Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities Impact of Perinatal Health Issues on Infant Mo

1. Bronx Center to Reduce and Eliminate Ethnic and Racial Health DisparitiesImpact of Perinatal Health Issues on Infant Mortality and Morbidity in the Bronx Deborah Campbell, MD, FAAP Division of Neonatology June 15, 2007

2. 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.

3. Bronx Health Center and Community Districts

4. 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

5. 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

6. 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

7. Live Births, Induced Terminations and Spontaneous Terminations

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

9. 2005 Live Births, Spontaneous and Induced Terminations of Pregnancy

10. Live Births, Induced TerminationsNYC, 2005

11. Live Births by Maternal Ethnicity

12. Live Births by Race/Ethnicity & Borough 2005

13. Bronx Live Births 2005: 20,766

14. NYC Live Birth Characteristics

15. Distribution of Births By Gestational Age

16. 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 Bronx – 20,766 LB Puerto Rican 1337 Dominican 4052 Mexican 1754 African-Am. 4005 Jamaican 745 Other Hispanic 1132

18. 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

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

20. Teen Live Births: 2003-2005

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

22. 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

23. 2005 IMR by Borough

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

27. 2005 Infant Mortality Rate by Ethnicity

29. Distribution of Deaths: Fetal-Neonatal-Infant Mortality

30. Components of Perinatal Period of Risk

31. The Role of Maternal Morbidity and Mortality

32. Maternal Mortality Ratios for White Women:1987-1996 (REFER TO SLIDE) New York represented the highest in the nation for white women: 7.6 Ratio Three states reached the Year 2000 maternal mortality objective of 3.3 per 100,000 live births for white women: Massachusetts (2.7), Washington (3.0) and Nebraska (3.2). Eight other states report maternal mortality ratios of less than 4 per 100,000 live births for white women. Maternal mortality ratios for white women range from 2.7 in Massachusetts to 9.2 in Vermont. (CLICK FOR NEXT SLIDE) Speaker background information: States in Blank indicate: Point estimates for states with fewer than seven maternal deaths fore 1987-1996 are considered unreliable (relative standard error :>38%.) (REFER TO SLIDE) New York represented the highest in the nation for white women: 7.6 Ratio Three states reached the Year 2000 maternal mortality objective of 3.3 per 100,000 live births for white women: Massachusetts (2.7), Washington (3.0) and Nebraska (3.2). Eight other states report maternal mortality ratios of less than 4 per 100,000 live births for white women. Maternal mortality ratios for white women range from 2.7 in Massachusetts to 9.2 in Vermont. (CLICK FOR NEXT SLIDE) Speaker background information: States in Blank indicate: Point estimates for states with fewer than seven maternal deaths fore 1987-1996 are considered unreliable (relative standard error :>38%.)

33. (NYC RATE WILL AUTOMATICALLY APPEAR) (REFER TO SLIDE) (CLICK FOR NEXT SLIDE) Speaker background information: Western Region: Chautauqua 64.9 (1998); Erie 8.9 (1999) Finger Lakes Region: Monroe 10.5 (2000); Wayne 157.1 (1998);Yates 366.3 (2000) Central Region: Onondaga 33.3 (2000) New York Penn: Chenango 0 (2000); Tioga 182.5 (1998) North Eastern Region: Albany 0 (2000); Delaware 218.3 (1999); Renssalaer 47.7 (1993) Hudson Valley: Ulster 55.6 (2000); Westchester 22.6 (2000) Nassau: 17.7 (2000) Suffolk: 4.9 (2000) Source: http://www.health.state.ny.us/nysdoh/chac/cha00/matmort.htm (NYC RATE WILL AUTOMATICALLY APPEAR) (REFER TO SLIDE) (CLICK FOR NEXT SLIDE) Speaker background information: Western Region: Chautauqua 64.9 (1998); Erie 8.9 (1999) Finger Lakes Region: Monroe 10.5 (2000); Wayne 157.1 (1998);Yates 366.3 (2000) Central Region: Onondaga 33.3 (2000) New York Penn: Chenango 0 (2000); Tioga 182.5 (1998) North Eastern Region: Albany 0 (2000); Delaware 218.3 (1999); Renssalaer 47.7 (1993) Hudson Valley: Ulster 55.6 (2000); Westchester 22.6 (2000) Nassau: 17.7 (2000) Suffolk: 4.9 (2000) Source: http://www.health.state.ny.us/nysdoh/chac/cha00/matmort.htm

34. Findings of the SMICauses 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 %

35. 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%)

36. 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

37. 37 This slide shows the Infant mortality rate by ethnicity for 1992-2001. These trends show that although IMR has decreased citywide, there are wide disparities across ethnic groups. The top line– black, non-Hispanic infant mortality rate is consistently higher for every time point. The next line down- IMR for Puerto Ricans is also consistently higher across time. - In general the IMR for all ethnicity is decreasing. This slide shows the Infant mortality rate by ethnicity for 1992-2001. These trends show that although IMR has decreased citywide, there are wide disparities across ethnic groups. The top line– black, non-Hispanic infant mortality rate is consistently higher for every time point. The next line down- IMR for Puerto Ricans is also consistently higher across time. - In general the IMR for all ethnicity is decreasing.

38. 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

39. 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

40. NYC MMR Review 1998-2000:BMIRH Enhanced Surveillance

41. Location of Death: BMIRH 1998-2000 Note: NEED ACTUAL NUMBERS FOR THIS GRAPH!!Note: NEED ACTUAL NUMBERS FOR THIS GRAPH!!

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

43. MMR and Race/ EthnicityBMIRH 1998-2003

44. US Historical Perspective: Racial Disparities

46. MMR by Birth PlaceBMIRH 1998-2003

47. Comparing Leading Causes of Death (%)

48. Hemorrhage Related DeathsBMIRH 1998-2000 Black 64 % Hispanic 21 % White 8 % Asian/Pacific Isl. 8 % In hospital 97%

49. Obesity: Maternal Mortality Risk From HemorrhageBMIRH 1998-2000

50. Hemorrhage Initiative Hemorrhage alert – Commissioner of Health, NYC Hemorrhage protocols Hemorrhage Poster Unusual collaboration between the NYC DOH, NYS DOH and ACOG

51. What About the Bronx?

52. MMR by BoroughBMIRH 1998-2003

54. 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

55. 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)

56. 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

57. Newborn and Infant Care Issues

58. 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%)

60. 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) Birth Weight Categories

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

64. Central Bronx: LBW and IMR

65. South East Bronx

66. Hunts Point – Mott Haven

67. 2005 US Breastfeeding Rate: Ever Breastfed (Annual Summary VS, Pediatrics 2007)

73. 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