• Library Compiles Resources on Prematurity and Preterm Birth
• Campaign Expands to Encompass All Sleep-Related, Sudden Unexpected Infant Deaths
• Analysis Identifies Factors Causing or Contributing to Fetal Death and Fetal Size
• Article Assesses Effectiveness of Social Marketing to Increase Awareness of the African-American Infant Mortality Disparity
• Authors Look at Impact of Reporting Requirements on Mortality Rates and Racial Disparities

Special Notices / Multimedia Featured Resources:

• The August 31, 2012, issue of MCH Alert: Focus on Infant Mortality featured the State of Michigan Infant Mortality Reduction Plan. The current document is available at http://www.michigan.gov/documents/mdch/MichiganIMReductionPlan_UPDATED_395151_7.pdf
• October 1, 2012, is Child Health Day. This year's theme is reducing infant mortality. Resources on areas of targeted improvement are available from the Maternal and Child Health Library at http://mchlibrary.info/childhealthday.html
• October is Sudden Infant Death Syndrome (SIDS) Awareness Month. The National SUID/SIDS Resource Center has compiled resources to support state, community, family, and individual efforts to reduce SIDS rates throughout the United States at http://sidscenter.org/october_awareness.html. The resource center has also updated its Safe Sleep page to include current, high-quality information and materials on safe sleep practices and SIDS-suffocation risk reduction for parents, caregivers, and health professionals. The page is available at http://sidscenter.org/SafeSleep/index.html

---

1. Library Compiles Resources on Prematurity and Preterm Birth

Prematurity and Preterm Birth: Resource Brief is a guide to websites and related professional resources compiled by the Maternal and Child Health Library (MCH Library) at Georgetown University with support from the Health Resources and Services Administration's Maternal and Child Health Bureau. The brief contains links to federal agency and other organizational websites, along with descriptions of selected resources. Also featured are selected resources developed by the MCH Library, such as an annotated bibliography on prematurity and knowledge paths on infant mortality, pregnancy loss, and preconception and pregnancy resources for families. The brief is available at http://www.mchlibrary.info/guides/prematurity.html

MCH Library resource briefs on other topics are available at http://mchlibrary.info/guidestopic.html. The MCH Library welcomes feedback on the usefulness and value of the resource briefs. A feedback form is available at http://www.mchlibrary.info/feedback/index.html

---

2. Campaign Expands to Encompass All Sleep-Related, Sudden Unexpected Infant Deaths

The Safe to Sleep campaign aims to educate parents, caregivers, and health professionals about ways to reduce the risk for SIDS and actions they can take to reduce the risk of other sleep-related causes of infant death, such as suffocation. The campaign builds on the Back to Sleep campaign started in 1994. Collaborators include the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Health Resources and Services Administration's Maternal and Child Health Bureau, the Centers for Disease Control and Prevention's Division of Reproductive Health, the American Academy of Pediatrics (AAP), the American College of Obstetrics and Gynecology, First Candle, and the Association of SIDS and Infant Mortality Programs. The strategies outlined in the campaign resources are based on recommendations defined by the AAP Task Force on SIDS. Resources include the following:

Safe Sleep for Your Baby. This 12-page brochure provides answers to common questions about SIDS and encourages parents and other caregivers to share the the follmessages with everyone who cares for their infant or for any infant younger than age 1. The brochure is available as follows:

• In English at http://www.nichd.nih.gov/publications/pubs/upload/safe_sleep_general_brochure_2012.pdf
• In Spanish at http://www.nichd.nih.gov/publications/pubs/upload/PongaASuBebeADormirSinPeligro_092012.pdf
• For outreach to African Americans at http://www.nichd.nih.gov/publications/pubs/upload/SafeSleepForYourBaby_AA_2012.pdf
• For outreach to American Indians and Alaska Natives at http://www.nichd.nih.gov/publications/pubs/upload/SafeSleepForYourBaby_AIAN_2012.pdf

What Does a Safe Sleep Environment Look Like? This single-page handout provides information on crib-safety guidelines and other strategies to reduce the risk of SIDS and other sleep-related causes of infant death. The handout is available as follows:

• In English at http://www.nichd.nih.gov/publications/pubs/upload/safe_sleep_environ_sheet_2012.pdf
• In Spanish at http://www.nichd.nih.gov/publications/pubs/upload/cual_aparience_ambiente_2012.pdf

More information about the Safe to Sleep campaign is available at http://www.nichd.nih.gov/SIDS

---

3. Analysis Identifies Factors Causing or Contributing to Fetal Death and Fetal Size

"Among stillbirths ascertained through the WiSSP [Wisconsin Stillbirth Service Program], the proportion of LGA [large for gestational age] infants is greater than expected by chance, suggesting that LGA infants have, in general, an increased risk of stillbirth, and/or suggesting that specific conditions that cause an infant to be larger than expected may also cause fetal death," write the authors of an article published in the October 2012 issue of the American Journal of Medical Genetics. About 1 in 160 pregnancies ends in a stillbirth and another 3 percent with a second-trimester miscarriage. While a known trend of smaller body size is observed in stillbirths compared to live births, little review has been performed on any cohort of LGA losses. The article describes a study to retrospectively review the WiSSP database of over 2,600 stillbirth and second-trimester miscarriages for LGA losses to determine whether there were more macrosomic infants than expected, and if there were, which factors might account for the increase.

The authors found that

• In the database of 2,632 referrals, 2,451 (93.1 percent) contained sufficient information to determine appropriate size based on gestational age. Of these, 186 (7.6 percent) were found to be LGA.
• In this study, 43.5 percent, 22.6 percent, and 11.2 percent of losses had a fetal, placental, or maternal cause of death, respectively. These results differ significantly from previous studies in the same database unselected for gestational age, where 21.5 percent, 40 percent, and 12.7 percent of losses were found to have a fetal, placental, and maternal cause of death, respectively.
• Hydrops (a condition that occurs when large amounts of fluid build up in tissues and organs causing extreme swelling) was the most frequent lethal fetal abnormality, accounting for 60 cases (32.3 percent). The most common pathological cause for hydrops was idiopathic (cause unknown) (16, 26.6 percent), followed by cardiac abnormality (11, 18.3 percent), Turner syndrome (8, 13.3 percent), and twin-twin transfusions (6, 10.0 percent).
• Maternal diabetes was observed in 39 (21.0 percent) LGA losses, including 16 (51 percent) with gestational diabetes. The prevalence of diabetes was highest later in pregnancy, with 36 cases (32 percent of all LGA losses) after 28 weeks.
• In the diabetic women, the cause of fetal death was most commonly placental (35.9 percent), followed by fetal (30.7 percent), and maternal (5.1 percent). In the diabetic women, placentas were large in 81.5 percent, appropriate sizes in 14.8 percent, and small in one case (3.7 percent). This was not different from the entire LGA group.

"To further these goals of understanding the causes of hydrops, recognizing impending placental failure, and improving survival of the offspring of diabetic mothers, investigations of LGA stillbirths including autopsy and placental pathology as well as early recognition and treatment of maternal diabetes are crucial," the authors conclude.

Burmeister B, Zaleski C, Cold C, et al. 2012. Wisconsin Stillbirth Service Program: Analysis of large for gestational age cases. American Journal of Medical Genetics 158A(10):2493-2498. Abstract available at http://onlinelibrary.wiley.com/doi/10.1002/ajmg.a.35578/abstract

---

4. Article Assesses Effectiveness of Social Marketing to Increase Awareness of the African-American Infant Mortality Disparity

"Campaigns to increase awareness [of disparities] in African-American infant mortality (IM)] can be effective and may be an important step in engaging . . . [the African-American] community in efforts to reduce this disparity," write the authors of an article published in Health Promotion Practice online on September 18, 2012. Increasing evidence supports the role of social determinants of health and community-level risks factors as being at least as important as individual-level biological and behavioral risk factors as underlying causes of racial and ethnic health disparities. In this article, the authors report on the effectiveness of a social marketing (SM) campaign conducted in San Francisco, CA, aimed at increasing awareness among African Americans of (1) the IM disparity between African-American infants and white infants and (2) proper infant sleep position to reduce the risk of sudden infant death syndrome (SIDS).

Three campaigns were conducted to increase awareness among African Americans in the four San Francisco neighborhoods where most African-American births occur. The three campaign themes were (1) awareness of the IM disparity, (2) importance of proper infant sleep position, and (3) need to take action to reduce IM disparities. The same mediums were used in all campaigns: ads on buses and bus stops, posters, cards, brochures, handouts, church fans, and radio public service announcements (PSAs). To assess the impact of the campaigns, a telephone survey (Time 2; N=654) was conducted in 2005 at the conclusion of Campaign 3 with African Americans in the priority communities and compared with a survey conducted with the same population in 2003 (Time 1; N=804), before the campaigns were initiated.

The authors found that

• Data from Time 2 reveal substantial exposure to the awareness campaigns. Almost 62 percent of respondents reported exposure to Campaign 1 on disparities, 48.5 percent to Campaign 2 on sleep position, and 48.9 percent to Campaign 3 on taking action. In total, 30.4 percent reported exposure to all three campaigns, 23.2 percent to two, and 20.3 percent to one, leaving 26 percent without any exposure.
• Among respondents reporting exposure to one or more campaigns, most reported exposure to more than one medium. Across all campaigns, bus advertising was the most frequently reported form of exposure, followed by radio PSAs, posters, handouts, and church fans.
• For sleep position, there was no overall increase in the percentage of respondents who knew that placing an infant on its back to sleep could help reduce SIDS risk. However, analyses from Time 2 examining those exposed to Campaign 2 on sleep position compared with those not exposed revealed a significantly higher level of awareness among those exposed that proper sleep position can reduce SIDS risk.
• The strongest predictor of respondents ever having heard about the disparity was exposure to Campaign 1 on disparities, followed by exposure to Campaign 3 on taking action, participation in the Time 1 survey, knowing a local organization working to improve the health of African-American infants, and participation in activities to benefit the African-American community.

The authors conclude that "a successful effort [to reduce disparities] should begin by assessing awareness of disparities within the community followed by a tailored multimedia SM campaign to increase awareness and frame the health disparities as a group issue."

Rienks J, Oliva G. 2012. Using social marketing to increase awareness of the African American infant mortality disparity. Health Promotion Practice [published online on September 18, 2012]. Abstract available at http://hpp.sagepub.com/content/early/2012/09/06/1524839912458107

---

5. Authors Look at Impact of Reporting Requirements on Mortality Rates and Racial Disparities

"Our results indicate that fetal death reporting requirements contribute to substantial differences in fetal death reporting at lower gestational ages," state the authors of an article published in the September-October 2012 issue of Public Health Reports. The article looks at reasons for national variation in early neonatal and fetal mortality rates and racial disparities.

Data for the analysis were drawn from the 2000-2002 birth and linked infant death and fetal death records from the National Center for Health Statistics Division of Vital Statistics. The study population included all singleton live births and fetal deaths to non-Hispanic white and non-Hispanic black (hereafter referred to as white and black) maternal residents of the United States. The primary outcomes were early neonatal mortality rates (deaths occurring between 1 and 6 days of life, expressed per 1,000 live births); fetal mortality rates (expressed per 1,000 live births); and racial disparities. (The researchers selected early neonatal mortality as opposed to neonatal or infant mortality because it allowed for a more specific examination of the deaths that would be most amenable to variations in reporting laws.) The primary exposures were state-level fetal-death reporting requirements. State fetal-death reporting laws were categorized based on the latest revision of the Fetal Death Registration Requirements and then consolidated into areas thought to capture most of the reporting differences that may occur through differences in birthweight or gestational age criteria. The four reporting areas resulting from this aggregation included states that reported fetal deaths as follows: (1) all products of conception, regardless of birthweight or gestational age; (2) birthweight criteria or gestational age criteria; (3) birthweight criteria only; and (4) gestational age criteria only.

The authors found that

• Race-specific analyses indicated that early neonatal and fetal mortality rates among black infants were significantly higher than mortality rates among their white counterparts in each reporting area. In general, area 3, which used birthweight-only reporting for fetal deaths, tended to have higher disparity-rate differences in early neonatal mortality and lower disparity-rate differences in fetal mortality.
• Among infants at 20-22 weeks' gestation, the highest total early neonatal mortality rate was seen in area 3; fetal mortality rates at 20-22 weeks' and 23-27 weeks' gestation were significantly lower in area 3 than in all other reporting areas.
• Black infants in most gestational categories up to 37 weeks were less likely to die than their white counterparts in all reporting areas and in the United States overall, with the exception of births at 20-22 weeks' gestation, in area 3. For fetal deaths, however, the black survival advantage was noted only in the two gestational age categories of 20-22 weeks and 23-27 weeks. Higher than that threshold, fetal deaths were significantly more common in black infants in each reporting area.

"State differences in fetal death reporting requirements appear to influence important differences in the reported number of early neonatal deaths and fetal deaths," conclude the authors. They add, "the adoption of a uniform criterion for reporting fetal deaths in all states would reduce systematic differences in the reporting of live births and fetal deaths, and give a more accurate record of state early neonatal and fetal mortality rates and their associated racial disparities."

Tyler CP, Grady SC, Grigorescu V, et al. 2012. Impact of fetal death reporting requirements on early neonatal and fetal mortality rates and racial disparities. Public Health Reports 127(5):507-515. Available to subscribers at http://www.publichealthreports.org/issuecontents.cfm?Volume=127&Issue=5

---

To subscribe to MCH Alert, send an e-mail message to MCHAlert-request@lists.mchgroup.org with SUBSCRIBE in the subject line. You do not need to enter any text in the body of the message.

To unsubscribe from MCH Alert, send an e-mail message to MCHAlert-request@lists.mchgroup.org with UNSUBSCRIBE in the subject line. You do not need to enter any text in the body of the message.

---

MCH Library shares notices of new issues of MCH Alert on Twitter at http://bit.ly/OKv5Y

---

MCH Alert © 1998-2012 by National Center for Education in Maternal and Child Health and Georgetown University. MCH Alert is produced by Maternal and Child Health Library at the National Center for Education in Maternal and Child Health under its cooperative agreement (U02MC00001) 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.

Permission is given to forward MCH Alert, in its entirety, to others. For all other uses, requests for permission to duplicate and use all or part of the information contained in this publication should be sent to mchalert@ncemch.org.

We welcome your submissions, suggestions, and questions. Please contact us at the address below.

EDITOR/ADMINISTRATOR: Jolene Bertness, M.Ed.
CO-EDITOR: Tracy Lopez, M.S.L.S.
COPYEDITOR/WRITER: Ruth Barzel, M.A.

Maternal and Child Health Library
Georgetown University
Box 571272
Washington, DC 20057-1272
Telephone: (202) 784-9770
Fax: (202) 784-9777
E-mail: mchalert@ncemch.org
Website: http://www.mchlibrary.info/alert
Twitter: http://www.twitter.com/mch_library