Missouri is a leading state for infant mortality. What can be done to curb it?
Health care leaders and researchers are exploring why the number of babies who died less than 12 months after birth in Missouri jumped 16% last year.
In 2022, a total of 68,985 births and 467 infant deaths were reported in Missouri, an increase from 69,453 births and 406 deaths the year before, according to the Centers for Disease Control and Prevention.
The increased rate is one of the highest among the states. Only three other states experienced a significant jump in infant deaths, according to the CDC.
Nationally, infant mortality increased by 3% during that time. It was the first year-to-year increase nationally in two decades.
While the increase in Missouri infant deaths may be alarming to some, provisional numbers from the Missouri Department of Health and Senior Services show that the state’s infant mortality rate in 2022 was the highest it’s been since 2016 and has been declining for years.
“From a historical standpoint, Missouri has consistently been higher,” said Martha Smith, DHSS Missouri maternal child health director. “Missouri rates for infant mortality have consistently been higher than national rates for at least the past decade.”
Still, the trend has caught the attention of state leaders.
“Frankly, it is embarrassing and absolutely unacceptable for us to be failing in this area,” Gov. Mike Parson said during his 2023 State of the State address. “If we can’t get it right for our mothers and children across our state, we might as well pack our bags and let someone else occupy these seats.”
Missouri does not have a statewide fetal and infant mortality review, although there are “local processes” to review cases in the Kansas City and St. Louis metro areas, Smith said. Data from those local efforts isn’t shared with the state.
Smith told the Missourian that to make sure state data is being compared properly, it is vital to make sure data collection uses the same methodology for data collection and analysis.
“While the increase in infant deaths between 2021 and 2022 is concerning, annual observed rates may fluctuate dramatically, and year to year fluctuations need to be interpreted with caution,” Smith said.
Maternal complications and bacterial sepsis were among the reasons for infant fatalities, with the largest increase nationally. Although Missouri-specific data has yet to be released, Smith said there was a 42% increase from 2021 to 2022 in “accidental deaths.”
“We are seeing a significant increase in Missouri in fentanyl poisonings in our infants and young children, and that may have contributed to our increase in infant mortality,” Smith said. “Unsafe sleep is also a significant contributor to infant mortality.”
To get a fuller picture of the alarming rates of infant mortality, Smith said researchers need to take it a step further to understand the issue and better brainstorm solutions.
While numbers do tell a lot, Smith and other community members attributed the high infant mortality rates to factors only discovered through qualitative research.
“(Factors include) the overall social determinants of health, such as access to nutritious food, access to playgrounds or areas to exercise, access to quality child care so that parents can go to work,” said Karen Florio, a maternal-fetal medicine specialist and OB/GYN at MU Health Care. “I think that all of those things play into the rising mortality rates of both infants and moms.”
Accessible health care issues
Missouri could look to other states or countries to find possible solutions, Florio said. For example, in Costa Rica, the health care system works by “tiering up” care, prioritizing patients based on the severity of their medical issues.
“Those people (who are) considered low risk can stay within their communities with their family practice doctors or midwives, and those that are a little more high risk — people that have comorbidities — they get sent up to the next level of care,” Florio said. “I think that if we start looking at our state in a way that other places provide care, we would have a lot better outcomes.”
While multiple factors contribute to the infant mortality rates in Missouri, Florio said accessible health care and financial burdens are undeniable contributing reasons, stating that some people have to choose between rent and medicine.
Barriers to health care were “exacerbated in the post-COVID era,” Florio said, and data has shown that post-COVID vaccination rates have decreased, another factor she believes to be important.
Benefits of at-home visits
Brighter Beginnings is a “collaborative of home visiting, social service, and health care providers” that assists pregnant families throughout Boone County, according to its website.
Brighter Beginnings has a focus on racial disparities in birth and other childhood outcomes, an issue reported in the current CDC data, according to a Columbia/Boone County Public Health and Human Services news release.
Nationally, American Indian and Alaskan Native populations had the highest percent increase in infant mortality rates, rising 21% from 2021 to 2022. In Missouri, the rate of infant mortality in the same time frame for white infants increased by 18%, according to Smith.
Despite this, Black infants remained the group with the highest infant mortality rate, with a 3% increase from the year before nationally and an 8% increase in Missouri.
“Some of our project objectives have been to increase the number of Black and African-American families that participate in home visiting and increase the number of prenatal families that participate also in home visiting,” said Kelly Scheuerman, social services program coordinator for the organization.
But, why home visiting?
Studies have shown that home visits by nurses are “a promising means of reducing all-cause mortality among mothers” and “preventable-cause mortality in their firstborn children living in highly disadvantaged settings.”
“Home visiting can help overcome some of those disparities with people getting access to what they need and improving those early childhood outcomes for children to be ready for kindergarten readiness,” Scheuerman said.
Advocacy groups like Kids Win Missouri work on ways to increase access to evidence-based home visits that would ideally start prenatally and continue through delivery and postpartum.
“It’s just another way to really help provide that more social safety net support and a way to help parents connect to the resources that they need to be able to better support their infant in that time,” said Casey Hanson, deputy director of Kids Win.
Scheuerman hopes that the negative stigma around home visits can dissipate in the coming years, stating that they do not always happen at the patients home.
“We meet them where they’re at and where they’re most comfortable,” she said.
Brighter Beginnings is a free service and operates as a single point-of-entry referral and intake system to connect families to resources that fit them.
Scheuerman shared that the majority of the referrals are from health professionals, stressing the importance of “trusting relationships.”
Florio, who serves as the chair of Missouri Perinatal Mortality Board, found through the board’s research that patients still overwhelmingly have trust in their doctors, even though some research casts doubt on that trust. She encourages health care providers to communicate with their patients now more than ever.
“There is trust within the Black and brown communities that we didn’t think was there, but we actually know is there,” Florio said. “It’s really important for health care providers to have those discussions about healthy food, to have those discussions about the importance of vaccinations, to have those discussions about home visiting because patients trust their health care providers. We have seen that in the data.”
The importance of policy
Over 40% of births in Missouri are from mothers on Medicaid, according to Hanson, and the Missouri Perinatal Mortality Board found the bulk of maternal deaths happen to Medicaid patients, Florio said.
Advocacy groups and health care providers lobbied with legislators to extend the state’s postpartum care beyond 60 days. In July, state legislation expanded postpartum Medicaid coverage to one year.
“I think a lot of the solutions are reliant, to be frank with you, on some level of policy change or investment,” Hanson said.
Florio agrees from a medical standpoint, stating that policy change is “incredibly important,” and advocacy groups, legislators and health care professionals banding together is vital.
“We can’t do what we do without the lawmakers joining arm and arm with us and helping support our initiatives,” Florio said.
As part of Parson’s state-funded $4.3 million plan to curb maternal mortality, the Missouri Department of Health and Senior Services is working on a maternal-child health dashboard that will make maternal and infant health rates publicly available. Smith anticipates seeing “at least the first iteration” of the dashboard in the next six to 12 months.
Smith emphasized the agency’s focus on “working through the voices of lived experiences,” shifting the spotlight to the women affected most by the subject.
This focus includes training mothers in leadership positions where they will learn skills about ways to talk to policymakers and be better informed to “lead the charge.”
“We want to help find solutions, and it may not be the Department of Health that will be responsible for leading the charge on every single one of those,” Smith said, “but we can play a role in ensuring that the entity or entities that do need to be leading and that everybody who needs to be at the table is at the table.”