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 and

  July 25, 2008

1. Report Presents Current Information and Trends on the Nation's Health System Performance
2. State Analysis Assesses Relationship Between Pre-Pregnancy Maternal Obesity and Risk of Infant Death
3. Study Investigates Alcohol Consumption During Pregnancy and the Risk of Early Fetal Death
4. Authors Examine How Sudden or Unexpected Deaths May Be Particularly Difficult for Physicians
5. Article Identifies Maternal and Infant Characteristics Associated with Infant Sleep Positioning


Special Notice: The MCH Library's Web site now serves as a guide to comprehensive data from Title V-supported programs administered by the Health Resources and Services Administration's Maternal and Child Health Bureau (MCHB) to improve the health of all mothers and children. The Web site contains information on (1) MCH formula grants to states and (2) discretionary grants. Access to data from MCH formula grants to states is provided via the Title V Information System. Access to data on discretionary grants is provided via the MCH Projects Database and the Discretionary Grant Information System (DGIS). The MCH Projects Database, unique to the MCH Library Web site, now contains information on projects funded through October 1, 2004 (before and including FY2004). DGIS contains data on those funded after October 1, 2004 (FY2005 and beyond). The updated Web site also features search options for obtaining information and access to final reports produced by MCHB-funded projects, including an option for downloading reports in full text. The Web page is available at



"Across 37 indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the United States," state the authors of a report published by the Commonwealth Fund. The report examines key indicators of national health system performance and compares national performance for each indicator against benchmark levels achieved by top-performing groups within the United States or other countries.

The 2008 scorecard uses the same framework, methods, and set of performance indicators included in the first scorecard, which was published in 2006. The updated analyses compared baseline and current national averages, as well as the change in the range of performance, in five core dimensions: healthy lives, quality of care, health care access, efficiency of the health system, and equity in the health system. System capacity to innovate and improve was also examined.

For infant mortality, the authors found that

"Overall, performance has not improved since the first National Scorecard was issued in 2006," state the authors, concluding that "new national policies that take a coherent, whole-system, population view are essential for the nation's future health and economic security."

Commonwealth Fund Commission on a High Performance Health System. Why not the best? Results from the National Scorecard on U.S. Health System Performance, 2008. New York, NY: Commonwealth Fund. Available at



"This analysis indicates that maternal obesity is associated with increased odds of infant death," state the authors of an article published in the July-August 2008 issue of Public Health Reports. Consistent with the increasing focus on weight and health outcomes for the general population, maternal pre-pregnancy weight is also being assessed for its impact on perinatal health outcomes. In March 2004, Florida implemented a revised birth record that includes maternal height and pre-pregnancy weight. The addition of these two measures made it possible to conduct population-based analyses using body mass index (BMI). The purpose of the analysis, as presented in the article, was to assess and quantify the relationship between pre-pregnancy BMI and risk of infant death for the 2004 Florida birth cohort.

Data were drawn from the Florida resident birth records for the period March-December 2004. A total of 166,301 resident birth records were linked to 1,015 infant death records for the analysis. BMI calculations were used to classify maternal pre-pregnancy weight into five categories as defined by clinical guidelines: underweight, normal, overweight, obese, and morbidly obese. Infant death was used as the dependent variable and the BMI categories as dummy variables in the first model. Maternal race, marital status, age, education, tobacco use, first birth, and trimester of entry into prenatal care were included in subsequent models to adjust for potential confounders. These variables were also assessed as potential effect modifiers for the BMI variables. The extent of the potential influence of maternal diabetes mellitus, hypertension, and preeclampsia was also determined by comparing adjusted odds rations (AORs) for women without the specified conditions to the AORs for all women.

The authors found that
"The integration of an important component of preconception health and obesity prevention into effective community-based interventions may lead to beneficial outcomes for the overall population, including women of childbearing age," the authors conclude.

Thompson DR, Clark CL, Wood B, et al. 2008. Maternal obesity and risk of infant death based on Florida birth records for 2004. Public Health Reports 123(4):487-493. Abstract available at

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

-Infant Mortality: Knowledge Path at

-Preconception and Pregnancy: Knowledge Path at



"In this large retrospective cohort study of more than 650,000 pregnancies, we report elevated risks of stillbirth among mothers who admit to alcohol ingestion during pregnancy," state the authors of an article published in the August 2008 issue of Alcohol. Alcohol intake during pregnancy is correlated with myriad adverse birth outcomes. The validity of previous studies of the relationship between maternal alcohol intake and fetal death (i.e., stillbirth) has been questioned owing to study-design considerations, small sample sizes, errors in classification of exposure, and failure to account for confounding factors. Finally, most published studies of maternal drinking and fetal death do not distinguish between fetal deaths that occur at different stages of pregnancy. The article presents findings from a study to investigate the independent association between alcohol consumption during pregnancy and early fetal death using a large population-based data set.

Data for the study were drawn from the Missouri maternally linked cohort data files for the period 1989-1997. In this data set, siblings are linked to their biologic mothers using unique identifiers. Following delivery (live birth or fetal death), information was obtained from the women regarding sociodemographic factors (including alcohol intake during pregnancy) and other pregnancy-related experiences. The analysis included only births within the gestational age range of 20-44 weeks, separated into categories of early (less than 28 weeks' gestation) and late (28 or more weeks' gestation) fetal death. The analyses determined differences in sociodemographic characteristics and maternal pregnancy complications between nondrinking and drinking women, with adjusted estimates derived by using nondrinking women as the reference group.

The authors found that
"The exact pathway by which alcohol predisposes to stillbirth remains to be determined," state the authors. However, they conclude, "our findings will prove beneficial in counseling pregnant mothers or women intending to conceive on the risks associated with alcohol abuse in pregnancy."

Aliyu MH, Wilson RE, Zoorob R, et al. 2008. Alcohol consumption during pregnancy and the risk of early stillbirth among singletons. Alcohol 42(5):369-374. Abstract available at

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

- Substance Use During Pregnancy: Bibliography at



"This national survey reveals that perinatal death has a profound effect on delivering obstetricians," state the authors of an article published in the July 2008 issue of Obstetrics and Gynecology. Virtually all obstetricians who deliver neonates encounter perinatal death. It is estimated that approximately 15% of pregnancies end in early losses (before 20 weeks' gestation), and 1.3% end in either fetal death (losses after 20 weeks but before delivery) or infant death (deaths in the first year of life). It is well known that a perinatal death has a significant effect on bereaved families, but little is known about how client deaths in general affect physicians and specifically about how fetal or infant deaths affect obstetricians. The article presents findings from a study to identify U.S. obstetricians' experiences with and attitudes about perinatal death, their coping strategies, and their beliefs about the adequacy of their training on this topic.

The researchers used simple random sampling to identify U.S. obstetricians from the American Medical Association Physician Masterfile confirmed to have an active U.S. license according to state medical board Web sites. Each obstetrician received up to three mailed copies of the four-page anonymous survey. The survey included questions on personal experiences and beliefs about perinatal death and client care, bereavement training and skills, and demographics. A total of 804 obstetricians completed the full survey, for a response rate of 54%. The analyses examined obstetrician attributes associated with the following outcome variables: whether fetal death takes a large emotional toll on the obstetrician, whether the obstetrician had ever considered giving up obstetrics due to the emotional toll of stillbirths, belief that the obstetrician's own training was adequate to cope with fetal or infant death, belief that health professionals in general have adequate training to cope with fetal or infant death, blaming self or feeling guilty when no cause of death is known, and worrying about legal or disciplinary action when no cause of death is known.

The authors found that
"Perinatal death takes a significant emotional toll on obstetricians, and physician training offers an important opportunity to assist physicians in coping when this traumatic experience occurs," conclude the authors.

Gold KJ, Kuznia AL, Hayward RA. 2008. How physicians cope with stillbirth or neonatal death. Obstetrics and Gynecology 112(1):29-34. Abstract available at

Readers: More information is available from the NSIDRC's Professional Resources Web page at



"We found several infant and maternal characteristics that may help identify populations to be targeted for future sleep positioning interventions," state the authors of an article published in the August 2008 issue of the Journal of Pediatrics. Since the early 1990s, prone (stomach) sleep positioning has been a recognized risk factor for sudden infant death syndrome (SIDS). In December 1996, new evidence suggested that lateral (side) placement was associated with an increased risk of SIDS, compared with supine (back) placement. The American Academy of Pediatrics (AAP) task force 1992 recommendation that infants be placed to sleep in the supine position (which was updated in 1996 to state that the supine position is preferred over the lateral position) is believed to be largely responsible for the 40% reduction in the national incidence of SIDS that occurred between 1992 and 1997. The study described in this article aims to identify factors predictive of either infant prone or lateral sleep positioning.

Study participants were mothers and their infants who took part in the Pregnancy Risk Assessment (PRAMS) statewide population-based survey between 1996 and 2000 in Washington State. PRAMS is an ongoing behavioral survey developed by the Centers for Disease Control and Prevention administered to a sample of new mothers in 37 states when their infants are approximately 2 to 5 months old, when the risk of SIDS is high. Since 1996, the survey has included the question "how do you most often lay your baby down to sleep now?"

The authors found that
The authors conclude that "SIDS prevention efforts may benefit from consideration of factors predicting either lateral or prone infant sleep positioning."

McKinney CM, Holt VL, Cunningham ML, et al. 2008. Maternal and infant characteristics associated with prone and lateral infant sleep positioning in Washington State, 1996-2002. Journal of Pediatrics 153(2):194-198. Abstract available at

Readers: More information is available from the NSIDRC's Safe Sleep Environment Web page at


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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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