Infant Mortality

The infant mortality rate, the rate of infant deaths per 1,000 live births, is a common measure of maternal and child health, the community’s overall health and well-being that also tells the important story of equity within our community. Infant mortality is defined as the death of a child before their first birthday.

Over the last 20 years Guilford County has had consistently higher infant mortality rates than the state of North Carolina and the United States. The trendlines for rolling five-year infant mortality rates by race in the chart below illustrate the critical feature of Guilford County birth outcomes: persistent racial disparities. In 2018, the overall Guilford County infant mortality rate was 8.5 per 1,000 live births, while it was 15.1 for African Americans, as compared to 2.9 to Whites.

Low Birth Weight and Preterm Birth

African Americans also experience low and very low birth weight (under 2,500 grams and under 1,500 grams respectively) and preterm birth (before 37 weeks of gestation) at substantially higher rates than Whites. CHA quantitative data analysis identified a critical factor driving 87% of the racial disparity in Guilford County infant deaths: the higher prevalence of African American births in the lowest birth weight categories (see Chapter 5, CHA). Pre-term birth often co-occurs with low birth weight. As the chart below depicts, the percentage of low birth weight births was almost double for African American births as compared to Whites.

There are multiple medical risk factors for low birth weight: such as high blood pressure; diabetes; heart, lung and kidney problems; sexually transmitted infections; and eating disorders. There are also environmental risk factors such as exposure to air pollution, lead, and discrimination, and behavioral risk factors such as smoking and substance use. 2019 CHA survey and workshop participants also identified additional stressors that underlie these risk factors: racism, low wages, inflexible work schedules, toxic stress, poverty, inadequate emotional support and bias within healthcare.

Early Prenatal Care

Healthy NC2030 also identified early prenatal care, receiving pregnancy-related care services during the first trimester of a pregnancy, as a protective factor for many negative outcomes for mothers and their babies. Guilford County mirrors North Carolina’s sharp disparities between those who receive and do not receive early prenatal care. As the chart below depicts, in 2018, only 60.2% of pregnant women received early prenatal care and for African American, Asian and Hispanic women, the percentage was even lower, at 53.9%, 47.3% and 47.5% respectively.

In our “deeper dive” of maternal and child health in our 2019 Community Health Assessment, key informant workshop participants were asked to share words or phrases that expressed their views of the current state of pregnancy and birth outcomes, and the most common phrase was “barriers”, followed by “disheartening” and “inequitable.” While these word clouds are not precise statements of fact, they may be interpreted as barometers of current values, perceptions, moods and priorities (see image below).

2019 CHA key informant participants also discussed the impact of racism on pregnancy and birth outcomes. “It seems like racism is expressed through social determinants,” one participant stated, and many participant comments reflected the sentiment that race, ethnicity, income and education are intertwined. In turn, these act as key drivers of access to fundamental building blocks of health, including housing and transportation. There was a consensus that tackling racism and discrimination would have a significant impact on maternal and child health, and an acknowledgement that we lack knowledge of effective interventions and solutions to achieve that goal. The participants also commented on access to high quality, affordable childcare as an important impact on health, affecting both the child’s development and the mother’s ability to secure employment and improve a family’s financial sustainability.

Among 2019 CHA key informants, there was acknowledgement that inequity of outcomes required addressing issues like racism in society and within healthcare, and system change that includes universal access, as much as possible. This group also commented on the challenges posed by limited access to healthcare because of eligibility guidelines for Medicaid that leave many low-income working women without healthcare between pregnancies. Many workshop participants saw a universal approach to healthcare access as a possible remedy. They commented that universal healthcare access would improve women’s access to interconceptional care to better address chronic health issues, such as diabetes, perinatal mood disorders, substance use and other issues that affect maternal health and birth outcomes. Key informants also shared words or phrases that expressed their views of what makes them hopeful about the future for women and infants in Guilford County (see image below).

The community partners serving the health and wellbeing of women and children in Guilford County, especially the most vulnerable, is broad and deep. Below are just a few of the Guilford County collaboratives that are striving to improve the maternal and child health outcomes in our community:

Guilford County Coalition on Infant Mortality formed in 1991 as an initiative of the Women’s Health Division of the Guilford County Department of Public Health, with the goal to increase public awareness on infant mortality and to develop strategies to provide for more healthy birth outcomes. The Coalition is currently organizing a collective action strategic planning process that envisions bold goals, develops collective action strategies and redesigns the Coalition to address the stark health disparities in birth outcomes and infant mortality in Guilford County. The Coalition is partnering with Root Cause, a purpose-driven consulting group in this process, which will conclude in spring of 2021. 

Concurrently, the Coalition continues to implement the Adopt-a-Mom program and will organize a Fetal and Infant Fatality Review (FIMR), a community based, action-oriented process aimed at improving services, systems and resources for women, infants and families. The Adopt-a-Mom program coordinates prenatal care for low to medium-risk pregnant women annually who are not eligible for Medicaid, do not have private insurance to cover the cost of care and cannot afford to pay out of pocket for care. The FIMR process brings a multidisciplinary community team together to examine confidential, de-identified cases of fetal and infant deaths. These case reviews help teams understand families’ experiences and how those experiences may have affected maternal and child outcomes. The FIMR process assesses how infant morbidity and mortality occurs in local communities and works to improve service systems and community resources for women, infants and families. For more information about the Coalition go to https://www.guilfordcountync.gov/our-county/human-services/health-department/health-and-wellness/coalition-on-infant-mortality-and-the-adopt-a-mom-program or FIMR, go to National Center for Fatality Review and Prevention at https://www.ncfrp.org/fimr/.

Partnership for Children of Guilford County strives to make sure every child in Guilford County enters school safe, healthy and ready to succeed. Through public dollars and private donations, the partnership creates new programs and collaborates with existing ones to measurably strengthen families and improve the lives of children. In addition to administering the largest NC Pre-K program in the state, through Smart Start, they invest in a wide range of programs to promote health, family support and child care (http://www.guilfordchildren.org/).

Ready for School, Ready for Life (Ready, Ready) is a collaborative effort to build a supportive, responsive system of care that improves outcomes for all children in Guilford County. This partnership seeks to improve outcomes in planned and well-timed pregnancies, healthy births, on-track development for infants and toddlers, kindergarten readiness and success in third grade. In 2018, through their partnership with The Duke Endowment, Ready, Ready announced that Get Ready Guilford Initiative was chosen for a multi-year investment of $32.5 million from Blue Meridian Partners. Blue Meridian is a partnership of impact-driven philanthropists seeking to transform life trajectories of America’s children and youth by making large investments in promising solutions.

The Get Ready Guilford Initiative will support a system that over time will connect a wide range of services for the 6,000 children born in Guilford County annually. Priorities include expanding three existing and proven programs that serve families prenatally through age 3 (Guilford Family Connects, HealthySteps and Nurse-Family Partnership) as well as systems change, including a navigation system to connect families with effective services prenatally through age 3, Continuous Quality Improvement (CQI) within programs to build capacity, technologies to facilitate coordination among child- and family-serving agencies and organizations and rigorous evaluation. For more information go to: www.getreadyguilford.org.

In 2016, the Women’s Health Branch of the NC Department of Health and Human Services convened a group of partners to draft the NC Perinatal Health Strategic Plan 2016-2020 statewide plan focusing on infant mortality, maternal health, maternal morbidity and mortality, and the health status of women and men of childbearing age. This 12-point plan recommends strategies to improve health care and strengthen families, but it also goes further by recognizing the need to address upstream social determinants of heath, including gaps in education performance, poverty and systemic racism.

 Goal 1: Improving Health Care for Women and Men

1. Provide interconception care to women with prior adverse pregnancy outcomes.
2. Increase access to preconception health and health care to women and men.
3. Improve the quality of maternal care (includes prenatal, labor, delivery and postpartum care).
4. Expand healthcare access over the life course for all.

Goal 2: Strengthening Families and Communities

5. Strengthen father involvement in families.
6. Enhance coordination and integration of family support services.
7. Support coordination and cooperation to promote reproductive health within communities.
8. Invest in community building.

Goal 3: Addressing Social and Economic Inequities

9. Close the education gap.
10. Reduce poverty among families.
11. Support working mothers and families.
12. Undo racism.

To see the complete plan, NC Perinatal Health Strategic Plan 2016-2020 go to: https://whb.ncpublichealth.com/docs/PerinatalHealthStrategicPlan-WEB.pdf

Our 2019 Community Health Assessment primary and secondary data collection and community dialogues point towards the developing and supporting effective interventions that:

• address structural issues (such wages, housing and health coverage) that disproportionately affect low income women and women of color;
• are offered universally, acknowledging that all women and young families need support to be successful;
• advance equity in outcomes, by eliminating bias in care delivery, addressing differences in power, and evaluating outcomes by race and other critical dimensions of difference; and
• are coordinated within our community, linking multiple agencies that offer care to young families.