Why Are We Here Together?

1. Every Baby Counts on You!Fetal-Infant Mortality Review FY 2020-2021 Project KickoffAugust 27, 2019

2. Why Are We Here Together? FIMR is a community-based, action-oriented process to review fetal and infant deaths and make recommendations that spark systemic changes and prevent future deaths in the community. ~National Center for Fatality Reviews & Prevention

3. Why Are We Here Together? FIMR is a community-based, action-oriented process to review fetal and infant deaths and make recommendations that spark systemic changes and prevent future deaths in the community. ~National Center for Fatality Reviews & Prevention

4. Why Are We Here Together? FIMR is a community-based, action-orientedprocess to review fetal and infant deaths and make recommendations that spark systemic changes and prevent future deaths in the community. ~National Center for Fatality Reviews & Prevention

5. Why Are We Here Together? FIMR is a community-based, action-orientedprocess to review fetal and infant deaths and make recommendations that spark systemic changes and prevent future deaths in the community. ~National Center for Fatality Reviews & Prevention

6. Why Are We Here Together? FIMR is a community-based, action-orientedprocess to review fetal and infant deaths and make recommendations that spark systemic changes and prevent future deaths in the community. ~National Center for Fatality Reviews & Prevention

7. The FIMR Process Angie (Records Abstractor): Reviews prenatal and hospital records for mother and baby Tamira (Maternal Interviewer): Interview mothers who volunteer Sinmi(Coordinator) and Partners: Gather other health and systems records (HCAM centralized intake, home visiting, WIC, BCDSS, BHSB, public schools, criminal justice)

8. The FIMR Process Our Case Review Team Public health professionals, city agencies, hospitals and health care providers, and community organizations review the data, identify trends, and make recommendations for systemic change

9. The FIMR Process B’more for Healthy Babies Citywide initiative to reduce infant mortality and improve outcomes from birth to age 5 uses FIMR recommendations to drive work that happens at the policy, community, services, and individual levels

10. The FIMR Process The Change We Want to See Better supports and services for mothers and families, improved health care and social services, policies that are equitable and create healthy environments, empowered residents and communities

11. Equity in Birth Outcomes Every Baltimore baby—no matter who she is, where he lives, how much money her family makes, or the color of his skin—should have the opportunity to thrive and grow into a healthy child.

12. Baltimore’s Racial Disparity in Infant Mortality Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2005-2017.

13. What’s Killing America’s Black Infants? • It’s Not RaceDifferences in maternal behavior and genetics do not explain the racial disparity • It’s Not PovertyPoverty and education matter but also don’t fully explain the disparity • It’s Experiences of Racism (interpersonal and institutional) • Racial residential segregation (isolation) • Biological response to chronic stress over the life course (allostatic load)

14. What Drives the Racial Disparity in Baltimore? Very low birth weight deliveries (less than 3.3 pounds) Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2011-2015.

15. Each category corresponds to certain factors that are likely to be driving deaths in that category

16. FY 2020-2021 Case Review: Maternal Obesity • Review 40 cases of VLBW deliveries + mothers had a BMI of 30 or greater • Preconception health/sources of primary care • Nutrition and related counseling in prenatal care • Screening, treatment, and referrals around hypertension, diabetes, and sleep apnea • Linkage to primary care at the postpartum visit • Obtain 16-20 maternal interviews • Concern about weight and weight loss attempts preconception • Access to healthy foods and safe places to exercise • Provider sensitivity, treatment, relevance, helpfulness • Experience with WIC • Continued focus on exposure to trauma and racism

17. Preliminary Goals for FY 2020-2021 • Develop a common understanding as a team of: • Complexity of factors affecting maternal body weight • Weight stigma and impact on health, intersection of weight stigma and racism • Role of WIC and SNAP in improving birth outcomes • Learn through case review, data analysis, and student projects: • Contribution of obesity to poor birth outcomes in Baltimore City • Mothers’ experiences related to weight and nutrition • Concerns related to quality of care • Nutrition and fitness landscape in Baltimore City • Make specific recommendations to inform: • BHB’s nutrition strategy/WIC strategic plan • Provider outreach on quality of care

18. Next Steps • Today’s meeting: • Review some data on maternal obesity • Review ACOG guidelines and recommendations for care • Acknowledge the complexity of obesity and the impact of stigma • Review two cases • After the meeting: • Read orientation packet • Take the Implicit Association Test • Complete the Cultural and Linguistic Self-Assessment • Upcoming meetings: • Case reviews • Guest speakers on key topics (obesity in pregnancy, food environment, stigma)

19. Maternal Obesity = Body Mass Index of 30+

20. Maternal Obesity and Infant Mortality • Every 5-unit increase in maternal BMI is associated with: • 1.21times the risk of fetal death • 1.16 times the risk of perinatal death • 1.15 times the risk of neonatal death • 1.18 times the risk of infant death • Maternal obesity (BMI of 30+) is associated with: • 3 times the odds of maternal hypertension • 3 to 8 times the odds of gestational diabetes • 1.5 to 4 times the odds of extremely preterm delivery • 2 to 3 times the odds of neural tube defects Sources: Aune et al., 2014; Cnattingius et al., 2013; Leddy et al. 2008

21. One-Third of All Births Are to Mothers with BMIs in the Obese Range Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2013-2017.

22. Maternal Obesity Impacts Black Women More Than White and Hispanic Women Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2013-2017.

23. Infant Mortality is Elevated in Mothers with BMIs in the Obese Range Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2013-2017.

24. Preterm Birth is Higher in Mothers with BMIs in the Obese Range Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2013-2017.

25. If all maternal obesity were eliminated in Baltimore City, 11% of all very low birth weight births would be avoided (about 18 births every year) Property of Baltimore City Health Department. Data Source: BCHD Analysis of MDH Vital Statistics, 2011-2015.

26. ACOG Practice Bulletin • Issued in 2015, reaffirmed 2018 • Sets clinical recommendations for care based on levels of evidence

27. Monitoring Quality of Care in FIMR

28. Complexity of Obesity: Systems Map Source: Government Office for Science, 2010

29. Complexity of Obesity: Systems Map Source: Government Office for Science, 2010

30. Link Between Chronic Stress and Obesity Source: Torres & Nowson, 2007

31. Weight Bias or Stigma Source: University of Connecticut Rudd Center for Food Policy and Obesity

32. Impact on Provider-Patient Relationship • Studies show that physicians hold negative attitudes and stereotypes about patients with obesity and view them as: • Less compliant • Less motivated • Less disciplined • Less adherent to medications • Less trustworthy • Moreannoying • As patients’ BMI increases, physicians report: • Lesspatience • Less desire to help the patient • Less respect for patients • Greaterperception of patient as a waste of time Source: University of Connecticut Rudd Center for Food Policy and Obesity

33. Consequences of Weight Stigma Source: University of Connecticut Rudd Center for Food Policy and Obesity

34. Questions for Increasing Self-Awareness • What are my views about the causes of obesity? • Do I believe common stereotypes about obesity (e.g., eating too much or lack of motivation) to be true or false? • Do I make assumptions about an individual’s character, intelligence, abilities, health status, or lifestyle behaviors based on his or her weight? • How do my views and assumptions about obesity affect my attitude toward individuals of higher weight status? Source: University of Connecticut Rudd Center for Food Policy and Obesity

35. Discussion How should our review and recommendations process be influenced by: • The racial disparities data for Baltimore City? • The complexity of the causes of obesity? • The impact of weight stigma on health outcomes?

36. Case Review