The Epidemiology of Infant Mortality and Disparities in Birth Outcomes in Ohio

The Epidemiology of Infant Mortality and Disparities in Birth Outcomes in Ohio Elizabeth J Conrey, PhD, RD State MCH Epidemiologist Ohio Department of Health Ohio Equity Institute July 23, 213

Acknowledgements MCH Epidemiology Section Connie Geidenberger Sarah Miller Missy Vonderbrink Rich Thomas Vital Statistics John Paulson Fellows/Interns Celia Quinn Wengora Thompson Alison Nelson

Ohio Equity Institute July 23, 213 INFANT MORTALITY

Infant mortality rates by state, 21 Ohio black IM rank = 2 nd Ohio overall IM rank = 4 th

Decline in infant mortality rates by state, 25-21 WA MT ND ME OR ID WY SD MN WI MI NY VT NH MA CT RI CA NV UT CO NE KS IA MO IL IN KY OH WV VA PA DE NJ MD DC AZ NM OK AR TN SC NC MS AL GA TX LA FL AK U.S. change = -1.5 HI Statistically significant decline of 2% or more Statistically significant decline of <2% No significant change Source: National Vital Statistics System, NCHS, CDC

Infant mortality rates, Ohio & US, 199 212 rate per 1, live births 12 1 NO change Ohio 8 United States 6 4 NO change 12% decline 2 Source: Office of Vital Statistics, Ohio Department of Health *212 data preliminary NCHS, *US 211 data preliminary

Infant Mortality Rate per 1, Live Births 16 14 12 1 8 6 4 2 Infant Mortality Rate by Maternal Race/Ethnicity, Ohio, 21 6. Non Hispanic White 14.1 7. Non Hispanic Hispanic Black Maternal Race/Ethnicity 7.5 Total Healthy People 22 Goal: 6. Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death File

Neonatal and postneonatal mortality rates, Ohio and United States, 2-211 Rate per 1, live births 6 5 4 3 2 1 Ohio, Neonatal Deaths US, Neonatal Deaths** Ohio, Postneonatal Deaths US, Postneonatal Deaths** 2 21 22 23 24 25 26 27 28 29 21 211 Source: Ohio Department of Health Vital Statistics Birth and Death Files NCHS linked birth/infant death data set, 2 29, mortality data set 21, and preliminary mortality data set, 211 **Statistically significant at 5% level

PREMATURITY and LOW BIRTH WEIGHT Ohio Equity Institute July 23, 213

Infant mortality by gestational age, 2 18 178.4 Ohio, 28 Infant mortality rate per 1, live births 16 14 12 1 8 6 4 2 7.2 2.5 6.7 3.4 2.2 2.4 Total <32 32 33 34 36 37 38 39 41 42+ Weeks of Gestation Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death Data Set

Percent of births and infant deaths by gestational age (weeks), Ohio, 28 Live Births Infant Deaths 2% 2% 8% <32 32 33 34 36 37+ 88% Source: Ohio Department of Health Vital Statistics linked birth/infant death data set

Percentage of preterm births Ohio, 2 211 14 12 34 36 weeks <34 weeks 12.9 13.1 12.9 12.3 12.5 11.4 11.6 12.3 11.8 12.2 12.1 12.3 Percent preterm 1 8 6 4 8. 8.2 8.3 8.6 8.8 9.1 9.3 9.1 8.5 8.4 8.4 8.1 2 3.4 3.5 3.6 3.5 3.5 3.7 3.8 3.8 3.8 3.8 4.1 4.2 2 21 22 23 24 25 26 27 28 29 21 211 Source: Ohio Department of Health Vital Statistics Birth Data

Percent distribution of births by gestational age, Ohio, 26 and 21 6 5 51.9 52.6 4 26 21 Percent 3 2 3. 23.3 1 9.3 7.7 3.8 3.8 4.8 4.9 <34 34 36 37 38 39 41 42+ Weeks of Gestation Source: Ohio Department of Health Vital Statistics Birth Certificate Data

Preterm and Low Birth Weight Births Ohio, 26 211 7 6 Percent of Births 5 4 3 2 1 >38 Weeks* 37-38 Weeks 29-36 Weeks <29 Weeks+ <25 g 26 27 28 29 21 211 Source: Ohio Department of Health Vital Statistics Birth Certificate Data

Percent of Births Low Birth Weight, Preterm & Early Term Singleton Births, by Race/Ethnicity, Ohio, 21 211 3 25 2 15 1 5 1. 2.7 1.3 Preterm, <29 Weeks 1.2 15. 11.3 Preterm, 29-36 Weeks 24.4 26.6 26.5 Early Term, 37-38 Weeks Non-Hispanic White Non-Hispanic Black Hispanic 7.5 13.8 7.7 Birth Weight <2,5g Source: Ohio Department of Health Vital Statistics Birth Certificate Data

Percent of Preterm Births by County, 28 211 Source: Ohio Department of Health Vital Statistics Birth Certificate Data

Percent of Low Birth Weight Births by County, 28 211 Source: Ohio Department of Health Vital Statistics Birth Certificate Data

Ohio Perinatal Quality Collaborative (OPQC) Change in Full Term + Near Term Births 7 Percent distribution of OPQC full term and near term births, by month January 26 to April 211 6 5 Percent 4 3 2 1 Baseline averages were calculated from the initial 24 months, January 26 to December 27. Jan 6 Mar 6 May 6 Jul 6 Sep 6 Nov 6 Jan 7 Mar 7 May 7 Jul 7 Sep 7 Nov 7 Jan 8 Mar 8 May 8 Jul 8 Sep 8 Nov 8 Jan 9 Mar 9 May 9 Jul 9 Sep 9 Nov 9 Jan 1 Mar 1 May 1 Jul 1 Sep 1 Nov 1 Jan 11 Mar 11 Near term (36 38 weeks) Full term (39 41 weeks) Baseline, near term Baseline, full term A quality improvement initiative launched in 28 with 2 large Ohio birthing hospitals to reduce inductions <39 weeks gestation without medical indication Data Source: Ohio Vital Statistics Birth Certificate 26-211

Near Term Births (36 39 wks gestation), by Race and Delivery Hospital OPQC Participation Ohio, 27 1 4 35 Percent of Live Births 3 25 White, QI Hospital White, non QI Hospital Black, QI Hospital Black, non QI Hospital 2 27 28 29 21 YEAR

Why did black women experience a smaller reduction in near term births than white women from 27 to 21? Because most early births to black women are for reasons unaffected by the initiative: The initiative targeted births from 36 38 weeks, but Black women were more likely than white to give birth even before 36 weeks After reaching 36 38 weeks, Black women are more likely to have spontaneous labor or a medical indication for induction Elimination of disparities in preterm and near term birth will require approaches that target the common reasons for birth <39 weeks among black women and reduce Early and spontaneous preterm births Medical indications for induction before 39 weeks gestation

CAUSES OF INFANT MORTALITY Ohio Equity Institute July 23, 213

Top 1 Causes of Infant Death, Ohio, 211 Hemorrhagic and hematological disorders of newborn 2% Newborn affected by complications of placenta, cord and membranes 5% Transport accidents 7% Sudden infant death syndrome 9% Diseases of the circulatory system 2% Maternal complications of pregnancy 9% Other 17% Congenital Malformations 21% Unknown 1% Disorders related to preterm birth, low birth weight 18% Source: Ohio Vital Statistics

Infant mortality rate per 1, live births Infant mortality rates for the five leading causes of infant death in 211: Ohio, 2, 25, and 211 18 16 14 12 1 8 6 4 2 158.5 163. 151.6 Congenital Malformations 19.8 142. 136.9 Short gestation/low birthweight 73.9 55.3 2 25 211 68.1 68.8 69.6 53.9 SIDS Maternal complications 18.6 42.5 52.2 Unintentional injuries Source: Ohio Department of Health Vital Statistics Birth and Death Files

Reviews of Infant Deaths by Leading Cause of Death, 26 21 Source: Ohio Child Fatality Review n = 5,546

Spotlight on sleep related deaths 41% of infant deaths after 28 days 39% to black infantsdisproportionate to the 17% of the population they represent Source: Ohio Child Fatality Review

RISK FACTORS FOR INFANT MORTALITY Ohio Equity Institute July 23, 213

Breastfeeding Breastfeeding Initiation in HRSA Region 5 States, 28 1 8 Breastfeeding initiation, duration and exclusivity at 8 weeks, Ohio, 29-21 Ever Breastfed Any breastmilk at 8 weeks Only breastmilk at 8 weeks Percent (%) 6 4 2 Insurance Race Education Source: National Immunization Survey Ohio Pregnancy Risk Assessment Monitoring System, 29-21, Ohio Department of Health

Mothers reporting placing their infant to sleep on back, by race Source: Ohio Pregnancy Risk Assessment Monitoring System, 29-21, Ohio Department of Health

Perinatal Smoking Ohio, 21 Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

Smoking During Pregnancy (last 3 mos), by Demographics, Ohio, 29 1 Percent OVERALL AGE (YEARS) <2 2-24 25-34 35+ EDUCATION (YEARS) Less than 12 12 More than 12 RACE White, non-hispanic Black, non-hispanic INSURANCE STATUS Medicaid Non-Medicaid WIC DURING WIC Non-WIC COUNTY TYPE Appalachian Rural, non- Metropolitan Suburban 5 1 15 2 25 3 35 4 Source: Ohio Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

Rate per 1 live births Teen Births Infant Mortality, by Maternal Age, 12 Ohio, 21 1 8 6 4 2 15 17 18 19 2 24 25 29 3 34 35 39 4 44 Rate per 1 population Trends in Teen (15-17) Births, by Race and Ethnicity, Ohio, 26-211 5 45 4 35 3 25 2 15 1 5 White, non Hispanic Black, non Hispanic Hispanic Total 26 27 28 29 21 211

Birth Rate to Adolescents aged 15 17 years, by County, Ohio, 29 11 *Birth Rates are per 1, females aged 15-17 years. **Rates based on less than 2 observations may be unstable and are not reported. Teen Birth Rate for the State of Ohio 29-211: 16.3 per 1, females aged 15-17 years. The mean of the county birth rates on which the standard deviations were based (map key) was 16. per 1, females aged 15-17 years. Source: Ohio Department of Vital Health Statistics and U.S. census (21)

Social Determinants of Health The conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities the unfair and avoidable differences in health status seen within and between countries The World Health Organization

Infant Mortality Rate per 1, live births Infant Deaths per 1, Live Births 14 12 1 8 6 4 2 Healthy People 22 Objective 6. Lower Middle Higher Cuyahoga County (27 211) Franklin County (27 211) Hamilton County (27 211) Socioeconomic Tertile 1 Infant Mortality Rate Lower SES 12.3 Middle SES 8.6 Higher SES 4.1 Lower SES 11.1 Middle SES 6.2 Higher SES 4. Lower SES 11.4 Middle SES 8.9 Higher SES 7. Cuyahoga County Franklin County Hamilton County Ohio United States Ohio (27 211) 7.7 United States (27 21) 6.6 Socioeconomic status defined by median household income and attainment of a bachelor degree by individuals 25 years of age Sources: Socioeconomic status calculated from American Community Survey 5 year estimates (27 211) Ohio Risk Factor Data from Ohio Department of Health Vital Statistics Birth Files (27 211) United States Estimates from National Vital Statistics System Birth Data (27 21)

Percent of Low Birth Weight Births Low Birth Weight Births Less than 2,5 grams 16 14 12 1 8 6 4 2 Cuyahoga County Franklin County Hamilton County Lower Middle Higher Healthy People 22 Objective 7.8% Ohio United States Cuyahoga County Franklin County Hamilton County Socioeconomic Tertile 1 % Low Birth Weight Lower SES 13.7 Middle SES 9.5 Higher SES 7.6 Lower SES 12. Middle SES 8.8 Higher SES 7.1 Lower SES 12. Middle SES 9.5 Higher SES 8. Ohio (27 211) 8.6 United States (27 21) 8.2 Socioeconomic status defined by median household income and attainment of a bachelor degree by individuals 25 years of age Sources: Socioeconomic status calculated from American Community Survey 5 year estimates (27 211) Ohio Risk Factor Data from Ohio Department of Health Vital Statistics Birth Files (27 211) United States Estimates from National Vital Statistics System Birth Data (27 21)

Preterm Births Less than 37 weeks gestation Percent of Preterm Births 25 2 15 1 5 Lower Middle Higher Healthy People 22 Objective 11.4% Cuyahoga County (27 211) Franklin County (27 211) Hamilton County (27 211) Socioeconomic Tertile 1 % Preterm Lower SES 17.9 Middle SES 13.1 Higher SES 1.9 Lower SES 15.9 Middle SES 12.7 Higher SES 1.8 Lower SES 16.3 Middle SES 13. Higher SES 11.3 Cuyahoga County Franklin County Hamilton County Ohio United States Ohio (27 211) 17.9 United States (27 21) 13.1 Socioeconomic status defined by median household income and attainment of a bachelor degree by individuals 25 years of age Sources: Socioeconomic status calculated from American Community Survey 5 year estimates (27 211) Ohio Risk Factor Data from Ohio Department of Health Vital Statistics Birth Files (27 211) United States Estimates from National Vital Statistics System Birth Data (27 21)

9 8 7 6 5 4 3 2 1 Early Prenatal Care First Trimester Cuyahoga County Healthy People 22 Objective 77.9% Franklin County Hamilton County Ohio Lower Middle Higher United States Cuyahoga County (27 211) Franklin County (27 211) Hamilton County (27 211) Socioeconomic Tertile 1 % with Early Prenatal Care Lower SES 57.5 Middle SES 69.5 Higher SES 78.3 Lower SES 54.8 Middle SES 69.2 Higher SES 8.4 Lower SES 54.2 Middle SES 71.3 Higher SES 79.1 Ohio (27 211) 54.8 United States (27 21) 67.9 Socioeconomic status defined by median household income and attainment of a bachelor degree by individuals 25 years of age Sources: Socioeconomic status calculated from American Community Survey 5 year estimates (27 211) Ohio Risk Factor Data from Ohio Department of Health Vital Statistics Birth Files (27 211) United States Estimates from National Vital Statistics System Birth Data (27 21)

Mothers Who Did Not Begin Prenatal Care As Early As Wanted, By Race, Ohio, 29 21 3 25 2 Percent 15 1 19. 23.7 17.3 5 Overall Black, non Hispanic White, non Hispanic Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

Reasons for Not Beginning Prenatal Care As Early as Wanted, Ohio, 29 21 Didn't want others to know about Didn't know about pregnancy No child care Didn't have Medicaid card No time off from work/school Too busy Doctor/health plan wouldn't start No transportation Not enough money or insurance Couldn't get appointment 1 2 3 4 5 6 Percent Note: Mothers could select all that applied Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

25 2 15 1 5 Maternal Smoking During Pregnancy Cuyahoga County Franklin County Hamilton County Ohio Lower Middle Higher Healthy People 22 Objective 1.4% United States Cuyahoga County (27 211) Franklin County (27 211) Hamilton County (27 211) Socioeconomic Tertile 1 % Smoking Lower SES 15.5 Middle SES 1.2 Higher SES 4.7 Lower SES 22. Middle SES 12.2 Higher SES 4.7 Lower SES 16.8 Middle SES 12.3 Higher SES 7.8 Ohio (27 211) 18.5 United States (27 21) 9.5 Socioeconomic status defined by median household income and attainment of a bachelor degree by individuals 25 years of age Sources: Socioeconomic status calculated from American Community Survey 5 year estimates (27 211) Ohio Risk Factor Data from Ohio Department of Health Vital Statistics Birth Files (27 211) United States Estimates from National Vital Statistics System Birth Data (27 21)

Infant Mortality Rate per 1, Live Births Infant Mortality Rate by Quality of Prenatal Care Measured by the Kotelchuck Index, Ohio, 21 2 18 16 14 12 1 8 6 4 2 6. 4.1 18.1 1.8 Adequate Intermediate Inadequate No PNC/ Unknown Quality of Prenatal Care Healthy People 22 Goal: 6. Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death File

Infant Mortality Rate per 1, Live Births Infant Mortality Rate by Maternal Education, Ohio, 21 14 12 1 8 6 4 2 8.9 8th Grade or Less 12.5 Some High School 8.2 High School Graduate 6.9 Some College 4.4 4.8 College Graduate Healthy People 22 Goal: 6. Post Graduate Maternal Education Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death File

White Black Dissimilarity Index* and Infant Mortality Rates** for Selected Ohio Cities Ohio City Dissimilarity Index Infant Mortality Rate (per 1, births) Overall White, non Hispanic Black, non Hispanic Cincinnati.63 1.4 6.8 18.7 Columbus.61 8.7 7.1 15.4 Cleveland.79 9.2 5.5 15.7 *Calculated from http://censusscope.org using Census 2 data **Ohio Department of Health Vital Statistics Final Death Files (29-211) Note: Infant mortality calculated using deaths in Hamilton, Franklin, and Cuyahoga counties

Prevalence of Stressful Events in the 12 Months Before Baby Was Born, By Race, Ohio, 29 21 5 45 4 35 Black, non Hispanic White, non Hispanic 3 Percent 25 2 15 1 5 Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health Note: Mothers could select all that applied

Number of Stressful Events in the 12 Months Before Baby Was Born, By Race, Ohio, 29 21 Percent 5 45 4 35 3 25 2 15 1 5 Black, non Hispanic White, non Hispanic None 1 to 2 3 to 5 6 to 13 Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

Mothers Who Always, Often, or Sometimes Felt Unsafe in Their Neighborhood, By Race, Ohio, 29 21 25 2 Percent 15 1 19.2 5 11.5 1. Overall Black, non Hispanic White, non Hispanic Source: Pregnancy Risk Assessment Monitoring System, Ohio Department of Health

Thank you! ElizabethJ.Conrey@odh.ohio.gov

EXTRA SLIDES

Infant mortality, Ohio, 27-212 (212 is preliminary) Year Infant deaths Births Infant Mortality Rate 27 1,163 15,784 7.71 28 1,144 148,592 7.7 29 1,19 144,569 7.67 21 1,68 139,34 7.68 211 1,86 138,24 7.87 212 (preliminary) 1,4 138,863 7.49-4.8% Source: Office of Vital Statistics, Ohio Department of Health

Infant mortality rates by race/ethnicity, Ohio, 2, 25 and 211 Infant mortality rate per 1, live births 18 16 14 12 1 8 6 4 2 7.5 2 25 211* 17.44 15.91 14.6 8.26 8.68 7.87 7.92 6.26 6.65 6.3 6.8 Total Non Hispanic White Non Hispanic Black Hispanic Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death Data Set

Infant mortality, rates by race Ohio resident occurrences only, 27 212 (212 preliminary) 18 rate per 1, births 16 14 12 1 8 6 4 African American Total White Black/White disparity ratio declined from 2.52 (211) to 2.17 (212) 2 Source: Office of Vital Statistics, Ohio Department of Health

Neonatal and Post neonatal mortality rates Ohio occurences only, 27 212 (212 is preliminary) 6 rate per 1, births 5 4 3 2 1 Neonatal Post-neonatal Source: Office of Vital Statistics, Ohio Department of Health

Neonatal and Post neonatal mortality rates, by race Ohio occurences only, 27 212 (212 preliminary) 12 rate per 1, births 1 8 6 4 2 Black Neonatal Black Postneonatal White Neonatal White Postneonatal Source: Office of Vital Statistics, Ohio Department of Health

Infant Mortality Rate per 1, Live Births Infant Mortality Rate by Month of Prenatal Care Initiation, Ohio, 21 5 45 4 35 3 25 2 15 1 5 5.5 6.6 5.5 First Trimester Second Trimester Third Trimester 11.4 47.3 7.5 Unknown No PNC Total Healthy People 22 Goal: 6. Prenatal Care Initiation Source: Ohio Department of Health Vital Statistics Linked Birth/Infant Death File