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.sidscenter.org/alert/archives.html.

  July 25, 2008

1.REPORT PRESENTS CURRENT INFORMATION AND TRENDS ON THE NATION'S HEALTH SYSTEM PERFORMANCE

"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

• The rate of infants born in the United States who die before their first birthday improved slightly from 2002 to 2004 (from 7.0 to 6.8 deaths per 1,000 live births), thus returning to earlier levels. Yet, the U.S. average remains well above rates in the states and countries with the lowest rates.
• Rates of infant mortality in the worst-performing states are more than twice those in benchmark states.
• The gap between leading and lagging states grew wider in 2004, as states with the highest rates -- primarily poor and located in the South -- experienced an increase in infant mortality.
• The United States ranked last among eight industrialized countries that report infant mortality using the same methodology, with a national rate more than double that of the leading countries (2.8 to 3.1 deaths per 1,000 live births in Japan, Iceland, and Sweden in 2004).
  

"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 http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682.

• Infants born to women who were obese had odds of infant death that were 23% higher than the odds for the reference group of infants born to women with normal BMIs.
• The association between maternal pre-pregnancy weight and infant death was more pronounced for infants born to women classified as morbidly obese, with odds of infant death that were 70% higher than odds for the reference group.
• The results were not substantially affected by presence or absence of the specified maternal conditions as recorded on the birth record.
• Only the maternal race variable was associated with statistically significant effect modification (AORs were significantly different for black vs. non-black women).

• A total of 3,508 counts of fetal death were identified in the entire study sample, yielding a fetal death rate of 5.4 per 1,000; the rate among drinking women was 8.3 per 1,000, and the rate among the reference group (nondrinking women) was 5.3 per 1,000.
• The risk of fetal death was 40% higher among drinking women compared to nondrinking women. Notably, the risk of early fetal death was 80% higher among drinking women compared to nondrinking women, whereas the risk of late fetal death exhibited a 20% increase that did not reach statistical significance.
• Among women who consumed five or more drinks per week during pregnancy, the risk of fetal death was 70% higher, compared to nondrinking women.
• The elevated risk for early or late fetal death among drinking women did not reach statistical significance when broken down by level of alcohol intake.
• The greatest risk for experiencing fetal death, early or late, was exhibited among women who reported drinking during pregnancy but failed to provide information on the number of drinks they consumed per week.

• When asked whether caring for clients with a current fetal death took a large emotional toll on them personally, 22% of respondents strongly agreed, and 53% agreed.
• Eight percent of respondents reported that they had considered giving up obstetric practice because of the emotional difficulty of caring for clients with a fetal death.
• Respondents who reported adequate training to cope with fetal and infant death were significantly less likely to report having felt guilty for a death without known cause.
• When asked to indicate all the measures they had used to cope with their own emotions after a perinatal death, the two most common methods reported were talking informally with colleagues (87%) and talking about the death with friends or family (56%).

• There were 11,340 Washington State PRAMS survey respondents from 1996 to 2002 who answered the sleep position question as primarily supine (7,029), prone (1,188), or lateral (3,123) and whose records were linked to birth certificate and hospital discharge data; 65% typically placed their infants to sleep in the supine position, 10.6% in the prone position, and 24.1% in the lateral position.
• Dramatic changes in sleep positioning occurred in Washington State over this period. The prevalence of supine positioning increased by more than 30%; concomitantly, prone and lateral positioning declined substantially.
• Maternal African-American race, being born in the United States, primiparity, and earlier infant birth year were most predictive of prone sleep positioning. Maternal residence outside the Seattle area and infant male sex were also positively associated with prone sleep positioning.
• The factors most highly predictive of lateral sleep positioning were maternal nonwhite and non-Native American race, Medicaid payment for delivery, infant's earlier birth year, and mother's county or residence being other than the Seattle area. Other independent, positive predictors included primiparity, mother's receipt of government benefits during pregnancy, prematurity, and infant of normal birthweight (vs low birthweight).