MCH Alert: Focus on Infant Mortality


Maternal and Child Health Library

MCH Alert: Focus on Infant Mortality is developed by the Maternal and Child Health Library in collaboration with the National Sudden Infant Death Resource Center. This and past issues are available online at http://www.mchlibrary.info/alert/archives.html and http://www.mchlibrary.info/suid-sids/alert/archives.html.


April 25, 2008

1. MCHB Announces Initial Release of Discretionary Grant Web Reports
2. Report Presents Pregnancy Rates for 1990-2004
3. Authors Examine Correlation Between Cardiorespiratory Events and Epidemiological Risk Factors for SIDS
4. Study Explores Effects of Crash Characteristics and Maternal Restraint on Fetal Outcomes After Motor Vehicle Crashes
5. Research Findings Provide New Data on Which to Base Decisions About Intensive Care for Extremely Premature Newborns

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1. MCHB ANNOUNCES INITIAL RELEASE OF DISCRETIONARY GRANT WEB REPORTS

The Discretionary Grant Information System (DGIS) Web reports display financial, national performance measure, and abstract data collected annually from more than 900 grants issued by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), including data from grants to reduce disparities in infant mortality. The public reports contain data collected by MCHB via a Web-based system that allows grantees to report their data online as a part of the grant-application and performance-reporting processes. Data contained in the reports help MCHB assess the effectiveness of its programs and help staff monitor the progress made under these grants. The DGIS complements the existing Title V Information System (TVIS), which electronically captures data from the annual Title V Block Grant applications and reports submitted by all 59 U.S. states, territories, and jurisdictions. The TVIS provides information on key measures and indicators of maternal and child health (MCH) in the United States. The DGIS and Title V reports are intended for use by public health professionals, researchers, and the public in accessing concise information about programs working to improve the quality of and access to health care for MCH populations. Additional reports to be released in the future will focus on other program and performance measure data. The DGIS reports and the TVIS are available at http://www.mchb.hrsa.gov/data.

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2. REPORT PRESENTS PREGNANCY RATES FOR 1990-2004

"This report presents pregnancy rates . . . for women in age groups 10-14 through 40-44 years in the United States for the years 1990 through 2004," state the authors of an article published in the April 14, 2008, issue of National Vital Statistics Reports. Rates are presented by pregnancy outcome; by age, race, and Hispanic origin; and by marital status, race, and Hispanic origin. The data presented in this report, together with previously published pregnancy rates for earlier years, provide a consistent series of rates for the United State for 1976-2004.

Statistics for live births are based on complete counts of births provided by every state to the Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics (NCHS) through the Vital Statistics Cooperation Program of the National Vital Statistics System. Estimates of induced abortions are from abortion surveillance information collected from most states by CDC's National Center for Chronic Disease Prevention and Health Promotion and national estimates of abortion totals by the Guttmacher Institute. Estimates of fetal losses are derived from the pregnancy history data collected by the National Survey of Family Growth, conducted by CDC's NCHS.

The authors found that
The authors conclude that "factors that are closely related to pregnancy rates -- sexual activity, contraceptive use, and patterns of marriage, divorce, and cohabitation -- are in turn affected by other factors. These include: the level of effort toward, and the nature of, programs focusing teenagers' attention on preventing pregnancy and STDs; the number of children desired by men and women; the economic and social environments in which people live; changes in access to health care and health insurance; and other changes in the health care system, including programs aimed toward reproductive health and family planning."

Ventura SJ, Abma JC, Mosher WD, et al. 2008. Estimated pregnancy rates by outcome for the United States, 1990-2004. National Vital Statistics Reports 56(15):1-25. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_15.pdf.

Readers: More information is available from the following MCH Library resource:

- Knowledge Path: Preconception and Pregnancy at
http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html

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3. AUTHORS EXAMINE CORRELATION BETWEEN CARDIORESPIRATORY EVENTS AND EPIDEMIOLOGICAL RISK FACTORS FOR SIDS

"The duration of any event that marks entry into a danger zone that will inevitably be followed by an infant's death remains to be determined," state the authors of an article published in the May 2008 issue of the Journal of Pediatrics. The historical focus on apnea as either a cause of sudden infant death (SIDS) or a mechanism of death has decreased because studies have failed to implicate these events directly. This article presents findings from a study to further examine the role of apnea in the etiology of SIDS and the possibility that either conventional events (apnea persisting for at least 20 seconds) or extreme events (apnea persisting for more than 30 seconds) can predict imminent SIDS deaths.

Data were drawn from the Collaborative Home Infant Monitoring Evaluation (CHIME), a study conducted during the 1990s for which systematic home monitoring was performed on more than 1,000 infants in five U.S. clinical centers. The present study included the home-monitoring records of 306 healthy term infants; 170 siblings of SIDS infants (SSIDS), 50 of whom were preterm; 152 infants with an idiopathic apparent life-threatening event (ALTE), 45 of whom were preterm; and 454 preterm infants. The analyses evaluated three definitions of outcome events: (1) having at least one extreme event; (2) having at least one conventional event without having an extreme event; or (3) belonging to the half with the most events. In addition, the researchers examined the presence of extra-long apneic periods (40 seconds or more). Because prematurity was found to be highly predictive of having at least one extreme event in the original study, this variable was always used as a covariate in the multivariate analyses. Analyses were performed first for all infants and all events during the entire monitoring period and then separately for the events occurring before and at 44 weeks postmenstrual age (PMA) and those occurring after 44 weeks PMA. (The highest risk for SIDS in preterm infants is earlier and has a much wider dispersion.) The effect of time of night on the incidence of events was established using repeated observations for each subject. The relationship between extreme and conventional events (i.e., the rate of decline as a function of maturity) was examined as well.

The authors found that
"Neither extreme nor conventional events were associated with primary epidemiologic risk factors for SIDS, supporting our hypothesis that they are not immediate precursors of or causally related to SIDS," state the authors. They conclude that "conventional and extreme events are probably normal, part of a continuum and not fundamentally different in mechanism."

Hoppenbrouwers T, Hodgman JE, Ramanathan A, et al. 2008. Extreme and conventional cardiorespiratory events and epidemiologic risk factors for SIDS. Journal of Pediatrics 152(5):636-641. Abstract available at http://www.jpeds.com/article/S0022-3476(07)00959-6/abstract.

Readers: More information is available from the following MCH Library resources:

- Knowledge Path: Infant Mortality at
http://www.mchlibrary.info/KnowledgePaths/kp_infmort.html

- Prematurity (bibliography) at
http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_premature.html&-MaxRecords=all&-DoScript=auto_search_premature&-search

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4. STUDY EXPLORES EFFECTS OF CRASH CHARACTERISTICS AND MATERNAL RESTRAINT ON FETAL OUTCOMES AFTER MOTOR VEHICLE CRASHES

"This study shows that proper use of a belt restraint [during a motor vehicle crash] by a pregnant occupant has a significant positive effect on fetal outcome," state the authors of an article published in the April 2008 issue of the American Journal of Obstetrics and Gynecology. The public health problem of fetal loss and injury from maternal involvement in motor vehicle crashes is difficult to quantify. Reliable statistics on fetal loss resulting from automotive trauma are not available because maternal involvement in crashes has not been consistently recorded on fetal death certificates. In addition, the pregnancy status of women involved in crashes has been tracked in national databases only since 1995. The purpose of the study described in this report was to conduct in-depth investigations of motor-vehicle crashes involving pregnant occupants, with a focus on determining how restraint conditions and specific crash characteristics affect fetal outcome.

The authors investigated crashes involving 57 pregnant occupants. Maternal and fetal injuries, restraint information, measures of external and internal vehicle damage, and details about the crash circumstances were collected. Crash severity was calculated using vehicle crush measurements. Chi-square analysis and logistic regression models were used to determine factors with a significant association with fetal outcome.

The authors found that
The authors conclude that "the results of this study support the current recommendation that pregnant women should properly wear 3-point seatbelts."

DeSantich Klinich K, Flannagan CAC, Rupp JD, et al. 2008. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. American Journal of Obstetrics and Gynecology 198(4):450.e1-450.e.9. Full-text available at http://www.ajog.org/article/S0002-9378(08)00145-2/fulltext.

Readers: More information is available from the following MCH Library resource:

- Injury Prevention (organizations resource list) at
http://www.mchlibrary.info/action.lasso?-database=Organizations&-layout=Web&-response=/databases/OrgLists/orgs_injury.html&-MaxRecords=all&-DoScript=auto_search_injury&-search

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5. RESEARCH FINDINGS PROVIDE NEW DATA ON WHICH TO BASE DECISIONS ABOUT INTENSIVE CARE FOR EXTREMELY PREMATURE NEWBORNS

"Our findings challenge the widespread use of gestational-age thresholds alone deciding whether to administer intensive care to extremely premature infants," state the authors of an article published in the April 17, 2008, issue of the New England Journal of Medicine. The evidence base providing support for decisions to initiate or forgo intensive care for extremely premature infants is limited, and the measurement error in assessing pregnancy length may prompt different treatment decisions. The article presents findings from a study designed to better inform such decisions. The study assessed a large cohort of infants born at 22 to 25 weeks' gestation in the Neonatal Research Network (NRN) of the National Institute of Child Health and Human Development and related gestational age and other risk factors assessable at or before birth to the likelihood of death or adverse neurodevelopmental outcomes.

The study sample included 4,446 infants born at 22 to 25 completed weeks of gestation in 19 NRN centers between January 1, 1998, and December 31, 2003. Researchers estimated the percentages of infants with the following pre-specified primary outcomes: survival, survival without impairment, and survival without profound impairment (based on standardized neurodevelopmental assessments performed at a corrected age of 18 to 22 months). Each outcome was then analyzed for infants who received intensive care. (The researchers considered intensive care to have been provided if mechanical ventilation was initiated.) All infants who underwent ventilation were categorized into risk groups according to birthweight, sex, exposure or nonexposure to antenatal corticosteroids, and single or multiple births. (Analyses found race or ethnic group and the type of delivery to be unrelated to the three outcomes.) For each group, the percentage of infants with an unfavorable outcome was predicted with the use of gestational age alone and according to multiple risk factors. The observed and estimated rates were then compared.

The authors found that
The authors conclude that "consideration of multiple factors is likely to promote treatment decisions that are less arbitrary, more individualized, more transparent, and better justified than decisions based solely on gestational-age thresholds."

Tyson JE, Parikh NA, Langer J, et al. April 17, 2008. Intensive care for extreme prematurity: Moving beyond gestational age. New England Journal of Medicine 258(16):1672-1681. Full-text available at http://content.nejm.org/cgi/content/full/358/16/1672?query=TOC.

Readers: The NRN Web site contains a tool that clinicians can use to estimate the likelihood that intensive care will benefit individual infants (after considering the extent to which outcomes might differ from those identified by the NRN). The tool is available at http://www.nichd.nih.gov/neonatalestimates.

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MCH Alert © 1998-2008 by National Center for Education in Maternal and Child Health and Georgetown University. MCH Alert: Focus on Infant Mortality is produced by Maternal and Child Health Library at the National Center for Education in Maternal and Child Health under its cooperative agreements (U02MC00001 and U48MC08717) with the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. The Maternal and Child Health Bureau reserves a royalty-free, nonexclusive, and irrevocable right to use the work for federal purposes and to authorize others to use the work for federal purposes.
 
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