Infant and Maternal Health Mortality

Susan Castellano, Maternal and Child Health Section Manager

Child and Family Health Division

Trends Impacting Perinatal Health

1/16/2019 2

The Increasing diversity of Minnesota

0

5

10

15

20

25

30

35

40

45

50

2005 2010 2015 2020 2025 2030 2035

Percent of Total Population Projected to Be Nonwhite or Latino, by Year

Minnesota United States Hennepin County

3Data Source: Minnesota State Demographic Center

Neonatal Abstinence Nationally

1/16/2019

Nationally, the rate of babies born with NAS per 1,000 hospital births was 1.2 in 2000, 1.5 in 2003, 1.96 in 2006, 3.39 in 2009 and 5.8 in

2012. The rate of maternal opiate use per 1,000 hospital births was 1.19 in 2000, 1.26 in 2003, 2.52 in

2006, and 5.63 in 2009.

4

Patrick et. Al., JAMA 2012, Patrick et. Al., Journal of Perinatology.

STDs in MinnesotaRate per 100,000 by Year of Diagnosis, 2007-2017

0

1

2

3

4

5

6

7

8

9

10

0

50

100

150

200

250

300

350

400

450

500

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Rate

of P

&S Syp

hilis

Rat

e o

f C

hla

myd

ia a

nd

Go

no

rrh

ea

Chlamydia Gonorrhea P&S* Syphilis

* P&S = Primary and Secondary

Source: Sexually Transmitted Disease (STD) Surveillance Report, MN Dept. of Health, 2017

Deaths in MN from Suicide, Homicide, Alcohol and Drug Overdose, 2000-2016

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Infant Mortality

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Key Fetal/Infant MN Statistics: 2016

8

• Live Births: 69,835

• Number of infant deaths (Infants aged < 1 year): 357

• Number of neonatal deaths (Infants aged < 28 days): 242

• Number of post neonatal deaths (Infants aged 28 days to < 1 year): 115

• Fetal (Stillbirth) deaths (20+ weeks gestation): 420

• Infant mortality rate per 1,000 live births: 5.1

• Fetal mortality rate per 1,000 live births + fetal deaths: 5.3

What Is the Infant Mortality Rate?

1. The infant mortality rate (IMR) is expressed as the number of infant deaths per 1,000 live births.

2. IMR Calculation Example: In 2014, there were 346 infant deaths and 69,916 live births in Minnesota. What was the infant mortality rate?

346/69,916 x 1,000 = 4.9 infant deaths per 1,000 live births

Interpretation: In 2014, the IMR in Minnesota was 4.9 infant deaths per 1,000 live births.

9

Infant Mortality Rates for Selected OECD Countries

5.95.1

4.24.1

4.04.0

3.93.9

3.73.7

3.43.33.33.3

3.23.13.1

2.92.9

2.82.72.7

2.52.52.5

2.32.2

1.71.6

0 1 2 3 4 5 6 7

United States

Slovak Republic

Hungary

Latvia

Greece

Poland

Switzerland

United Kingdom

Denmark

France

Ireland

Belgium

Germany

Netherlands

Australia

Austria

Israel

Italy

Portugal

Luxembourg

Estonia

Korea

Czech Republic

Estonia

Sweden

Norway

Iceland

Finland

Slovenia

Rate per 1,000 Live Births1/16/2019 10

Source: OECD (2018), Infant mortality rates (indicator). doi: 10.1787/83dea506-en (Accessed on 12 March 2018)

29th

Infant Mortality Rates 1996-2015: Minnesota and U.S.

7.2

5.9

5.06.0

0

1

2

3

4

5

6

7

8

1996-1998 1998-2000 2000-2002 2002-2004 2004-2006 2006-2008 2008-2010 2012-2014 2013-2015

Rat

e p

er 1

,00

0 L

ive

Bir

ths

US Minnesota Healthy People 2020 Target

1/16/2019 11Source: National Center for Health Statistics

Infant Mortality Rates by Race/Ethnicity of Mother, Minnesota 2000-20161

0

2

4

6

8

10

12

2000-2004 2001-2005 2002-2006 2003-2007 2004-2008 2005-2009 2006-2010 2007-2011 2008-2012 2009-2013 2010-2014 2011-2015 2012-2016

Rat

e p

er 1

,00

0 L

ive

Bir

ths

Total Black/African American

American Indian or Alaska Native Asian/Pacific Islander

Hispanic* Non-Hispanic White1/16/2019 12

*Hispanic can be of any race1Five-year averages Source: Minnesota Department of Health, Linked Birth/Infant Death File

Leading Causes of Infant Mortality in Minnesota, 2012-2016

Race/Ethnicity First Second Third Fourth

Total CongenitalAnomalies(26.0%)

Prematurity (24.7%) Obstetric Conditions (12.6%)

SUID (12.5%)

Black/African American Prematurity (26.4%) Congenital Anomalies (23.0%)

SUID (16.3%) Obstetric Conditions(12.4%)

American Indian Obstetric Conditions (31.3%)

# # #

Asian/Pacific Islander Prematurity (34.0%) Congenital Anomalies (26.7%)

Obstetric Conditions (15.3%)

#

Hispanic* CongenitalAnomalies (25.4%)

Prematurity (23.8%) # #

Non-Hispanic White CongenitalAnomalies (27.9%)

Prematurity (23.0%) SUID/SIDS (12.6%) Obstetric Conditions(11.0%)

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*Hispanic can be of any race#indicates unstable proportions; fewer than 20 casesSUID includes SIDS and other sleep-related deaths

Source: Minnesota Department of Health. Linked Birth/Death File

Minnesota Stillbirth rates 2003-2016

4.9

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Rat

e p

er 1

,00

0 li

ve b

irth

s +

Still

bir

ths

Early (20-27 weeks) Late (28+ weeks) Overall (20+ weeks)

In 2013, the U.S. fetal mortality rate was 6.0 compared to 4.9 in

Minnesota.

Data Source: Minnesota Department of Health, Minnesota Resident Final Fetal Death File

Stillbirth rates by race/ethnicity Minnesota 2006-2016

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Rat

e p

er 1

,00

0 li

ve b

irth

s +

Still

bir

ths

3-Year Rolling Average

African American/Black

American Indian

Asian/Pacific Islander

Hispanic

Non-Hispanic White

Data Source: Minnesota Department of Health, Minnesota Resident Final Fetal Death File

Once a day =

Many are preventable

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Fetal and Infant Mortality Review

1/16/2019 17

History of FIMR in Minnesota

1/16/2019 18

• Statutory authority and resources no longer exists

• Previous statewide American Indian Infant Mortality Review conducted

What is a Fetal and Infant Mortality Review?

1/16/2019 19

Conduct systematic, scientific, and objective review of cases to identify underlying causes, contributing factors and systems-level issues, monitoring trends and changes over time

Case summaries reviewed by an interdisciplinary team, develops recommendations based on themes or patterns in the information

Community Action Team charged with developing and implementing solutions to address systems- and community-level problems

Ultimate goal: avert preventable fetal and infant deaths by improving education, services and community resources via a broad range of policies and interventions

Maternal health

59.0

41.4

33.1

17.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

PER

1,0

00

FEM

ALE

S A

GES

15

-19

Data Source: Minnesota Resident Final Birth File & US Census Bureau, American Community Survey

Minnesota teen pregnancy rate 1990-2016

Teen Birth by Race/Ethnicity

98.5104.7

52.5

103.4

20.4

37.1

69.6

108.1

40.2

87.6

17.121.1

56.3

91.3

32.5

62.7

14.99.7

32.8

54.6

19.3

32.2

9.43.9

0.0

20.0

40.0

60.0

80.0

100.0

120.0

African American/Black American Indian Asian/Pacific Islander Hispanic Non-Hispanic White Other & Unknown

Rat

e p

er 1

,00

0 F

em

ales

Age

s 1

5-1

9

Minnesota Teen Birth Rate by Race/Ethnicity

2000 2005 2010 2015

22Data Source: Minnesota Resident Final Birth File & US Census Bureau, American Community Survey

Percent Preterm Births by Race/Ethnicity of Mother Minnesota, 2017

9.7

15.2

8.4

9.68.6

12.5

8.9

0

2

4

6

8

10

12

14

16

Black/AfricanAmerican

American Indian Asian/PacificIslander

Hispanic* White Other/Unknown MN Total

Perc

ent

(%)

1/16/2019 23

Notes:*Hispanic can be of any racePreterm births are births that occur before 37 completed weeks of gestation.The data shown are for the percent (%) of all births that are pretermSource: Minnesota Department of Health, Birth File

Percent of Unintended Pregnancies, 2013-2015

24

21% 21%

43%

33%

25%

0%

10%

20%

30%

40%

50%

White Asian African American American Indian Hispanic

Data Source: Minnesota PRAMS

Maternal Depression

• Pregnancy – a vulnerable time for depression

• Research has demonstrated maternal depression can have a significant impact on infant development

• Prevalence of depression in pregnant and post-partum women range from 5%-25% depending on the source of the information and degree of severity. Can be:

• Mild - Baby Blues, 50% - 80%

• Moderate - Postpartum Depression, 10% - 20%

• Severe - Postpartum Psychosis, 0.1% - 0.2%

Source: Screening for perinatal depression. ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e208-12 25

26Source: Tarlov AR. (1999). Public policy frameworks for improving population health. Ann NY Acad Sci 1999; 896: 281-93.

Determinants of Health

Factors that Influence on Health

27

Experiences During Pregnancy

1/16/2019 28

7.5%

23.9%

28.6%

9.9%

4.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

White US born AfricanAmerican

American Indian Hispanic* Other/Unknown

Pe

rce

nt

wit

h <

5 o

r ≥

5 S

tre

sso

rs 5 or more stressors

Source: PRAMS Survey Hispanic Ethnicity may include other racial categories

29

Stressors by Race/Ethnicity for pregnant women Minnesota, 2009-2013

Stressful Life Events

41.6

12.1

28.8

49.6

10.6

32.3

26.021.6

29.8

1.6

16.1

25.2

15.3

29.8

2.3

17.3

0

10

20

30

40

50

60

Moved Homelessness Problems paying the rent, mortgage, or other bills

Perc

ent

Categories of Stressful Events

Percentage of mothers who reported experiencing housing related stressors 12 months before the baby was born by race/ethnicity: Minnesota, 2012-2015

U.S.-born Black American Indian Hispanic* White Other Total

1/16/201930

*Hispanic can be of any raceData not shown when there are fewer than 30 casesSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.Funding for MN PRAMS is made possible by grant number: 5U01DP006217-03 from the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion

Stressful Life Events

15.9

20.7

25.2

16.6

14.3

20.5

13.4

23.7

7.5

5.2

14.2

7.9

13.5

8.56.6

15.5

0

5

10

15

20

25

30

Husband/Partner lost job Lost job but wanted to go on working Husband/Partner or I had cut in work hours or pay

Perc

ent

Categories of Stressful Events

Percentage of mothers who reported experiencing employment related stressors 12 months before the baby was born by race/ethnicity: Minnesota, 2012-2015

U.S.-born Black American Indian Hispanic* White Other Total

1/16/201931

*Hispanic can be of any raceData not shown when there are fewer than 30 casesSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.Funding for MN PRAMS is made possible by grant number: 5U01DP006217-03 from the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion

First Trimester Prenatal Care

Early access:

• Healthy People 2020 goal: 77.9% of pregnant women to begin prenatal care in the first trimester

• Only non-Hispanic whites are above this HP goal

1/16/2019 32

0

20

40

60

80

100

2010 2011 2012 2013 2014 2015

Percent of Minnesota Births Starting Prenatal Care in First Trimester, 2010-2015

HP2020 MN African American/Black

American Indian Asian/Pacific Islander Hispanic

Per

cen

tSource: Center for Health Statistics, Minnesota Department of Health 2010-2015

Adequacy of Prenatal Care, Minnesota 2010-2016

33

Percent Reporting No Prenatal Care First TrimesterMinnesota, 2012-2015

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*Hispanic can be of any raceSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.

Funding for MN PRAMS is made possible by grant number: 5U01DP006217-03 from the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion

72.5 68.4 72.6

89.8

72.7

85.2

27.5 31.6 27.4

10.2

27.314.8

0

20

40

60

80

100

US-Born Black American Indian Hispanic* White Other Total

Perc

ent

Yes No

Barriers to Prenatal Care

47.7

24.0

56.3

20.3

29.028.2

16.3

32.8

19.8

6.8

0

10

20

30

40

50

60

70

80

Did not know I was pregnant Didn't have enough money orinsurance to pay for my visits

Didn't have any transportation toget to the clinic/doctor's office

Perc

ent

Percentage of mothers who reported experiencing the following barriers when trying to access prenatal care Minnesota, 2012-2015

U.S.-born Black American Indian Hispanic* White Other Total

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1/16/2019 35*Note: Hispanic can be of any raceSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health

3.8

8.37.9

4.04.5 4.3

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

White Black/AfricanAmerican

American Indian Asian Hispanic* MN Total

Rat

e p

er

1,0

00

Liv

e B

irth

s

*Can be of any raceSource: Minnesota Department of Health, Center for Health Statistics 36

Infant Mortality disparities persist despite first Trimester Prenatal Care Initiation, Minnesota 2009-2013

Experiences after the baby was born

1/16/2019 37

Social Support After Pregnancy

79.484.0 82.781.5

85.3 84.5

73.5

85.0 83.8

92.2 94.9 93.1

58.2

75.2 73.7

86.291.2 89.6

0

10

20

30

40

50

60

70

80

90

100

Someone to loan me $50 Someone to talk to with about my problems Someone to help me if I were sick and needed tobe in bed

Perc

ent

Categories of Stressful Events

Percentage of mothers who reported that they had the following types of social support after their baby was born by race/ethnicity: Minnesota, 2012-2015

U.S.-born Black American Indian Hispanic* White Other Total

1/16/201938

*Hispanic can be of any raceSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.Funding for MN PRAMS is made possible by grant number: 5U01DP006217-03 from the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion

Social Support After Pregnancy

81.485.585.3 86.7

82.6 81.0

93.7 94.2

79.1 79.0

90.5 90.9

0

10

20

30

40

50

60

70

80

90

100

Someone to take care of my baby Someone to help me if I were tired and feeling frustrated with my new baby

Perc

ent

Categories of Stressful Events

Percentage of mothers who reported that they had the following types of social support after their most recent pregnancies months by race/ethnicity: Minnesota,

2012-2015

U.S.-born Black American Indian Hispanic* White Other Total

1/16/201939

*Hispanic can be of any raceSource: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.Funding for MN PRAMS is made possible by grant number: 5U01DP006217-03 from the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion

Maternal Mortality

National Trends in Maternal Mortality

7.2

9.4 9.8 10.0 10.310.8 11.1

12.9

11.3 11.3

12.912.0

13.2

14.5 14.714.1

16.8

15.2 15.4 15.7

14.515.5

17.8

16.7

17.8

15.9

17.318.0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pre

gnan

cy-r

ela

ted

mo

rtal

ity

rati

o*

Trends in pregnancy-related mortality in the United States, 1987-2014

41

* Note: Number of pregnancy related deaths per 100,000 live births

Data Source: CDC, Pregnancy Mortality Surveillance System

Maternal Mortality Definitions

• ACOG and CDC definitions

Pregnancy-associated death: The death of a woman while pregnant or within 1 year of termination of pregnancy, irrespective of cause.

Pregnancy-related death: The death of a woman while pregnant or within 1 year of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes.

42

Berg, C., Danel, I., Atrash, H., Zane, S., & Bartlett, L. (2001). Strategies to reduce pregnancy-related deaths: From identification and review to action. Centers for Disease Control and Prevention: 1-214

National Maternal Causes of Death

15.2% 14.7%

12.8%11.5%

10.3%9.1%

7.4%

3.8%

5.5%

0.3%0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Pe

rce

nta

ge o

f al

l pre

gnan

cy-r

ela

ted

de

ath

s Causes of pregnancy-related mortality in the United States, 2011-2014

43

* Note: The cause of death is unknown for 6.5% of all 2011-2014 pregnancy-related deaths.

Data Source: CDC, Pregnancy Mortality Surveillance System

Causes of Death, 2011-2017

18%, Obstretic complications

11%, Unintentional Poisoning

10%, Violence

9%, Non-Obstretic complications

9%, Motor Vehicle Crash

8%, Suicide

20%, Other/Misclassified/

Unknown

6%, Cancer

5%, Heart & circulatory System

3%, Nervous System 2%, Respiratory System

44Data Source: Minnesota Department of Health, Minnesota Resident Maternal Mortality File

Minnesota Maternal Mortality Reviews

• Cases identified: check box on death certificate, clinician reporting and other

• Clinician conducts medical review of each case, develops a summary

• Review team assembles 2-3 times per year to review case summaries, identify causes, contributing factors and trends

• Some state include Morbidity reviews as well, would require statutory authority and resources to include in Minnesota

45

All Maternal Deaths - Preliminary

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

2011 2012 2013 2014 2015 2016 2017

Minnesota’s Maternal Mortality Rate, 2011-2017

46Data Source: Minnesota Department of Health, Minnesota Resident Maternal Mortality File

Disparities in pregnancy-related mortality, United States 2011-2015

12.4

40.0

17.8

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

White Black Other Races

Pre

gnan

cy-r

ela

ted

mo

rtal

ity

rati

o*

Disparities in pregnancy-related mortality in the United States, 2011-2014

47

* Note: Number of pregnancy related deaths per 100,000 live births

Data Source: CDC, Pregnancy Mortality Surveillance System

MN Maternal Mortality Rates by Race/Ethnicity2011-2017

0

50

100

150

200

250

300

Non-Hispanic White African American/Black American Indian

Per

10

0,0

00

Liv

e B

irth

s

Data Source: Minnesota Department of Health, Minnesota Resident Maternal Mortality File

Maternal Mortality in Minnesota, 2011- 2017

15%, African American/

Black

12%, American

Indian

4%, Asian/Pacific

Islander

6%, Hispanic

62%, Non-Hispanic

White

1%, Other & Unknown

PROPORTION OF MATERNAL DEATHS11%, African American/

Black2%,

American Indian

8%, Asian/Pacific

Islander

7%, Hispanic

72%, Non-Hispanic

White

1%, Other & Unknown

PROPORTION OF BIRTHS

Data Source: Minnesota Department of Health, Minnesota Resident Maternal Mortality File

MN Place of Maternal Death, 2011-2017

Physical Location

• Inpatient Hospital 40%

• Hospital E.R. / Outpatient 17%

• At Home 26%

• Interstate/Hwy/Road 6%

• In transport to Hospital 1%

• Other 10%

Geographic LocationProportionof Deaths

Proportion of Births

Hennepin County 27% 24%

Ramsey County 9% 11%

Suburbs* 17% 22%

Greater Minnesota

47% 43%

Data Source: Minnesota Department of Health, Minnesota Resident Maternal Mortality File

*Suburbs include: Anoka, Carver, Dakota, Scott, Washington

Thank you Contact information:

Susan Castellano | Maternal and Child Health Section ManagerJoan Brandt | Child and Family Health Division DirectorMira Grice Sheff | State MCH Epidemiologist, PRAMS PIKatie Linde | Women and Infant Health SupervisorMichelle Chiezah | Infant Mortality SpecialistMolly Meyer | Senior Research Scientist

Minnesota Department of HealthSusan.Castellano@state.mn.us(651) 201-3872

51