understand the need for increased nutrition. • Provide client with information regarding Kent County maternal and infant health programs. Including the YMCA programs, WIC and information on local food pantries.

19. Inter-Conception Program of Kent County (ICP) • Kent County Health Initiative. • Long term goal is to decrease infant mortality, targeting but not limited to African American Women (AAW). • Between March 2007-Sept 2010, 156 ethically diverse women enrolled, 58% were African American. • Supplemental wellness programs to assist with women’s health prior to pregnancy including nutrition and exercise programs. • Partnered with Planned Parenthood for birth control options.

20. Inter-Conception Program Results • Greater inter-conception intervals,32% of women were discharged from program after reaching 18 months between pregnancies. • 27 births were observed during enrollment • 21 of them waited 12 months or more between pregnancies. • Program enrollment showed a decrease in the number of NICU admissions from 48% to 11%. • The percentage of stillbirth or miscarriage experienced by those women enrolled decrease from 22% to ZERO O%. • No infant deaths were reported in this study.

21. Limitations to the Program • The cost of this preventative program was estimated to be 34 times less than the overall cost of treatment, yet budget cuts have significantly reduced the number of clients the program can support. • Only 156 women were enrolled in the past 3 years. • Budget restrictions have allowed for only 50 at risk women to enroll in 2011. Kent County Health Initiative Report 2011

22. What Else Can Kent County Do? • Follow-up phone calls to low-income first time mothers. • Once a week phone calls for first 8 weeks after delivery. • Implement an infant support program, that would enrolled infants in follow-up programs that would ensure they received appropriate follow-up care, immunizations, which would then resulted in less ER visits. • Provide mothers with various numbers they can call for questions. (poison control, health department) • Provide support so mothers can experienced improved post partum health and decreased stress levels.

23. Could Follow Up Telephone Calls Work in Kent County? • The group of women in the Florida study are comparable to many women in Kent County. • The study consisted of 139 first time mothers, ages 18-36, 51% were married, most spoke English,69% had high school education, made less than $20,000 per year and were unemployed. • The role of the nurse in this study provided support to these women, which then encouraging them to continue appropriate follow-up care. As well as helping them problem solve daily issues that directly affected their infants. This program proved to be a simple yet cost effective way to increase over-all health.

24. How Policies Affect Women’s Health • One reason women put off preventative health measures is because of cost and availability. • Many programs that promote women and children’s health are financed through grants and state budgets. Many programs are cut due to budget restrictions. • The Affordable Care Act will provide up to 32 million Americans with access to health care. • Many of the laws and regulation in the Act encourage and provide health prevention methods to women and children. • Most preventative care will be available with no co-pays or out of pocket expense.

25. Preventative Care • The Affordable Care Act: women and children health care issues. • Yearly check-ups for women. • Provide well-child visits. • Screen pregnant women for conditions that may be harmful for pregnancies such as RH factor blood incompatibility and infections. • Counseling to encourage breastfeeding and support nursing mothers.

26. Lewin’s Model of Change • Unfreezing: Getting the community to be aware of the dangers of poor nutrition and health in relation to poor infant outcomes. Teach African American women about the increased risk associated with short pregnancy intervals and educate about pregnancy prevention. • Changing: Assist in changing attitudes about nutrition, healthy school lunches, hold information meetings for parents, nutritional education at every well child visit to help young men and women grow into healthy adults. • Sustainability (refreezing): Increase accessibility to healthy foods in urban neighborhoods, provide preventative healthcare to all reproductive age females.

27. Overall Goal of Community Nursing Project • Goal is to decrease the disparity between African American and Caucasian Infant deaths by 10% a year until it no longer exists. • Track how many African American women receive annual wellness visits prior to becoming pregnant. Assess percentage of women who have nutritional deficiencies in their first trimester through Kent County Healthy Initiative Plan which tracks statistics for this disparity. • Track birth weights and gestational age of at least 80% of all African American infants.

28. Desired outcome • One of the major indicators of overall public health is infant mortality rates. With the disparity and high rates seen in African Americans the overall goal of this community project is to reduce and eliminate the gap. • With community education and the onset of the preventative measures in the new health care act this gap should be significantly reduce over the next 10 years.

29. References Benefits for Women and Children of New Affordable Care Act Rules on Expanding Prevention Coverage. (2010). Retrieved on Nov. 17, 2012. From: http://www.healthcare.gov/news/factsheets/2010/07 Dunlap, A., Kramer, M., Hogue, J., Menon, R., & Ramakrishan, U. (2011). Racial Disparities in preterm birth: an overview of the potential role of nutrient deficiencies. Acta Review , 133-1341. Fetal Infant Mortality Review. (2010). 2010 Annual Report: Nine Years of FIMR. Kent County: Healthy Kent 2020. Retrieved from http://www.healthykent.org/# Hannan, J. (2012, December 5). APN telephone follow up to low-income first time mothers. Journal of Clinical Nursing , 1-9. Harkness, G. A. & DeMarco, R. F. (2012). Community and Public Health Nursing Practice: Evidence for Practice. Wolters Kluwer/Lippincott, Williams & Wilkins: Philadelphia. ISBN: 987-0-7817-5851-2. Muecke, M. (1984). Community Health Diagnosis in Nursing. Public Health Nursing, 23-35.