Minnesota Title V MCH Needs Assessment Fact Sheets

Pregnant Women, Mothers and Infants

Low Birth Weight, Preterm Births, and Infant Deaths

Fall 2004

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Size of the Problem

Over 68,000 births annually are recorded in Minnesota with an estimated 1,096,832 women of child-bearing age (15 to 44 years old) in the state [1]. Minnesota’s rate of infant mortality (deaths per 1,000 live births) declined over the last decade. However, infant deaths can be reduced further with continued community education and intervention to reduce the rates of preterm births, low birth weight, birth defects, and Sudden Infant Death Syndrome (SIDS).

In 2002:

  • 6,463 preterm births, 4,286 low birth weight births, 828 very low birth weight births and slightly over 2000 small for gestational age births occurred;
  • 362 infants died in their first year of life;
    • 98 died of birth defects
    • 44-54 died of LBW/PTB and related causes
    • 28 died from SIDS
    • 17 died from sleep-related unintentional injuries such as overlay and suffocation or asphyxia; and
    • the remainder died from a variety of causes such as infections, injuries, and diseases.
Minnesota and US Infant Mortality Rate, 1995-2002
  Deaths/1,000 Births
Year US Infant Death Rate MN Infant Death Rate
1995
7.6
6.8
1996
7.3
5.9
1997
7.2
5.9
1998
7.2
5.9
1999
7.1
6.2
2000
6.9
5.6
2001
6.8
5.4
2002
6.9
5.3
Source: MDH. Minnesota Center for Health Statistics- Overview of 2002, Minnesota and United States Infant Deaths.

Seriousness

People affected by infant deaths. The Healthy Minnesotans 2004 goal is to have fewer than 5 infant deaths per 1,000 live births. As of 2002, Minnesota’s rate was 5.3 deaths per 1,000 live births. Infant mortality rates are an important public health indicator of the conditions in our communities that are favorable or unfavorable for childbearing families.

Much research has focused on determining causes, risk factors, and effective interventions for preterm/ low birth weight births. An infant’s weight at birth is one of the most important predictors of health and survival in the first year of life. Definitions:

  • Low birth weight (LBW), less than 5 lbs. 8 oz.
  • Very low birth weight (VLBW), less than 3 lbs. 5 oz.
  • Preterm birth (PTB), a birth occurring before the 37th week of pregnancy.
  • Intrauterine growth retardation (IUGR), fetal growth that is less than normal during pregnancy [2].

LBW infants are at least 20 times more likely to die than heavier babies and those who survive, especially those who are VLBW, are more likely to suffer long-term illnesses, neurological and developmental disabilities [3].

Minnesota’s rate of low birth weight births has risen to 6.3% (2002). This trend puts the state at risk of failing to meet the Healthy People 2010 goal that no more than 5% of all births annually will be LBW [2].

Multiple gestation births (twins and higher order births) have increased in Minnesota and across the US in the past 10 years, contributing to increases in the LBW rate since most multiples are born preterm. Two trends are driving this increase: more women are having babies at older ages which naturally results in more multiple gestations; and more women are being treated for infertility which is also associated with multiple gestations [4].

Minnesota Low Birth Weight Rate, 1997-2002
  Percent
Year US 2010 Minnesota
1997
5
5.9
1998
5
5.8
1999
5
5.1
2000
5
6.1
2001
5
6.3
2002
5
6.3
Source: MDH. Center for Health Statistics-2002. 2004

Other risk factors contributing to LBW and PTB include:

  • Smoking during pregnancy (accounts for 20-30% of LBW)
  • Use of alcohol and illicit drugs during pregnancy
  • Poor maternal nutrition
  • Poor weight gain during pregnancy
  • Being underweight before pregnancy
  • Stress and lack of social and emotional support
  • Domestic violence
  • Periodontal (gum) disease
  • Maternal health conditions such as high blood pressure
  • Vaginal infections
  • Young maternal age
  • Hazardous environmental exposures
  • Heavy physical work and/or standing during pregnancy
  • Short intervals between pregnancies [5,6,7].
Minnesota Preterm Births (<37 weeks), 1997-2002
  Percent
Year US 2010 Minnesota
1997
7.6
8
1998
7.6
7.6
1999
7.6
9
2000
7.6
9.3
2001
7.6
9.4
2002
7.6
9.5
Source: MDH. Minnesota Center for Health Statistics-2002. 2004

Disparities
According to Minnesota birth certificate data, rates of infant mortality are 2-2½ times higher among populations of color compared to white infant deaths [8].

Minnesota Infant Mortality by Race,
1989-1993 and 1996-2000
  Infant Deaths/1,000 Births
Race 1989-1993 1996-2000
White 6.5 5.2
Hispanic 7.3 6.8
Asian 6.2 7
American Indian 16.5 12
African American 16.5 12.7
Source: MDH. MN Center for Health Statistics. 2003

Geographic disparities also exist for infant deaths. Infant mortality rates are higher in select regions of Minnesota:

  • Northwest region (7.2)
  • Northeast region (6.6)
  • Metropolitan region (6.6) [9].

African American infants have more than twice the rate of LBW than whites for reasons that remain somewhat unexplained by researchers. Current research has identified maternal medical conditions, stress, lack of social support, vaginal infections, and closely spaced pregnancies as the most promising explanations for the disparity [10].

Geographical disparities are also evident in recent (2001) county data. Counties with rates that are 50% over the state average for LBW or preterm singleton births include: Big Stone, Grant, Hubbard, Kittson, Rock, Swift, Traverse, and Wabasha [1].

The Minnesota SIDS death rate is 2-3 times greater for African Americans and 3-5 times greater for American Indian infants than for white infants [11].

Of the 16-20 Minnesota bedsharing infant deaths that occur annually, populations of color had a disparate number of these deaths [12].

Economic
The cost-effectiveness of early and adequate prenatal care to prevent PTB/LBW has been well documented. The Centers for Disease Control (CDC) estimate a savings of $14,755 per LBW birth prevented if all US women receive adequate prenatal care [13]. Estimates are that LBW adds anywhere from $15,000 to $49,000 in health care costs per infant with the smallest infants (VLBW), incurring the largest costs [14]. Hospital charges related to premature births were estimated at $13.6 billion nationally in 2001 [15].

Smoking during pregnancy creates a heavy financial burden on the health care system, The CDC estimates that smoking-attributable costs at delivery average $704 per maternal smoker. This has a significant impact on Medicaid costs since over a third of pregnancies covered by Medicaid are to women who smoke [16].

Annually, for 12 common birth defects, it is estimated that Minnesota will incur $131 million in costs to care for each year’s cohort over their lifetime [17].

Interventions

Nationally, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have collaborated in publishing Guidelines for Perinatal Care which specifically addresses the need for early and adequate prenatal care.18 The Minnesota-based Institute for Clinical Systems Improvement standards for prenatal care has a strong emphasis on early and adequate prenatal care [19]. The Association of State and Territorial Health Officials issued a policy statement in 2003 that recommends, “expand access to prenatal care services through targeted outreach and intervention” [20].

Key factors in reducing LBW in Minnesota include:

  • Assuring that all pregnancies are intended;
  • Assuring that all women of childbearing age have access to ongoing primary health and dental care, family planning services, preconceptional care, and early and continuous prenatal care with a provider they trust;
  • Assuring that all eligible pregnant women enroll in the Women, Infants, and Children (WIC) Nutrition Program;
  • Assuring that women at risk for LBW/PTB receive supportive services such as that provided by Family Home Visiting and/or Twin Cities Healthy Start;
  • Assuring that teen pregnancy prevention initiatives and support programs for pregnant and parenting teens are available throughout the state.
  • Assuring that providers are effective interventions to help pregnant and parenting women stop smoking.

On the national level, the AAP, the Maternal and Child Health Bureau (MCHB), the Association of SIDS and Infant Mortality Programs (ASIP), and the SIDS Alliance have made recommendations to decrease SIDS and other sleep-related infant deaths. Most significant of these is the recommendation that all babies should be placed on their backs to sleep, the AAP’s Back To Sleep campaign [21]. Additional Infant sleep safety education interventions include the following [21]:

  • Always place a baby to sleep on his/her back- even at naptime
  • Don’t smoke around baby
  • Don’t smoke if you’re pregnant
  • Place a baby on a firm mattress, such as in a safety-approved crib
  • Remove soft, fluffy bedding and stuffed toys from a baby’s sleep areas
  • Keep blankets and other coverings away from baby’s nose and mouth
  • Don’t put too many layers of clothing or blankets on a baby
  • Make sure everyone who cares for a baby knows that infants should be placed to sleep on their backs and the other ways to reduce SIDS risk.

Minnesota legislation in 2001 required all child care providers to be trained in SIDS risk reduction. The Minnesota SID Center developed an education curriculum and provides risk reduction education to child care providers statewide.

Effectiveness of Interventions
Many studies have documented the effectiveness of early and adequate prenatal care as a method to reduce infant mortality, LBW/PTB [21,22].

Minnesota SIDS incidence rate declined substantially after implementing the AAP’s Back to Sleep campaign [21,22] Since infant sleep safety training including Back to Sleep was required in the 2001 legislation, the SIDS rate in licensed childcare fell to 3% in 2002 compared to 23% in 2000. The Minnesota SID Center reported that this is the most dramatic decrease in SIDS occurring in childcare in the 20 years of data collection [22].

Prenatal or preconceptional genetic counseling offered to any couple with a defined increased risk for a fetal genetic disorder that can be diagnosed by one or more methods is an effective intervention to prevent birth defects. Prenatal genetic screening and early fetal diagnosis affords the opportunity to provide intrauterine treatment, prepare for the birth of an affected child, or to terminate the pregnancy [18].

Newborn bloodspot screening is a state mandated test that in 2003 identified 80 babies with blood spot disorders. Affected babies are at risk of mental and physical disabilities and even death. Early identification and treatment greatly improves their health, survival, and functioning.

Status

Minnesota Resources
Public health programs and strategies that reduce infant mortality, LBW, PTBs and SIDS include the following:

  • Public health nurse home visiting programs
  • WIC programs
  • Twin Cities Healthy Start
  • Health Plan Perinatal Programs
  • Metro Maternity Case Management Project
  • Culturally-specific programs to reduce infant mortality funded by MDH’s Eliminate Health Disparities Initiative (EHDI)
  • Southwest Minnesota Integrated Prenatal Project
  • Doula Programs
  • Save 10 Community Task Force
  • Tribal Health Initiatives
  • The Division of Indian Work in Minneapolis has recently developed and disseminated posters for community education to reduce infant deaths in the American Indian population.

Community Awareness
The March of Dimes launched a research and public education campaign on prematurity in 2003. The Minnesota SID Center of Children’s Hospitals and Clinics has promoted community awareness of the Back To Sleep Campaign which has resulted in a significant decrease in SIDS deaths. The SID Center in partnership with MDH has disseminated information about other infant sleep safety issues -- such as risks of bed sharing with young infants—to newborn nurseries and to local public health, tribal, and community-based agencies statewide.

The Division of Indian Work, the American Indian Family Center, the Indigenous People’s Task Force, and the tribal American Indian Infant Mortality projects have all promoted community awareness of issues around American Indian infant mortality.

The Save 10 Community Task Force initially has focused on increasing community awareness of African American infant mortality in the Twin Cities metro.

Twin Cities Healthy Start promotes healthy births and community awareness about infant mortality disparities in both the African American and American indian populations.

Efforts to improve community awareness began with local metro public health agencies over 10 years ago, especially St. Paul - Ramsey County Public Health and the Minneapolis Department of Health and Family Support who collaborated on Project LID (Lower Infant Deaths), an infant mortality review project. Fetal and Infant Mortality Review projects in St. Louis County and in 11 Southeast Minnesota counties in the late 1990s increased community awareness as well.

References

1. Minnesota Center for Health Statistics. 2003
2. MDH. Healthy Minnesotans: Public Health Improvement Goals 2004. September 1998.
3. MacDorman MF, Minino AM et al. Annual summary of vital statistics-2001. Pediatrics. 2002. 110(6):1037-1052.
4. Blondel B, Kogan MD, Alexander GA, Dattani N, et al. The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: An international study. AJPH. 2002. 92(8): 1323-1330.
5. Committee to Study the Prevention of Low Birthweight. Behrman RE (chair). Preventing low birthweight. IOM. Washington,DC. National Academy Press. 1988.
6. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). 2002. Guidelines for Perinatal Care. Washington, DC.
7. Improving Women’s Health and Perinatal Outcomes: Snapshot on the impact of oral diseases. Women and Children’s Health Policy Center. Bloomberg School of Public Health. Johns Hopkins University. February 2002.
8. MDH. Populations of Color in Minnesota Health Status Report- Update Summary. Fall 2003.
9. MDH. Infant Mortality. Population Health Assessment Quarterly 1(3). Winter 2000.
10. CDC’s Morbidity and Mortality Weekly Report. Infant mortality and low birth weight among black and white infants- United States, 1980-2000. 51(27):589-592. 2002.
11. MDH. Eliminating Health Disparities: Infant Mortality- Sudden Infant Death Syndrome (SIDS). March 2001.
12. MDH. Minnesota’s Infant Sleep Safety and Baby Bed Project Summary.2002.
13. CDC. An ounce of prevention: what are the returns? October 1999.
14. Rogowski R. Measuring the cost of neonatal and perinatal care. Pediatrics. 1999. 103(1):329-335.
15. National Governor’s Association. Center for Best Practices. Healthy Babies: Efforts to improve birth outcomes and reduce high-risk births. June 2004.
16. CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs—US. 1995-1999. MMWR. 2002;51 (14):300-303.
17. http://healthyamericans.org/state/birthdefects/ [Attn: Non-MDH Link] Accessed 7/04.
18. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). 2002. Guidelines for Perinatal Care. Washington, DC.
19. Institute for Clinical System Improvement. Routine Prenatal Care. 2003. www.ICSI.org [Attn: Non-MDH Link]
20. Association of State and Territorial Health Officials. State Policy Options to improve Birth outcomes. October 2003.
21. American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics 105(3):650-656. May 2000.
22. Data from the Minnesota SID Center and the Minnesota Center for Health Statistics. 2002