Infant mortality rates (IMRs) can be seen as reflections of a given society's commitment to ensuring access to health care, adequate nutrition, a healthy psychosocial and physical environment, and sufficient income to prevent the adverse consequences of poverty.
Sara Shields, M.D., M.S.
Sadly, our nation has a lot of work to do in these areas. The United States ranks as the seventh-richest country in the world(www.forbes.com) based on gross domestic product per capita. But, despite the fact that we spend $2.7 trillion a year on health care, the United States does not even crack the top 20 among industrialized nations when it comes to healthy babies.
A government advisory panel has made preliminary recommendations for a new national strategy to reduce IMRs. Family physicians can, and should, have a significant role in this major public health issue.
The IMR (i.e., the number of deaths that occur during the first year of life per 1,000 live births) is a widely used proxy for the health status of a nation. Progress has been made in reducing the U.S. infant mortality rate, with the most recent IMR at 6.4 in 2009. Although that is a historically low rate for the United States, it still leaves our country ranked 24th in infant mortality compared with other industrialized nations, according to information in the CDC's National Vital Statistics Reports(www.cdc.gov).
Moreover, inequality persists, with substantial and persistent racial/ethnic and income disparities reflected in the IMR. Family physicians who provide primary and longitudinal health care for women and families, often in the country's most needy communities(www.annfammed.org), play a critical role in improving IMRs generally and for these vulnerable populations.
In June 2012, HHS Secretary Kathleen Sebelius made a commitment to the development of the nation's first national strategy to reduce infant mortality. The Secretary's Advisory Committee on Infant Mortality (SACIM) has made recommendations for defining and implementing an official federal action plan. Most of these recommendations resonate with what we already do as family physicians.
To guide the national strategy to reduce the IMR, SACIM defined a set of core principles that reflect much of the philosophy of family medicine, calling for action steps that aim to reduce infant mortality to
- reflect a life course perspective;
- engage and empower consumers;
- reduce inequity and disparities and ameliorate the negative effects of social determinants;
- advance systems coordination and service integration;
- protect the existing maternal and child health safety net programs;
- leverage change through multisector, public and private collaboration; and
- define actionable strategies that emphasize prevention and are continually informed by evidence and measurement.
In addition to these principles, SACIM proposes six strategic directions(www.hrsa.gov) to address infant mortality, most of which involve services family physicians can deliver directly.
The first three of these strategic directions focus on ensuring that care is comprehensive, safe and effective, patient-centered and evidence-based.
Improve the health of women before, during and beyond pregnancy. Family physicians have long advocated that preconception care should be improved(www.cdc.gov), particularly for women with underlying medical issues that may affect pregnancy.
The Patient Protection and Affordable Care Act (ACA) has made clinical preventive services for well-woman care(www.hrsa.gov) more broadly accessible; these services include preconception care. Family physicians remain an important source of women's primary health care, providing about 20 percent of the nation's well-woman preventive health visits(www.stfm.org) before the ACA. In addition, although fewer family physicians are doing maternity care than previously, those who do are more likely than obstetricians to provide prenatal care to women at high risk for infant mortality -- women who are younger, live in rural underserved areas, or have Medicaid insurance(www.annfammed.org).
Ensure access to a continuum of safe and high-quality, patient-centered care. Quality care is safe, timely, effective, efficient, equitable and patient-centered; access to care demands sufficient primary care sites and practitioners distributed appropriately throughout the country. Family physicians are critical to the expansion of community health centers called for by the ACA.
In addition, the work that many family physicians are doing to develop and maintain quality-oriented patient-centered medical homes (PCMHs) fits with this strategic direction. These primary care medical homes need to integrate with maternity medical homes to include the most vulnerable women and infants. Family physicians also have been at the forefront of one innovative care model to improve patient-centered access -- group visits for both pregnant women and for well-infant care. Family physicians also can lead models that incorporate well-mother care to address unmet postpartum needs across the continuum of the early infant years because they have the training to address both infants' and women's health needs.
Redeploy key evidence-based, highly effective preventive interventions to a new generation of families. Breastfeeding, family planning, immunization, smoking cessation and safe sleep practices are proven, effective interventions for reducing infant mortality, but the national goals for rates of childhood immunization or exclusive breastfeeding continue to be elusive, particularly for the neediest populations. Family physicians provide about 15 percent of all well visits for children younger than age 2, during which these interventions can be addressed for both infants and parents. Incorporating interconception care for mothers into well-child visits can work especially seamlessly for family physicians.
In addition, family physicians are the only medical professionals who care for both partners of the breastfeeding dyad and, thus, are especially important in the ongoing promotion of this particular preventive care strategy. Innovative approaches to marketing public health messages to a new generation are needed to maximize their effectiveness in changing health behaviors. Family physicians trained in motivational interviewing and interdisciplinary work with behavioral health professionals are especially poised to affect prevention strategies that are about behavior changes.
Increase health equity and reduce disparities by targeting social determinants of health through both investments in high-risk, under-resourced communities and major initiatives to address poverty. Combating the striking health disparities in infant mortality will require comprehensive, community-based initiatives that increase access, opportunity and resources in high-risk areas. Family physicians work in these underserved areas and, thus, see upfront the effects of poverty and social determinants on maternal health and other indicators. Family medicine training has long included awareness of the wider context of the social determinants of health and strategies to involve communities beyond the traditional medical approaches. Family physician leaders who are involved in other programs to address health equity, such as the Institute of Medicine's work in this area(www.nap.edu), should remember to include infant mortality reduction as a specific goal.
Invest in adequate data, monitoring, and surveillance systems to measure access, quality and outcomes. At the national, state and local levels, data about maternal and child health outcomes often are delayed or incomplete, hampering the ability of both public health experts and primary care professionals to understand what interventions may be most effective for reducing infant mortality. Family physicians who work with local or regional quality or research collaboratives can emphasize the need for such surveillance.
Family physicians also can work to join or expand practice-based research networks that specifically address maternal and infant health, such as the Interventions to Minimize Preterm and Low Birthweight Infants through Continuous Improvement Techniques (IMPLICET) network in the mid-Atlantic and New England regions, which, since 2003, has collaborated to study quality improvement techniques to improve prenatal care practices that can reduce preterm birth rates.
Maximize the potential of interagency, public-private and multidisciplinary collaboration. In this age of government cost-cutting, integrating across diverse agencies to promote prevention and health without unnecessary duplication of services is critical. Thus, emerging national prevention strategies need to incorporate IMR reduction strategies. Family physicians involved in preventive care, long a hallmark of excellent primary care, are essential to this sort of integration of public health and primary care. Family physicians can help promote collaboration across disciplines, including by collaborating with childbirth educators, nurses and doulas.
Finally, this strategy calls for engaging women across generations so that mothers and grandmothers are part of the solution. Family medicine's longitudinal role with families provides a unique opportunity for such patient-centered multigenerational work.
The closing words of the SACIM's recommendations(www.hrsa.gov) evoke many of the essential principles of family medicine and can serve to inspire our discipline to help lead the charge to achieve this critical health outcome.
"SACIM believes in the vision of the United Nations 'Every Woman, Every Child' campaign: each nation should aim to ensure that every woman and every child have the same opportunities for health and life. We know that the first years of life lay the foundation for an individual to be healthy and thrive across the life course. Families, communities, states and the federal government must work together to optimize the potential of every child. A nation as wealthy as ours can and should commit to ensuring medical, economic and social support to families sufficient to allow every baby to be born in optimal health and to enter the world wanted and loved. Anything less would fail to achieve significant and lasting improvement."
Sara Shields, M.D., M.S., is a member of the HHS Secretary's Advisory Committee on Infant Mortality and a clinical professor of family medicine and community health at the University of Massachusetts.