A study released in November confirms that prematurity in babies is the reason the U.S. scores so poorly in infant mortality compared to other developed nations a truth most health experts say is a national disgrace. After decades of improvement, the U.S. infant mortality rate plateaued from 2000 to 2005 and had an insignificant decrease in 2006 from 6.86 to 6.71 per 1,000 live births, despite numerous national, state, and local efforts.
The study, released by the National Center for Health Statistics, compared data on infant deaths from the United States and Europe. Even when the study corrected for differences in the way countries report infant deaths, the adjusted U.S. rate of 5.8 was nearly twice that for Sweden and Norway (3.0), the countries with the lowest infant mortality rates, the report stated. Infant mortality rates for Hungary, Poland, and Slovakia were higher than the U.S. rate.
The primary reason for the United States higher infant mortality rate when compared with Europe is the United States has a much higher percentage of preterm births, the report concludes. These data suggest that preterm birth prevention is crucial to lowering the U.S. infant mortality rate.
The study backs up what we already knew and suspected, says Diane Ashton, MD, MPH, deputy medical director for the March of Dimes.
About one in eight babies is born before 37 weeks in the U.S., according to the March of Dimes. But preventing prematurity has been an elusive goal for maternal and child health practitioners and public health policymakers. Prematurity is caused by complex factors, including an increasing number of multiple births resulting from fertility treatments and delayed child bearing, a rising number of unnecessary cesarean sections and inductions, teenage pregnancy, and the gaping economic, social, and health disparities between whites, blacks, and other minority women, according to the March of Dimes.
In the past 20 years, maternal and child health experts have learned good prenatal care alone is not enough to ensure a healthy pregnancy for women at risk of poor outcomes because of poverty, lack of education, discrimination, poor health, and domestic or substance abuse. The traditional medical model of care in which pregnant women receive care from an obstetrician for nine months doesnt work, these experts say. Even expanded nonmedical models of prenatal care with education and referrals are insufficient.
Nurses Lead Innovative Programs
Maternal-child health should be a team approach that includes dieticians, mental health providers, social workers, and nurses, with RNs taking a much more prominent role than they now do, says Michael Lu, MD, associate professor of obstetrics and gynecology and public health at the University of California, Los Angeles. You cant expect OBs to sit with patients and talk about nutrition, stress, and environmental exposures at length, he says.
If fact, some of the most innovative models of care have been pioneered by nurses, such as Ruth Lubic, RN, CNM, EdD, founder of the Developing Families Center in Washington, D.C.; Sharon Schindler-Rising, RN, CNM, MSN, who pioneered the Centering model; and Merry-K Moos, RN, FNP, MPH, FAAN, who pioneered the concept of preconceptional health 20 years ago, he says. w
We should be paying more attention to [these models], says Lu. If we want to close the infant mortality gap, nurses need to play a strong leadership role.
Moos, who recently retired as a professor in the Department of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill, says womens healthcare, particularly for poor women, should be approached as a continuum and not broken up into episodic periods, such as for pregnancy. She believes that if the healthcare system focuses on keeping women well through prevention and education long before they become pregnant, then healthy babies will follow.
Healthcare providers should use every interaction with a woman to educate her and start her thinking about decisions related to future childbearing, says Moos. A womans health also needs to be followed in between pregnancies, especially if she already has had a miscarriage, still birth, diabetes, etc., to help prevent future complications a concept called interconception care.
Despite the discouraging U.S. infant mortality statistics, public health experts are hopeful the trend can be turned around. Am I discouraged? asks Moos. Not at all. The conversation is happening, and there is so much going on.
Focus on Minority Babies
In October, a small group of community activists, nurses, physicians, state officials, and family members gathered at a community center in Racine, Wis., to launch a public awareness campaign to lower the states infant mortality rate in its black population.
We have a major health problem going on here, said Karen Timberlake, Wisconsin Secretary, Department of Health Services. This problem should not be true in Wisconsin.
The uncomfortable truth in Wisconsin is that while it has one of the lowest rates of infant mortality for white babies, it has one of the highest rates of death for black babies, with only Delaware and the District of Columbia having worse rates. A black baby born in Wisconsin is three times more likely to die in its first year of life than a white baby.
When federal and Wisconsin state health officials decided to take action against the states glaring disparity in infant mortality rates, experts from across the country were called in for advice, including Mario Drummonds, MS, LCSW, MBA, from New York.
Drummonds is the executive director and CEO of the Northern Manhattan Perinatal Partnership (www.sisterlink.com), a network of community-based programs that has helped New York City become a national success story in lowering the infant mortality rate, particularly in impoverished neighborhoods such as Harlem.
Lu is the lead proponent of the Life Course Perspective theory, which views birth outcomes as the product of the entire life course of the woman leading up to her pregancy. The plan includes providing interconception care to women with prior adverse pregnancy outcomes, strengthening father involvement in black families, and investing in community building and urban renewal.
Drummonds believes New York has had such success because the perinatal network has been able to tightly coordinate and control numerous programs modeled on the Life Course perspective and targeted to individuals, neighborhoods, and policymakers, including the local health systems. In 1990, Central Harlem had the highest rate of infant mortality in the U.S., with almost 28 babies out of every 1,000 live births dying. The rate was down to 5.1 deaths by 2004.
Wisconsin officials hope to start doing the same. Timberlakes agency has started an intervention program called Journey of a Lifetime, based on Lus Life Course Perspective. Meanwhile, the University of Wisconsins School of Medicine and Public Health has launched a companion effort, the Healthy Birth Outcomes Initiative, with funding from its Wisconsin Partnership Program.
Were letting the community lead, says consultant Lorraine Lathen, who has been hired to implement Lus Life Course Perspective in Wisconsin. She set up focus groups in Milwaukee, Racine, Kenosha, and Beloit counties, where more than 90% of the black infant deaths occur.
Richard Allan Aronson, MD, MPH, director of the Humane Worlds Center for Maternal Child Health, says the programs that appear to work best are those that involve the community from start to finish. Its essential to include the voices of the women and family members who are in the midst of this, he says.
Lus theory also posits that the chronic stress black women experience throughout their lives from institutionalized racism, poverty, unemployment, inadequate housing, and violence causes wear and tear on multiple physiologic systems, which in turn predisposes their bodies to delivering premature infants.
Researchers are finding that even when black women are better educated and have higher social and economic standing, their babies still are more likely to die or have low birth weights than white women.
Gwen M. Perry-Brye, RN, APNP, a nurse practitioner with the Kenosha County Division of Health in Wisconsin, says it is important for nurses to recognize the stress black women face in their lives and how that can lead to poor birth outcomes. Perry-Brye helped found the Black Health Coalition of Greater Kenosha in 2006, which focuses on infant mortality, along with other health disparities.
Drummonds says that while racism and discrimination can help explain the high infant mortality rates in black women, it cannot be used as an excuse to say we cant do anything about it. We have to be willing to make incremental, transformational steps, or we will be wedded to the past.
Janet Boivin, RN, is a staff writer for www.Nurse.com.
For further information on the Developing Families Center, visit www.nurse.com/article/MakeStrides. Additional information about the centering pregnancy model is available at www.centeringhealthcare.org.