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Case Study: ‘All Hands on Deck’ to Address Infant Mortality

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The challenge

In 2016, Milwaukee’s infant mortality rate was 9.1, meaning that slightly more than nine babies died for every 1,000 live births. By contrast, the national infant mortality rate was 5.8 in 2014, the most recent year for which information is available, according to the Federal Interagency Forum on Child and Family Statistics. 

Disparities in birth outcomes present Milwaukee with a major challenge. In 2016, Milwaukee saw 14 deaths per 1,000 live births for some minority groups, as opposed to 7.2 deaths for non-Hispanic whites.

“It’s a tale of two cities when you look at our infant mortality,” says Milwaukee Commissioner of Health Bevan K. Baker.

Reducing overall infant mortality and ethnic and racial disparities in birth outcomes is Milwaukee’s top public health priority, in Baker’s view, and many others share that perspective. That’s why infant mortality among at-risk groups is repeatedly one of Milwaukee County’s top health issues in the shared Community Health Needs Assessment.

The shared assessments are sponsored by the Milwaukee Health Care Partnership, a public and private collaboration of the city’s health systems, Federally Qualified Health Centers, the Milwaukee Health Department and other stakeholders. Since the partnership’s first shared CHNA was published in 2010, the health systems have been working both individually and collectively through the partnership to address the issue, Baker says.

“This requires all hands on deck,” he says.

Approaching the problem

The city has been worrying about infant mortality in high-risk groups for decades; it published the first comprehensive review of the problem in 1993.

Collective action: In 2011, a community action plan was developed to address the disproportionately high rates of infant mortality among at-risk groups. The plan is being implemented by the Milwaukee Lifecourse Initiative for Healthy Families Collaborative through the United Way of Greater Milwaukee and Waukesha County.

“The mayor co-chairs the Lifecourse Initiative; that’s how important this is to him,” Baker says.

Joy Tapper, the partnership’s executive director, and Mark Huber, an Aurora Health Care executive who serves as a loaned executive to the partnership, co-chair the Lifecourse Initiative’s health care access subcommittee, which launched three strategies to increase access to care for at-risk women and infants.

One strategy: making sure women of childbearing age who have chronic medical or behavioral health conditions have the services needed to deliver healthy babies.

Through the Milwaukee Health Care Partnership’s Connecting High Risk Women to Care initiative to decrease infant mortality, navigators at each hospital work to link women to primary care and other health and community resources, pre- and post-pregnancy.

“Navigators also work to make sure patients have those wraparound services that they need to address social determinants of health, whether that’s parenting classes or housing or medications or food or anything else they need to be successful,” says Kerry Freiberg, vice president of community engagement at Froedtert Health.

Individual action: Additionally, individual health systems each have their own infant mortality-reduction strategies.

For example, Ascension Wisconsin, together with key community health organizations, and leaders in the faith-based community, has launched the Strong Baby Sanctuary program, which recruits Milwaukee-area churches to provide a wide range of support for pregnant women and new moms — from education on safe sleep practices to supplies that every newborn needs. The health system also partners with the city health department and others to sponsor Milwaukee Mayor Tom Barrett’s annual “Strong Baby Sabbath.” During this event, clergy members across the community raise awareness about how to prevent infant deaths.

In its most recent fiscal year, Ascension worked to increase access to dental care for pregnant women at its own dental clinic. Poor prenatal oral health is a risk factor for premature delivery. To address this problem, the health system set a goal of increasing the number of pregnant women who are given dental care by 25 percent during the year — and it exceeded the goal dramatically.

“We were laser-focused on what we could do to move the needle,” says Travis Andersen, president of Ascension Wisconsin’s South Region.

Aurora Health Care, meanwhile, has started giving Baby Boxes to mothers of babies born at its hospitals with the goal of reducing co-sleeping deaths. Fifteen unsafe sleep deaths in Milwaukee were identified in 2016, and five were recorded in the first quarter of this year. A Baby Box, which is a heavy-duty but lightweight cardboard box, provides a safe sleeping environment in homes without cribs or bassinets.

Better health, lower costs

In addition to the suffering of families caused by infant mortality, babies born prematurely or with birth defects have high health care costs. The medical costs of preterm babies, on average, are 10 times higher in the first year of life than those of full-term babies, according to the Wisconsin Partnership Program.

It estimates that premature births in Wisconsin resulted in $181 million in extra medical costs in 2015 alone, nearly half of which was borne by the state Medicaid program.

Health systems that work to improve birth outcomes are, by definition, working to reduce long stays in neonatal intensive care units.

“These babies, who can almost fit in the palm of your hand, are affecting all the health systems that have birthing centers,” Baker says.

Outcomes to date

No one is taking a victory lap, but there was some good news in Milwaukee’s 2016 infant mortality report. Using three-year rolling averages, the overall infant mortality rate from 2014 to 2016 was the lowest rate in recent history.

Next step

Milwaukee’s crisis is far from solved. Despite some progress, the city’s infant mortality rate still ranks among the highest in the nation, and the city is not on track to meet its goals for reducing disparities in birth outcomes for various ethnic groups.

The 2016 Fetal Infant Mortality Review report identifies three leading causes for infant deaths from 2012 to 2015. Birth defects accounted for 21 percent, and sleep-related issues were to blame for 16 percent. But the clear majority — 56 percent — stemmed from complications of prematurity.

Thus, reducing premature births is the most important goal. In a press release announcing the most recent statistics, Baker identified the root cause of the problem and issued a call to action:

“While we must redouble our efforts to improve access to quality health care and improve individual behaviors such as smoking, we will not be able to address this issue without focusing on the primary driver of premature births: chronic, unmitigated stress, particularly from poverty, unemployment, excessive incarceration rates, housing instability, racism and other socioeconomic factors.”

That call is in line with the Milwaukee Health Care Partnership’s most recent shared CHNA, which identified poverty, racism and other social determinants of health as top community health issues. In contrast, infant mortality and disparities in birth outcomes were not identified among the city’s most pressing health issues on this latest CHNA

Tapper attributes that to human nature. When other health issues, such as lead in water and the opioid crisis, get well-deserved attention in the media, survey respondents and even key informants tend to focus their attention on the new problems rather than long-standing, still unresolved issues like infant mortality.

“One of the lessons we need to keep learning is that we must stay the course over a period of time to really make fundamental system and policy changes,” she says.

That’s why infant mortality reduction is one of the partnership’s 2017-18 community health priorities, and it likely will remain on the top of the list for the foreseeable future.

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