Wednesday, July 25, 2012

COIN - Collaborative Improvement and Innovation Network addressing infant mortality


When I arrived in Minnesota in 1980, the issue of infant mortality was beginning to rise in importance in our state and nationally. Analysis of linked birth and death records along with fetal and infant death reviews were giving us new information about the causes of infant deaths. The data were also pointing out the huge racial disparities in this major health indicator. However, by 1991, with a change in priorities at the federal level, these efforts waned with the result that the US ranking on infant mortality declined and racial disparities in infant mortality rates remained at an unacceptably high level.

When I left the Minneapolis Health Department in 1995 for the University of Minnesota, my attention to the issue of infant mortality declined just like that of the federal government. Fortunately, just as I joined the Minnesota Department of Health, the Health Resources and Services Administration (HRSA) began to refocus its attention on reducing infant mortality in the United States. As part of that effort, HRSA has established something they call a COIN – Collaborative Improvement and Innovation Network with the goal of reducing infant mortality. The COIN focuses on five issues:
  • Improving regional perinatal care systems
  • Expanding smoking cessation efforts for pregnant women
  • Reducing Sudden Infant Death Syndrome/Sudden Unexpected Infant Deaths (SIDS/SUID)
  • Expanding inter-conception care, especially among high risk women and women on Medicaid
  • Reducing elective deliveries before 39 weeks gestation
As a State Health Official and the Region V representative to the Association of State and Territorial Health Officials (ASTHO) Board, I was invited to a meeting in D. C. to discuss the COIN. It’s been satisfying seeing some familiar faces from the past and getting re-immersed in an issue that was formative in my public health career - an issue that is core to public health throughout the world.

Sitting through the sessions today made me think about all the things that have been tried in our state to reduce this devastating event. Being here also brought back memories of some of the infants I cared for who didn’t make it to age 1. And it made me think of the parents whose lives changed dramatically because of the death of their infant. I vividly remember the story of one particular mother who I met in clinic during my first month as the Maternal and Child Health Director of the Minneapolis Health Department. Her story highlights the devastating and long-lasting impact an infant death can have.

People said I’d get over it. They said it might take a few weeks or even a few months -- maybe a year, but I’d get over it.

They said I had a good family, a good husband, a good home, good friends. That’s all I’d need to get over it.

I tried, I really tried, but I couldn’t get over it. My life began to fall apart. I dropped out of school, I saw a counselor, I went to some support groups but I still couldn’t get over it.

Finally, we decided to leave town. Maybe a new place would help me get over it. My husband quit his job; we packed up and moved to Texas. But that didn’t help. I still couldn’t get over it.

To make things worse, neither of us could find jobs. My husband then started to drink -- so did I. That helped us get over it at least for a little while, but it didn’t last. Then we started to fight -- a little at first but it got steadily worse. Soon we couldn’t talk to each other without fighting.

In one of our sober and saner moments we decided to move again. Maybe another new start would help me get over it. It didn’t.

We moved to Idaho. But things continued to go downhill. There were no jobs for us there either and we were soon out of money. Just as we were nearing rock bottom, I got pregnant. I thought a new baby might help us get over it, but it didn’t. My husband continued to drink and to become more and more distant from me. Finally, he became so distant that he just disappeared.

I was now alone, except for the baby. I had no job, no money, no insurance, no hope and I still wasn’t over it. My life was in shambles. I had no place to go. I decided to come back to my home here in Minneapolis and go back to school. But I found that I can’t even go back home. My mother won’t talk to me. After all these years she still blames me. She still thinks it was all my fault.

But, it was just as much her fault as mine. She’s the one who gave me the crib. It was the one that I used when I was a baby and I never got hurt. How was I to know that it would be the cause of my baby’s death?

Do you think I’ll ever get over it?

According to an April 4, 2012 report on infant mortality by the Congressional Research Service, Minnesota’s 2008 infant mortality rate is 6.0. That ranks us 20th in the country. Our 2009 rate has improved to 4.5 but still pales in comparison to Luxembourg, Slovenia, Iceland, and Sweden who have infant mortality rates of 1.8, 2.1, 2.5, and 2.5 respectively. Our vital statistics unit has shown that, using a 3 year moving average, the Minnesota infant mortality rate has actually increased from 4.8 in 2003-2005 to 5.6 in 2006-2008 and that racial disparities have remained unacceptably high. We are not making progress and are far from where we should be.

32 years ago my patient asked, do you think I’ll ever get over it? Today we should ask ourselves a similar question, should we ever divert our attention from addressing this major public health problem? I hope our answer will be no because one of the greatest gifts we can give a family is never having to be confronted with the death of an infant and that unanswerable question.

Ed