Battling Infant Mortality

The Key is Fewer Preterm Births

When Vanderbilt University hosted Family Re-Union 2010 in June, the event occurred with a gloomy backdrop – Tennessee's ranking as 47 in the nation for infant mortality, according to the Annie E. Casey Foundation, which publishes the annual KIDS COUNT reports on child wellbeing.
 
"Part of the reason we offered the conference was to increase awareness in the community," said Kimberly Harrell, Vanderbilt's director of Children's Health Advocacy. "Despite our rates and how dismal they are relative to other states, infant mortality is still not on the top of everybody's priority list, which is all the more reason why we need to do more conferences."
 

Offering Women & Children Hope

As the public becomes increasingly aware of Tennessee's dismal ranking for infant mortality rates, the hope is that expectant parents will also become cognizant of the services available in the community to help combat these statistics.
 
Outreach efforts at Meharry, Vanderbilt and Saint Thomas Health Services, target at-risk women. Other options include a number of faith-based clinics and organizations that offer prenatal and early childhood care. At the Hope Clinic for Women, exams are free for women under 18 are offered on a sliding fee scale for those 18 and older.
 
In addition, the Hope Clinic (www.hopeclinicforwomen.org) offers the BRIDGE program with free services including counseling and a trained mentor who provides support for clients as they go through their pregnancy and beyond … particularly the critical first two years of their child's life. The program also offers classes on a variety of topics including prenatal health, newborn care, nutrition and parenting skills. BRIDGE is designed to meet the practical needs of expectant and new parents by providing clothes and other items for the mother and baby while also meeting their deeper psychological, social and spiritual needs.
In its 12th year, the Family Re-Union conferences examine better ways to strengthen family life in America, and this year's event focused on infant mortality and prematurity. The day included panel discussions of local, state and national experts on the causes of infant mortality and prematurity, best practices for reducing infant mortality in underserved communities, and future actions for prevention. Nashville Mayor Karl Dean and Memphis Mayor A.C. Wharton were on hand, as well as Vanderbilt and Meharry Medical College faculty members.
 
Harrell said outreach and family education are key combatants in the infant mortality fight. She added that Tennessee's 14.9 percent poverty rate contributes to poor prenatal care, and the result is preterm births.
 

Tiny babies

"Actually, the greatest contributor to infant mortality in the United States is prematurity," said Jorge Rojas, MD, a neonatologist at Baptist Hospital. Baptist treats about 500 premature babies in its 52-bed neonatal intensive care unit each year. "Even though we have learned how to take care of those babies, there are still a lot of babies that don't make it," he said. "Even though the survival of premature babies has improved for the last 10 years steadily, we're getting smaller and smaller and smaller babies and more and more smaller babies."
 
Rojas said the greatest stride in saving these diminutive babes is medicine's ability today to aid respiratory function. "We can now treat those immature lungs and replace what's missing, which is surfactant," he explained. Technology that's gentler, less invasive and more attuned to a preterm baby's size is helping, too, he noted. "Most people don't realize that a transfusion for a baby that is a pound and a half is only a third of an ounce, and you have to give that over a four-hour period," he said.
 
While Rojas said that he's never seen a baby born at just 22 weeks of gestation survive, 91 percent of babies born at 23 weeks either die or suffer developmental anomalies. At 28 weeks, the survival rate is 90 percent with good outcomes. "There's simply no treatment for immaturity," he emphasized. "So the only way to keep reducing mortality is reducing the number of premature babies. The focus has to be on increasing prenatal care."
 

Contributing factors

On the Family Re-Union agenda was Veronica Gunn, MD, MPH, chief medical officer for the Tennessee Department of Health. "What drives preterm birth is complex, much more complex than the statistics themselves lead us believe," she explained. "Preterm birth is a factor of access to healthcare, utilization of healthcare, quality of healthcare. It is a reflection of mom's health before she ever conceives, and it's a reflection of all of the facets of our social and emotional and environmental being that affect our health and wellbeing overall."
 
Gunn said the state works to address a number of influences, particularly around behaviors that contribute to poor women's and maternal health. Initiatives encourage physical activity and nutrition, diabetes management, smoking cessation and avoidance of secondhand smoke.
 
Family planning services in all 95 county health clinics are offered on a sliding fee scale. Services include free well-woman checkups and counseling about planning a pregnancy. "In Tennessee, like in most other states, the majority of pregnancies are not planned, so mom's health prior to pregnancy is so critical," Gunn said.
 
Other state initiatives tackle infant health and safety after birth. "We certainly have babies who are full term who die when they go home due to SIDS or cosleeping or injuries that are avoidable," she noted.
 
Gunn said that while Tennessee's infant mortality rankings are "sobering," the state's rate of infant mortality has declined over the past three years. In 2006, the rate was 8.7 deaths per 1,000 live births; in 2007, it dropped to 8.3; in 2008, it dropped to 8.0
 

A success story

Last year, Meharry received a $750,000 grant from the Governor's Office of Children's Care Coordination for a prenatal care program called CenteringPregnancy®. Gwinnett Ladson, MD, an obstetrician and Meharry professor, said the initiative shows promise after less than a year. She reported on the program at the Family Re-Union.
 
Meharry is one of three group care sites in Nashville – the others are at Vanderbilt and the Vine Street Clinic – that focuses on the Centering model of prenatal healthcare delivery. The initiative encourages health assessment, education and support. Eight to 12 women with similar gestational ages meet, learn care skills, participate in discussions and develop a support network within the group. Each pregnancy group gathers for at least 10 sessions throughout pregnancy and early postpartum.
 
"They bond in the group, so that's a big part of it," Ladson said. "It's the support they receive from each other, and many of them actually look forward to the group." At Meharry, at least 60 mothers-to-be have participated so far. Early statistics show that more than 90 percent of the women delivered past 37 weeks and more than 90 percent have breastfed.
 
"They tend to overall have a general sense of wellbeing," Ladson said. And that's a good start.