“We have been working to reduce our infant mortality rate for years,” said Julie Kathman, a clinical nurse specialist at IU Health Bloomington Hospital. “But we really haven’t been able to make broad sweeping ?improvements.”
Infant mortality rates measure the number of deaths before one year of age per 1,000 live births.
In 2011, Indiana’s rate was 7.7 deaths, compared with the national average of 6.1, ranking the Hoosier state the 46th worst in the nation.
It’s one of the worst indicators of Indiana health, Kathman said.
“We don’t want to be 46th anymore,“ she said.
In 2012, Indiana’s rate improved to 6.7 deaths per 1,000 live births. But if Indiana had the same rate of infant deaths as the national average, 60 more babies would have survived that year.
State efforts
The Indiana State Department of Health has made reducing infant mortality one of its top three priorities. On Jan. 14, Gov. Mike Pence announced a new campaign called “Labor of Love.” The yearlong $1.3 million multimedia campaign will include advertisements on television, radio, bus shelters, billboards and online and will offer information about accessing prenatal care and resources to quit smoking.
“When Pence started his office, he decided his office was going to start funding to reduce the infant mortality rate because it was one of the worst indicators of Indiana,” Kathman said. “Two others are obesity and smoking, which also impact infant mortality. It was about realizing we had to allocate resources if we were going to make headway.”
Kathman is a committee member of the Indiana Perinatal Quality Improvement Collaborative. The IPQIC began in 2012 and aims to establish a statewide system of care, improve data collection and education, monitor quality improvement and find sources of funding.
Kathman’s committee looks at practices that are working in other states. One example is California, which has the fourth lowest infant mortality rate in the United States. California’s ?collaborative started in 1997.
“By looking at multiple states’ structures and outcomes, we are able to determine what may or may not work in Indiana,” Kathman said. “I hope that in 15 years, our rate will be as good as or better than California’s rate.”
Risk factors
Smoking and race are two significant risk factors for increased mortality rates. According to a 2014 study by the IPQIC, 16.6 percent of Indiana women smoke while pregnant. That rate is 45.2 percent higher than the national average.
For IU Health Bloomington clients, Kathman said the biggest infant mortality issue is maternal health ?related to smoking.
“Smoking leads to things like preterm delivery and small size for gestational age,” she said.
Another issue is the disparity between races. In 2011, the difference in infant mortality for blacks was nearly double that of whites. Kathman said Bloomington mirrors this inconsistency, which stems from multiple factors including genetics and economics.
Lack of insurance is also a problem for pregnant women. Women, Infants and Children is a federally funded program run locally by IU Health that provides care to children and mothers earning less than 185 percent of the national ?poverty level.
“The biggest issues in prenatal and postnatal care with our mothers is trying to get themselves on Medicaid,” said Jennifer Hildebrand, WIC program manager. “The system can be slow and this delays care. Also, after delivery, Medicaid is only good up through six weeks and some women do not have any insurance to fall back on if there are still health issues to be ?addressed.”
WIC is implementing changes to help reduce infant mortality rates, ?Hildebrand said.
“We are placing a breastfeeding peer counselor in our local hospital to help with early intervention in breastfeeding,” she said. “We have partnered with the Tobacco Cessation program through the hospital in order to offer free classes to our participants as well as free counseling and ?supplies.”
Improving data collection
One of the biggest roadblocks to reducing the infant mortality rate is incomplete or inconsistent data ?collection.
“A lot of the stuff we sometimes make decisions on is almost 10 years old,” Kathman said. “Getting data seems like it shouldn’t be a big deal. However, the way the data is defined and the way it is measured makes it difficult.”
For instance, infant deaths before 28 days, called neonatal, are often tied to the mother’s health during pregnancy. Deaths after four months vary in their causes, including accidents and ?neglect.
A problem typically drawn from these data sets is that they are also split across regions, making it difficult for medical practitioners to say where the biggest problem areas are for their patients.
Penny Caudill, administrator for the Monroe County Health Department, said she struggled to find data to compare the county’s rates during a five-year period.
“The two things that we have don’t match at all,” she said. “I would be taking a stab in the dark.”
According to the organization Indiana Indicators, the Monroe County infant mortality rate averaged 5.5 infant deaths per 1,000 between 2006 and 2010, which is lower than the state average.
Figuring out the root cause of infant mortality is difficult and certainly something that the state wants to look at, Caudill said.
“I think that going forward we will be able to collect that data much quicker,” she said. “Especially for a local health department with limited resources, being able to look at it quickly and access trends will be helpful.”
Eliminate early delivery
For the past two years, IU Health has worked on preventing unnecessary early deliveries. Early elective deliveries are induced before 39 weeks of gestation and increase the risk of infant mortality.
“It’s when a woman says ‘I’m tired of being pregnant,’” Kathman said. “Bloomington has been working on that quality indicator since at least 2007. We have had no early elective deliveries in the last at least two years.”
In that regard, Bloomington is a step ahead of the state, Kathman said.
Structure first
The State’s “Healthy People 2020” goal is to decrease the mortality rate to 6 infant deaths per 1,000 live births.
But a solid structure — from maternal care to delivery to infant care — will have to be set in place before Indiana will see declines in its infant mortality rates, Kathman predicted.
“I think we have to just remember that we cannot make huge strides right away, because we don’t have the structure yet,” she said. “We have to have the system in place first. That is probably frustrating. I know it’s frustrating firsthand as somebody who sees sick babies to say, ‘Why can’t we move this along yet?’”
