Addressing the infant mortality crisis in Ohio remains one of our top priorities at The Center for Community Solutions, as an avenue to improving public health. Infant mortality is defined as the death of an infant before their first birthday. Community Solutions has dedicated the last several years to improving Ohio’s outcomes for both birthing people and their children through our research and advocacy on the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), advocating for and spreading awareness about Medicaid’s 12 month postpartum expansion and elevating the importance of increasing and diversifying the perinatal workforce.

The Ohio Department of Health (ODH) recently released the 2020 Infant Mortality Annual Report of the state. This report outlines infant mortality rates by a myriad of measures including geography, race, ethnicity, and cause of death. This report is critical because babies and birthing people are the most vulnerable groups in our society; their health conditions determine our collective status in public health compared to other nations. Moreover, babies are the next generation that will shape our society through economic and cultural priorities.

Black infants are 2.7 times more likely to die than white infants.

Infant mortality decreased, but racial disparities remain

The statewide infant mortality rate decreased slightly from 6.9 per 1,000 live births in 2019 to 6.7 per 1,000 live births in 2020. Even though there was a decrease in Ohio’s infant mortality rate, racial disparities still remain.

Black infants are 2.7 times more likely to die than white infants. The infant mortality rate for Black infants was 13.6 per 1,000 live births compared to 5.1 per 1,000 live births for white infants.
The neonatal mortality rate for white infants was 3.4 per 1,000 live births and 8.9 per 1000 live births for Black infants. Black infants experienced a higher postneonatal mortality rate at 4.7 per 1,000 live births whereas white infants had a rate of 1.6 per 1,000 live births.

Leading causes of death for infants in Ohio

Additionally, ODH reported the leading causes of death for all infants in the state. The following shows the percentages of the leading causes of death for babies:

prematurity-related conditions: 29%
congenital anomalies: 20%
external injuries: 10%
sudden infant death syndrome (SIDS): 8%
obstetric conditions: 7%
perinatal infections: 4%
other infections: 3%The report ranked the top five causes of death by race and ethnicity in 2020. The top two causes of death for white infants were congenital anomalies and prematurity related conditions. For Black babies, prematurity related conditions and obstetric conditions are deemed at the top causes. The top causes for Hispanic babies were prematurity related conditions and congenital anomalies compared to prematurity related conditions and congenital anomalies for non-Hispanic babies. In addition, racial disparities exist in the top causes of death. Compared to white babies, Black babies were over three times more likely to die from prematurity related conditions. Sadly, Black babies were more likely die from each cause of death.

Geography’s role in infant and maternal health

As part of an effort to identify trends and gaps by region, ODH provided the average infant mortality rate by county over the previous five years (2016-2020) as seen below. Community Solutions took this data and overlayed it with the March of Dimes 2020 Maternity Care Deserts Report which identified, by county, where there is no or limited access to maternity care. As noted below, there are several counties, predominately in parts of the state known to be rural where the data was suppressed due to small numbers of deaths.

5-year infant mortality rate by Ohio County (2016-2020)

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Sources: (1) Infant Mortality Rates come from the Annual Infant Mortality Report from the Ohio Department of Health: https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/infant-and-fetal-mortality/reports/2020-ohio-infant-mortality-report (2) Maternity Care Deserts as reported by the March of Dimes https://www.marchofdimes.org/research/maternity-care-deserts-report.aspx (3) Maternal Vulnerability Index as reported by Surgo Ventures https://mvi.surgoventures.org/ [/caption]

Of the 14 counties considered to be maternity deserts in our state—having no hospitals providing obstetric care, no birth centers, no OBGYNs and no certified nurse midwife—nine of them had infant mortality data that was suppressed due to small numbers and the remaining five had some of the lowest averages in the state. While one may conclude from the map that rural areas don’t struggle with infant mortality at the same rates are their urban counterparts, this may not necessarily be the case. The CDC has previously concluded that infant mortality rates decrease as urbanization levels increase. This can be seen on the map when looking at the infant mortality rates in counties surrounding large metropolitan areas such as Lorain and Medina which border Cuyahoga County; Delaware and Licking which border Franklin County and Clermont; and Warren which borders Hamilton County. The infant mortality rates in rural Ohio counties with maternity wards are still facing challenges urban and suburban counties are not and are best explained by their greater socioeconomic disadvantage and limited access to health care.

Previously we have written extensively about Surgo Ventures Maternal Vulnerability Index which identifies not only where but why women in the United States are vulnerable to poor maternal health outcomes. While this tool focuses exclusively on maternal health, maternal and infant health go hand in hand as the challenges faced by birthing person can explain outcomes during and after birth for them and their infant. For this reason, we have pulled out key indicators in counties around the state using their tool that may also help to explain their infant mortality averages.

Birthing people who reside in a maternity care desert may receive little to no prenatal care due to the lack of providers in close proximity.

COVID-19's impact on infant and maternal health in Ohio

An important detail to note about the ODH report is that the numbers reflect up to the year 2020 when Ohioans had a very different approach to COVID-19. Vaccines were not widely available to the public at any point in 2020 and the impact the virus had on pregnant people and their children was unknown. ODH stated in the document that according to the Centers for Disease Control and Prevention (CDC), women who suffered from COVID-19 during pregnancy had an increased risk for negative neonatal and pregnancy outcomes such as preterm birth and newborns admitted into intensive care units.

In Ohio, 42 fetal deaths (stillbirths) and 7,126 live births were associated with maternal COVID-19 during pregnancy, also called a pregnancy-related infection (PRI). Twenty-one babies whose mother* had a PRI died during the neonatal period. Likewise, nine babies whose mother had a PRI passed away during the postneonatal period. Pregnancies that were connected to a 2020 PRI had a death rate of 5.9 per 1,000 pregnancies in comparison to the fetal death rate of 5.8 per 1,000 pregnancies for pregnancies not related to a PRI. This statistic is preliminary data, and it may increase when more data becomes available.

Improvements may be attributed to temporary COVID-19 related programming and Medicaid expansion

Since the beginning of the COVID-19 pandemic and subsequent Public Health Emergency, Community Solutions has provided updates on temporary programmatic changes enacted by both the state and federal governments that allow individuals and families to make sure their basic needs are met during unprecedented times.

Among these have been the inability of the state to redetermine eligibility and therefore disenroll individuals from Medicaid as part of an agreement to continue receiving increased resources from the federal government. While approximately two-thirds of pregnant people who qualify for Medicaid during pregnancy also qualify for Medicaid after the 60-day cut off post birth,** that still leaves about one-third of new birthing parents without coverage at any given time. Over the past 2.5 years, however, this has not been the case as the only way to get removed from the program was if a beneficiary requested removal, the beneficiary moved out of state (in which case, if they remain income eligible, they can likely reenroll in their new state), or the beneficiary dies.

Traditionally, Medicaid coverage for children has a higher income threshold than for adults, but research shows that expanding Medicaid for parents improves coverage and health for both parents and children. Insurance coverage is also associated with higher rates of primary and preventive care which are crucial to avoiding post-neonatal infant deaths (28 days – under 1 year).

Research continuously demonstrates the negative effects of food insecurity on maternal and infant health.

Additionally, many temporary changes to nutrition programs were enacted to combat rising food insecurity after the pandemic induced loss of 9.6 million jobs. This included but was not limited to the introduction of a Pandemic Electronic Benefit Transfer (P-EBT) program which provides additional funds to families with kids for missed school meals, Supplemental Nutrition Assistance Program (SNAP) Emergency Allotments which brings every SNAP household to the maximum benefit and the waiving of many administrative barriers that keep people from accessing programs in the first place.

Research continuously demonstrates the negative effects of food insecurity on maternal and infant health. When a pregnant person is food insecure, they are at an increased risk of depression as well as unhealthy weight gain and gestational diabetes. Food insecure parents also can struggle with breastfeeding which has long been considered a key strategy to combat infant mortality. Additionally, infants exposed to food insecurity in utero are more likely to experience negative health outcomes that lead to increased likelihood of death including anencephaly, an increased risk of vertical HIV transmission from pregnant person to child and low birth weight. Further, in addition to combatting food insecurity, new studies indicate SNAP is also a tool that can prevent child abuse.

First snapshot into maternal and infant health since the pandemic

In many ways, the 2020 Infant Mortality Annual Report serves two purposes for Ohio’s public health experts and advocates alike: a snapshot into the state of maternal and infant health since the COVID-19 pandemic began and whether current initiatives and programming by the DeWine Administration to tackle poor infant and maternal health outcomes have been successful.

Unfortunately, this report is the only piece of public data that exists from the state on infant and maternal health outcomes since the pandemic began. This is despite the fact that in the State Fiscal Year (SFY) 2020-2021 Operating Budget, Community Solutions successfully advocated for the Pregnancy-Associated Mortality Review (PAMR) Board to be codified into the Ohio Revised Code, making the Board’s biennial report mandatory. Still, a public maternity mortality report has not been released by the Ohio Department of Health since 2019, with the most recent deaths reviewed being from 2016. Now more than ever does the public need access to timely, relevant data as evidence is needed to not only target resources but to assess the impact of the COVID-19 pandemic on birthing people and their babies.

A public maternity mortality report has not been released by the Ohio Department of Health since 2019.

Looking ahead

Community Solutions will continue advocating on the local and state levels for the inclusion of strategies we have identified through our data and research that will improve Ohio’s infant and maternal health outcomes. This includes expanding and diversifying the professional and ethnic makeup of the perinatal workforce. Research continues to show that pregnant people and their babies, especially those of color, with low-risk births have better outcomes when they are engaged in relationship-based care with provider-patient race concordance, that is, when the provider and patient have race in common. For Ohio to integrate the non-traditional perinatal workforce into the normal course of care, we must consider the regulatory barriers keeping people out of the profession which in turn make them difficult for expecting families to access them. Ohio’s legislature currently has two opportunities to do just that before the end of the 134th General Assembly at the end of the year. House Bill 142 is a bipartisan bill that establishes a pathway for Medicaid reimbursement for doula services as well as a state registry for certified doulas and a Doula Advisory Board.

House Bill 496 is also an opportunity to bolster the perinatal workforce, especially considering the number of maternity deserts in our state

House Bill 496 is also an opportunity to bolster the perinatal workforce, especially considering the number of maternity deserts in our state. House Bill 496 would regulate the practice of non-nurse midwives in our state by creating a licensing pathway that recognizes the certifications that already exist in the field and maintaining much of the autonomy that attracts individuals to midwifery in the first place. We also seek improvement on data collection on mortality and morbidity for both pregnant people and their children. This data exists by nature of federal and state requirements, however public access to timely, relevant, and disaggregated data by key demographics including county, race and ethnicity remain abysmal. We are hopeful the state and key trade associations also recognize this need as public health officials and advocates continue monitoring outcomes.

* Although we at Community Solutions use the terms ‘women’ and ‘mothers’ here and in our previous writing due to how the data is reported, we acknowledge and recognize that not everyone who carries a pregnancy refers to themselves this way. We respect the diversity of all birthing people.

** During the 2022-2023 state budget, the Ohio Legislature opted into providing 12 full months of Medicaid coverage for beneficiaries who have given birth.

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