Perinatal landscape | every-woman-ct

The Current Connecticut Perinatal Landscape

To understand the current perinatal landscape and the benchmarks to measure the impact of the

Coalition’s work, this section provides background information on the following focus areas:

Fetal and infant mortality
Preterm birth and low birth weight
Teen births
Prenatal care
Unintended pregnancies
Preconception health

Connecticut is among the wealthiest states in the United States and fares better overall in terms of

perinatal health and birth outcomes compared to the nation. However, there are significant and persistent disparities by race, ethnicity, age, geography, and socioeconomic status. Below are selected findings from the 2014 Connecticut State Health Assessment, which were used to inform the process and efforts involved with the development of this Plan.3 These data indicate that, although perinatal programs in Connecticut appear to be having a positive effect on the maternal, infant and child population, much remains to be done to achieve optimal outcomes for all Connecticut mothers and babies.

The lifetime effects of race, racism, social class, poverty, stress, environmental influences, health policy, and other social determinants of health are reflected in the elevated rates of adverse outcomes and persistent disparities. The continuation of evidenced‐based programs, coupled with efforts to increase health equity and address social determinants of health, is essential to achieving improved birth outcomes and eliminating disparities. The strategies outlined in this plan are intended to move Connecticut toward this goal.

Fetal and Infant Mortality

Infant mortality is defined as the death of a baby before his or her first birthday. The infant mortality rate (number of infant deaths per 1,000 live births) is widely accepted as an indicator of the health and well‐being of a society. Although the rate of infant mortality in Connecticut is lower than the rate for the U.S. and many other states, significant disparities persist for various segments of Connecticut’s

population.

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The infant mortality rate for black non‐Hispanics (11.7 per 1,000 live births) was 3.2 times higher than that for white non‐Hispanics (3.7 per 1,000) and the infant mortality rate for Hispanics (6.1 per 1,000 live births) was 1.7 times higher than that for white non‐Hispanics in 2008‐2010. These differences in the infant mortality rate by race and ethnicity were statistically significant. Infant mortality rates have continued to decline over the last 20 years (1990‐2011) in Connecticut.

Infant mortality rates among singleton births have declined at a rate of 2.4% per year. Rates among multiple gestation deliveries have declined at a more modest 1.9% per year.

Figure 2: Fetal and Infant Mortality Rate, Connecticut (2001-2011).

Note: Indicates significant decline in infant mortality rate over this period for singleton and multiple gestation deliveries (p<0.05). Source: Connecticut Department of Public Health.

Often overlooked, fetal mortality is a prevalent public health issue.81 Fetal death refers to the spontaneous intrauterine death of a fetus at any time during pregnancy. Only fetal deaths at 20+ weeks’ gestation are reported in most states, including Connecticut. Unlike the rates of infant mortality, fetal mortality rates have not changed significantly in Connecticut over the last 20 years. The disparities in fetal mortality are

similar to those for infant mortality. In 2008‐2010, the fetal mortality rate for black non‐Hispanics and Hispanics was significantly higher than that for white non‐Hispanics. For black non‐ Hispanics (9.3 per 1,000 live births plus fetal deaths), the fetal mortality rate was 2.4 times the fetal mortality rate for white non‐Hispanics (3.9 per 1,000 live births and fetal deaths). The fetal mortality rate for Hispanics (5.3 per 1,000 live births plus fetal deaths) was 1.4 times higher than that for white non‐Hispanics.

Figure 3: Fetal Mortality Rate, by Race and Ethnicity, Connecticut (2008‐2010)

Note: * Indicates significantly higher fetal mortality rate for black non‐Hispanics and

Hispanics (p<0.05). Source: Connecticut

Department of Public Health.

Preterm Birth and Low Birth Weight

Preterm (<37 weeks gestation) and low birth weight (<2,500 g) births are important predictors of infant survival, child development, and well‐being. Preterm birth is the leading cause of infant deaths, accounting for approximately 35% of infant deaths in the United States. In Connecticut, almost half of infant deaths in 2008‐2010 were preterm‐related.82 Infants born prematurely are also at risk for neurological disabilities, respiratory conditions, or developmental delays. The risk for infant morbidity and mortality also increases with lower birth weight, which is associated with gestational age. Twin or higher multiple‐birth pregnancies increase the risk of low birth weight and preterm births.

Figure 4: Percent of Singleton Preterm Births, by Race and Ethnicity, Connecticut (2011).

Note: * Indicates significantly higher percent preterm birth for black non‐Hispanics and Hispanics (p<0.05).

Source: Connecticut Department of Public Health, Vital Statistics Registration Reports, 2011, Table 3.

In 2011, 8.0% of Connecticut singleton births were preterm. The proportion of preterm births for black

non‐Hispanic and Hispanic women was significantly higher than that for white non‐Hispanic women. The

percent of singleton preterm births among black non‐Hispanic women was 1.9 times higher than that for

white non‐Hispanic women. For Hispanics, the proportion of singleton preterm births was 1.4 times higher than that for white non‐Hispanics in 2011. From 2000 to 2011, there was little change in the percent of

preterm births for the total population and Connecticut’s largest racial and ethnic groups, suggesting that

the gap in preterm births between black non‐Hispanics and white non‐Hispanics is not improving.

In 2011, 5.6% of Connecticut singleton births were low birth weight. The proportion of low birth weight births among black non‐Hispanics (9.6%) and Hispanics (6.4%) was significantly higher than that for white non‐hispanics (4.1%).

From 2000 to 2011, there was no improvement in the proportion of low birth weight births for the total population or by race and ethnicity, suggesting that disparities in low birth weight births have not improved.

Figure 5: Percent of Low Birth Weight Births, by Low Birth Weight Status and Race and Ethnicity, Connecticut (2011)

Note: VLBW indicates very low birth weight and MLBW indicates moderate low birth weight. * Indicates significantly higher VLBW and MLBW for black non-Hispanics and significantly higher MLBW for Hispanics (p<0.05).

Source: Connecticut Department of Public Health.

Teen Births

Substantial social and economic costs are associated with teen pregnancy and childbearing.83 Teen pregnancy and birth are significant contributors to lower educational attainment and income. As compared with their peers, teen parents are less likely to graduate from high school or college, or to be fully employed as adults and more likely to experience an intergenerational cycle of teen parenting.83–87

Children of teen mothers are more likely to experience adverse outcomes that increase public sector costs, such as higher rates of dependence on public health care and welfare. As adolescents, children of teen mothers have higher incarceration rates and lower earnings. In 2010, Connecticut had the fourth lowest teen birth rate of any U.S. state.88 Nationally and in Connecticut, the teen birth rate has fallen substantially since its peak in 1991.89 From 2000 to 2011, there was a significant annual 4.2% decrease in the rate of births per 1,000 teen women. The overall rate of teen births in Connecticut declined by nearly 50% over the past decade, fueled by significant declines for each racial or ethnic group (ranging from ‐4.6% to ‐10.5% per year).

Despite this considerable progress, the importance of making further improvements is still compelling. In 2011, nearly 1 in 4 Connecticut teen mothers delivered a second pregnancy while still a teenager.90

Expectant teen mothers are at greater risk for poorer prenatal care and perinatal health habits, and higher rates of adverse outcomes such as low birth weight and premature delivery. In 2011, 27% of Connecticut teen mothers initiated prenatal care late or not at all compared with 12% of non‐teen mothers.90

Even with the substantial reduction in teen birth rates, Hispanic (47.2 per 1,000) and black non‐Hispanic (29.1 per 1,000) mothers had significantly higher rates in 2011 as compared with white non‐Hispanic mothers (5.8 per 1,000). The high teen birth rate for Hispanic women may be consistent with younger age specific birth rates among Hispanic women relative to other racial and ethnic groups and to the high birth rates among Hispanics overall.

Prenatal Care

The health and well‐being of mothers, infants, and children are important for our nation’s future health, well‐being and prosperity. Poor preconception health and inadequate access to prenatal care can influence the risk of adverse birth outcomes and later life health. Early entry into prenatal care allows providers to treat pre‐existing conditions early in pregnancy and establishes a relationship that lasts throughout the pregnancy.

In 2011, 13.0% of pregnant women received late or no prenatal care, and 77.8% received adequate prenatal care. The percent of women receiving non‐adequate prenatal care increased significantly from 2000 through 2005, with an 8.9% annual increase over this period. From 2006 to 2011, the proportion of women receiving non‐adequate prenatal care leveled off, with a 1.0% annual increase over this period.

In 2011, more than double the proportion of black non‐Hispanic mothers (20.9%) and Hispanic mothers (19.4%) received late or no prenatal care relative to white non‐Hispanic mothers (8.8%). These differences were statistically significant. In 2011, a significantly smaller percent of black non‐Hispanic mothers (71.5%) and Hispanic mothers (73.8%) received adequate prenatal care, compared to white non‐Hispanic mothers (80.7%).

Both white non‐Hispanic and black non‐Hispanic women experienced significant and high annual percent increases in non‐adequate prenatal care for the first part of the decade (2000‐2004 and 2000‐2005, respectively). The rate of increase in non‐adequate prenatal care slowed among white non‐ Hispanic

women after 2004, but still continued to increase steadily from 2005 to 2011. The percent of Hispanic mothers receiving non‐adequate prenatal care also increased significantly from 2000 to 2005, but then leveled off from 2006 to 2011.

Unintended Pregnancies

An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception.91 Unintended pregnancy is associated with an increased risk of problems for a woman and her infant. If a pregnancy is not planned before conception, a woman may not be in optimal health for

childbearing and may also delay prenatal care.

Slightly more than one‐third of Connecticut women (34.5%) reported that they had an unplanned pregnancy in 2010‐2011 (combined). Black non‐Hispanic (60.6%) and Hispanic (46.5%) women were more likely to report that they had an unplanned pregnancy compared to white non‐Hispanic women (25.4%).

Preconception Health

Preconception health is the health of men and women during their reproductive years, prior to conception. Because such a large proportion of pregnancies are unplanned, preconception health is important regardless of whether men or women plan to have children. Preconception health care is health care that focuses on conditions that may influence the likelihood of having a healthy baby.92

In 2010‐2011, 44.7% of Connecticut women reported that they discussed preconception health with a health care provider prior to their pregnancy. Black non‐Hispanic and Hispanic women were less likely to report having had these discussions with a health care provider. More than half of white non‐Hispanic women discussed preconception health with their health care provider prior to pregnancy, compared to only 28.9% of black non‐Hispanic women and 34.0% of Hispanic women in 2010‐2011.

Emerging Issues

Two significant emerging issues are not reflected in the Plan but that warrant being acknowledged and

factored into the Coalition’s work are Neonatal Abstinence Syndrome (NAS) and Assisted Reproductive

Technology (ART) Use. They underscore the need to be fluid in addressing the needs of women, children

and families within the policies and programs that are established to improve birth outcomes.

Neonatal Abstinence Syndrome (NAS)

Neonatal Abstinence Syndrome (NAS) is the medical term used to describe babies born dependent to medications, typically narcotics, that they were exposed to in utero. The syndrome is the newborn’s response to the quick withdrawal of medication that occurs after birth and can include excessive crying, tremors, vomiting, diarrhea, trouble sleeping as well as delays in motor and social development. Over the past ten years, there has been a nationwide rise in the incidence of neonates that must be kept in the hospital for extended stays due to their dependence on maternal narcotics. Extended hospital stays often interrupt the normal positive bonding between infant and mother and greatly increase medical costs. In Connecticut there has been a 2.7‐fold increase in babies born with neonatal abstinence syndrome over the past 9 years, costing the state over 22.8 million dollars in direct Medicaid expenses in 2011.

There has been an epidemic increase in the use, and subsequent abuse, of opioids in pain control therapy as the demand for new pain management strategies has grown. In the United States, between 1991 and 2010, prescriptions for opioid pain relievers grew from about 75.5 million to 205.5 million. The tremendous growth in availability of narcotic pain relievers has led to increased diversion for non‐ medical use in the general population. Prescription drug abuse affects both men and women and has cascaded into the maternal population. The increased incidence of NAS is a direct result of this occurrence.

The steep climb in the diagnosis of NAS has been a tremendous challenge to our healthcare system. Medical complications due to NAS include low birth weight, respiratory complications, feeding difficulties and slow weight gain, vomiting, tremors and seizures. Although incidence has increased there is no specific standard of care for the neonate with NAS and a full 50% of hospitals treating newborns do not have a protocol in place for treatment of NAS. Commonly, babies with NAS are kept in the neonatal intensive care unit (NICU) for monitoring. This separation can have a negative effect on both breastfeeding and mother-infant bonding.

When assessing infant outcomes the first step is prevention of harmful conditions. In Tennessee linking long‐term opioid use (over 30 days) to contraception is being explored. Connecticut is also beginning to implement policy changes, including prescription drug monitoring programs aimed at preventing the illicit use of opioid medications.

Once a child is diagnosed with NAS many supportive techniques may be employed which may empower families and decrease the symptoms of NAS. Breastfeeding and any other behavior that encourages skin-to‐skin touching can encourage mother‐infant bonding and can have a positive effect on both the mother and the neonate. Infants who room‐in with mothers, instead of being transferred to a NICU, had an increased likelihood of being discharged home with their mother and a decreased need for NAS drug therapy. Other non‐invasive techniques include: minimizing stimuli such as light and sound, avoiding infant movement by careful swaddling, responding early to an infant’s signals, adopting infant positioning and comforting techniques such as swaying, rocking, and pacifier use, and providing frequent small volumes of breast milk or formula to encourage adequate growth.

The rapid emergence of NAS necessitates an increase in understanding by the medical community about all types of treatment and its efficacy. The dramatic increase in the level of opioid addiction seen in Connecticut, as well as across the country, signals the need for public health to take a much stronger preventative role to improve infant outcomes.

Assisted Reproductive Technology (ART)1

One in every eight (12.9%) adult women of reproductive age (18 to 50 years old) in Connecticut during 2013 reported having infertility or difficulty carrying a pregnancy.93 The U.S. Centers for Disease Control and Prevention estimates that in 2010, Connecticut ranked fifth among all states in the country for per capita use of assisted reproductive technology (ART) to aid couples with fertility problems (4,996 per million women between 15 and 44 years of age versus 2,331 per million nationwide).94 The per capita rate in Connecticut during 2010 was over 6‐fold higher than that during 2005, when the rate was only 783 per million.95 Over 3.5% (1,404) of all births in the state were attributed to ART usage during 2010. During 2011, the most recent year for which data are available, the per capita use of ART in Connecticut remained high among other state, at 4,708 per million.96

1 Although various definitions have been used for assisted reproductive technology (ART), the technique generally

involves surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and

returning them to the woman’s body or donating them to another woman. ART generally does NOT include

treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which

a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved. ART has

been used in the United States since 1981 to help women become pregnant, most commonly through the transfer

of fertilized human eggs into a woman’s uterus (in vitro fertilization).

Figure X: Percent distribution of single, twin,

and higher order births, all births versus births

attributed to assisted reproductive technology,

Connecticut, 2010.

Source: CT Department of Public Health, Health

Statistics and Surveillance Section; Centers for

Disease Control and Prevention, Women’s

Health and Fertility Branch.

Figure Y: Percent distribution of birth weight outcomes, all births versus births attributed to assisted reproductive technology, Connecticut, 2010.

Source: CT Department of Public Health, Health Statistics and Surveillance Section; Centers for Disease Control and Prevention, Women’s Health and Fertility Branch.

Nearly half of every ART birth in Connecticut during 2010 (45%) resulted in twins, triplets, or higher order births (see Figure X), and 30% of ART births were either moderate or very low birth weight (see Figure Y).97 In sharp contrast, among all births in Connecticut during 2010, only 5% resulted in multiple births, and only 8% resulted in reduced low birth weight. Among all low birth weight events in the state during 2010, 14% were attributed to ART.

The statewide statistics in multiple births and low birth weight during 2010 represented a high over the past decade of increasing multiple births and low birth weight rates,3,90 suggesting that ART usage in Connecticut is at least in part driving the rate of multiple births. Some experts predict that the increasing trend in ART usage across the country will continue, and that future efforts to conceive may not be limited to couples with fertility problems.98,99 Yet, since birth of the first child conceived by ART was only 36 years ago, the long term health effects of ART remain unknown.100 The state must develop mechanisms for tracking ART usage and its impact on health outcomes.

Recent advances in ART techniques make possible procedures that reduce the likelihood of multiple births and low birth weight.101 Elective single embryo transfer (eSET) is a highly successful procedure for most women with a favorable prognosis,102 which is less likely to result in low birth weight.103 Whereas over 70% of ART treatments were eSET during 2010 in Sweden, and Australia and New Zealand (D. Kissin, CDC, personal communication), however, only 6.7% of ART treatments were eSET in Connecticut during the same period. Within the U.S., Connecticut ranked 18th among all states for eSET usage in 2010, well behind states such as Delaware, which ranked first with 45.0% eSET usage. These data indicate that much of the low birth weight experienced in the state as a result of ART is preventable, and that consumer awareness is needed to encourage women to select eSET, when clinically appropriate. Efforts are also needed among fertility clinics in the state to encourage widespread use of eSET, especially among women with favorable prognosis.

Recognizing the statewide contribution of ART to low birth weight, as well as the need to track ART activity and its impact within the state, DPH joined a collaborative of other states in 2013. The States Monitoring Assisted Reproductive Technology (SMART) Collaborative, with partners that include CDC, Massachusetts, Michigan, and the Society of Assisted Reproductive Technology, seeks to strengthen the capacity of states to evaluate ART-related maternal and perinatal outcomes through state-based public health surveillance systems. Through the SMART Collaborative, DPH plans to link information from ART surveillance at CDC with state birth records, infant and fetal death records, hospital discharge registries, birth defects registries, and cancer registries. The linked datasets will create a population-based data registry of ART and non-ART births that can be used to monitor and examine ART pregnancy outcomes.

The Association of State and Territorial Health Officers recently joined the SMART Collaborative, making possible a broader approach to developing strategies that improve birth outcomes. The DPH is also in partnership with the state March of Dimes on ART issues in the state, as well as the Medical Director for the state Medicaid program. These state and federal partnerships will allow DPH to broaden its surveillance activities to include low-income families, raise awareness of the impact of ART on public health in the state, and ensure that surveillance efforts in Connecticut are incorporated into strategies that encourage the use of eSET. These strategies would significantly reduce low birth weight rates in the state and could allow the state to meet the challenge of the Healthy Babies Initiative.104