Answering the ‘why’: Local officials step up efforts to reduce infant mortality

Local health officials are stepping up efforts to answer two urgent questions — why do so many infants in Bartholomew County die before their first birthday — and what can be done about it?

The answers to these questions, as officials from Columbus Regional Health, the Columbus Police Department and the Bartholomew County Coroner’s office have found, are often complex and can be difficult to pin down, if they can even be answered at all.

From 1999 to 2017, 165 infants who resided in Bartholomew County died before turning 1 year old, or slighter more than the seating capacity of a standard-sized yellow school bus, according to the Indiana State Department of Health.

In 2017, six infants who resided here died, the lowest number since 2009. It also was the first time since 2008 and 2009 that six or fewer infants died in consecutive years.

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The annual number of infant deaths widely varied from 1999 to 2017, ranging from 15 in 2015, 13 in 2011 and 12 in 2007 to as low as five in 2003 and 2009.

Though the number of infant deaths has declined since peaking at 15 in 2015, the infant mortality rate from 2014 to 2017 among infants who lived in the county was 8.65 deaths per 1,000 live births, a slight uptick from the rate of 7.63 seen from 1999 to 2003. The highest infant mortality rate seen since 1999 was 9.05 from 2009 to 2013.

Not all of these deaths, however, occurred in the county, as the state health department records infant deaths by the county in which the infant resided and the time of death, which is not necessarily the county in which the infant died, according to Megan Wade-Taxter, Indiana State Department of Health spokeswoman.

For example, the state would classify an infant who lived in Bartholomew County but died at a hospital in Marion County as a Bartholomew County death.

Data from the Bartholomew County Health Department, which only tracks births and deaths occurring within the county, show that 46 infant deaths occurred in Bartholomew County from 2008 to 2018.

The leading cause of infant death in the county from 2008 to 2018 involved preterm delivery and birth, according to county health records. Approximately one in three infant deaths in Bartholomew County, or 15 out of 46, was attributed to complications related to preterm delivery or birth. A baby is considered premature if born prior to the 37th week of gestation, according to the Mayo Clinic.

Six of the 15 deaths of preterm infants were related to complications from “extreme prematurity,” meaning that those babies were born after less than 28 weeks of gestation.

There were three cases of asphyxiation or suffocation, two cases were at least partly caused by unsafe sleeping environments and six cases of Sudden Infant Death Syndrome, which is the sudden unexplained death of an infant under the age of 1 year.

The infant mortality rate in Indiana in 2017 was 7.3 deaths per 1,000 live births — the seventh highest rate in the country. Only Mississippi, Arkansas, Oklahoma, South Dakota, Alabama and Tennessee had higher rates.

Bartholomew County’s rate was 5.74 in 2017, just under the U.S. average of 5.8. The county’s rate was 13.6 in 2015 and 4.88 in 2009. The U.S. was tied with Serbia for the 55th lowest infant mortality rate in the world in 2017, according to the Central Intelligence Agency’s World Factbook, which compiles a wide range of data on countries around the world for use by U.S. government officials.

The infant mortality rate is the ratio of infant deaths per 1,000 live births. For the purposes of calculating the rate, an infant is defined as a baby less than 1 year of age. Researchers and policymakers often consider the infant mortality rate to be a barometer of the overall health of a community.

Under review

Last year, CRH started a Fetal Infant Mortality Review (FIMR) team, which reviews every case of infant death in Bartholomew County. The local review team is one of the first such teams in Indiana.

Additionally, CRH has several educational efforts, as well as its Nurse-Family Partnership Program, an evidence-based community health program that brings nurses into a one-on-one coaching relationship with new mothers in their first pregnancy.

The Columbus Police Department and the Bartholomew County Coroner’s Office are increasing training and education on best practices in infant death investigations.

The idea behind all these efforts, officials said, is to collect sufficient data so that more informed interventions and policies can be formed to prevent future deaths and provide public education.

“These deaths are difficult enough, but as a community we want to be sure that we’re using these tragic situations to try to prevent future ones,” said Bartholomew County Deputy Coroner Jay Frederick, who is also a Columbus police officer. “If we’re not doing that, then what are we doing? Not all communities are this proactive.”

Columbus Regional Health started its Fetal Infant Mortality Review (FIMR) team in April 2018 after seeing troubling rates of infant mortality in the community, especially in 2015, when infant deaths were at their highest since at least 1999, hospital officials said.

The team includes four physicians, two nurses and two social workers who investigate possible medical, social, environmental factors that could have contributed to each local infant death.

CRH officials said they have always reviewed every infant death occurring in their facilities. The FIMR team was set up to also look at deaths that occurred outside their facilities to further to determine why they occurred and how CRH could have an impact, CRH officials said.

“We saw a need because of the higher percentages of infant mortality that we were seeing,” said Ann Morrow, clinical nurse specialist at Columbus Regional Health who works with the FIMR team.

The FIMR team has a community action component that focuses, among other things, on education and maternal health including smoking cessation among pregnant women, proper spacing between pregnancies, safe sleeping environments, making sure soon-to-be mothers are getting early prenatal care, among other initiatives. The FIMR’s community action team started in February, CRH officials said.

“It’s really pre-conception health,” Amanda Virostko, infant mortality prevention coordinator at Health Communities. “We’re just trying to make sure that moms are healthy before they get pregnant.”

However, CRH officials said they have run into obstacles. It has been difficult at times to get all the data they need to investigate beyond the immediate cause of death to determine what factors may have played a role, they said.

“We do not have a clear way to get data for those deaths that occur outside of our county or our walls,” said Chris Newkirk, CRH clinical quality adviser, who is on the FIMR team. “So that’s a been a little bit inhibitive of really trying to uncover the true reasons for the deaths.”

Newkirk said some healthcare providers are hesitant to share data about infants who die at their facilities out of fear of violating the Health Insurance Portability and Accountability Act, or HIPPA.

CRH’s FIMR team has been looking at around 40 different data points involving local infant deaths, including health habits, education, quality of prenatal care, obesity, substance abuse, socioeconomic status, among others, Newkirk said.

So far, they have not been able to identify any overarching trends, Morrow said. CRH officials estimate that they may need three to five more years of data before they start seeing trends.

“We’re not been able to identify that one trend,” Morrow said. “We don’t see one trend throughout all the cases that we’ve looked at. There are not a lot of singularities. You’d think that it would be that all of the women would be about the same age, or their education might be the same, but there’s nothing that has really been the same with any of them.”

Newkirk said one of the most difficult parts about reviewing cases of infant deaths is “not knowing what you don’t know.”

“I wish we could say that we’ve discovered that big, ‘Ah-ha, these are the reasons for the deaths,’” Newkirk said. “But we haven’t discovered that.”

Law enforcement

The Columbus Police Department and Bartholomew County Coroner’s office are also stepping up efforts to educate investigators on how to handle infant death cases.

On May 23, the Columbus Police Department and the Bartholomew County Coroner’s office, as well as law enforcement officials from surrounding counties, will participate in training from the Indiana State Department of Health at Columbus City Hall. The training will cover how to thoroughly investigate infant deaths and capture the data that needs to be examined, Frederick said. Columbus Police detectives and coroner’s office staff have had similar training.

“Most of us are parents ourselves, so it’s very different anytime we have to deal with a child death, and that’s any child,” Frederick said. “… We can no longer prevent it, we can only investigate it. That’s why we insist on using the information to see what if anything can be done to prevent future ones. That’s why the training is so important.”

Law enforcement is tasked with determining the cause of an infant’s death, which can involve hundreds of different factors, officials said. Often, the cause of death is never determined, Frederick said.

“People generally have a misconception about autopsies,” Frederick said. “A lot of people think we can put a dead body in the ward with a forensic pathologist and get a complete story of what happened, but it doesn’t really work that way.”

Law enforcement officials work with the infant’s family to fill out an eight-page form the U.S. Department of Health and Human Services and the Centers for Disease Control, called a Sudden Unexplained Infant Death Investigation, or SUIDI form. The form asks questions about how the infant was found, the position the infant was in, any medications the infant was taking, among others. The forensic pathologist that conducts the autopsy uses the form to help understand more about what happened.

Bartholomew County Coroner Clayton Nolting said the form, as well as witness/victim statements and other documentation, is paramount for the forensic pathologist to evaluate possible causes of death. Nolting, who is also a Columbus Police officer, said the upcoming training will help further educate investigators about infant deaths.

“Through education and improving our investigation skills, we can give more information to our pathologists,” he said. “Our pathologists can only work with the information that he or she is given.”

Frederick said investigating an infant death is a very complex process, and that there is a “professional and compassionate way to do it,” but, nevertheless, it’s “troubling” when a cause of death cannot be determined.

“The surprising thing is that in this day and age, for all that this society knows and has accomplished, there’s still a lot we don’t know about why an infant dies,” Frederick said.

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For more information from the state of Indiana about infant mortality, visit:

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  • Infant mortality is defined as the death of a baby before his or her first birthday
  • The infant mortality rate is the number of babies who die in the first year of life, per 1,000 live births
  • Of the 602 Indiana infant deaths in 2017, 37 occurred in the Southern Hospital region, which includes Bartholomew, Jennings, Jackson, Jefferson, Switzerland, Orange, Washington, Scott, Clark, Crawford, Floyd, and Harrison counties.
  • Black infants are 2.6 times more likely to die than white infants in Indiana. Black women in Indiana are more likely to have a low birth weight or preterm baby and not obtain prenatal care.
  • Smoking rates among pregnant women around the state are much higher than the national rate.
  • White women in Indiana are more likely to smoke during pregnancy.
  • Almost a third of pregnant women in Indiana do not receive early prenatal care.

Source: Indiana State Department of Health Division of Maternal and Child Health

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  • Improve overall health for women of child-bearing age
  • Promote early and adequate prenatal care
  • Decrease early elective deliveries before 39 weeks
  • Decrease prenatal smoking and substance abuse
  • Increase breastfeeding duration and exclusivity
  • Support birth spacing and interconception wellness
  • Promote safe sleep guidelines, including placing baby to sleep alone, on his or her back, in a crib — no blankets, bedding or pillows

Source: Indiana State Department of Health Division of Maternal and Child Health

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Indiana’s southern region, which includes Bartholomew County and 11 other counties, has the following characteristics:

  • There were 6,234 births in the southern region in 2017
  • The southern region has a lower percentage of low birthweight births and preterm birth when compared to Indiana’s rate
  • The southern region has a higher percentage of women receiving prenatal care in the first trimester.
  • It also has a higher percentage of women smoking during pregnancy and a lower percentage of women breastfeeding at hospital discharge compared to other regions.

Source: Indiana State Department of Health Division of Maternal and Child Health