Multiple births, sexually transmitted diseases and other infections are to blame for the 35.8 percent increase in infant mortality among African-Americans in the Baltimore area last year, according to a state investigation being released this morning.
Through different routes, each of these can cause premature delivery, which in turn can lead to death.
The lungs of these babies may not work well, their skin is so thin they may contract infections, or the fragile blood vessels in their brains may hemorrhage.
The investigation was prompted by the sharp increase in deaths of black babies in the Baltimore area, from 12.9 per 1,000 live births in 1996 to 17.6 per 1,000 births in 1997.
Although the figures refer to deaths of babies from causes other than trauma in their first year, investigators traced almost all of the increase to deaths in the first month.
During the same period, the death rate for white infants in the metropolitan area declined slightly, from 5.9 per 1,000 births in 1996 to 5.8 in 1997.
Doctors said that many of the 45 additional fatalities among African-American infants in their first month could have been prevented by aggressive screening and treatment, or by reducing the number of fetuses in multiple births.
Many of the babies were unplanned. Their mothers didn't know they had infections, or they didn't get prenatal care.
"It comes across clearly here that the babies are coming to birth with a number of strikes against them," said Dr. Ira Gewolb, division chief of neonatology at University of Maryland Medical Center.
Health officials were especially surprised to discover the impact of fertility treatments -- and the corresponding number of triplets, quadruplets and higher-order births.
Among African-Americans in the Baltimore area, the number of these cases rose from 19 in 1996 to 40 in 1997.
"That was a big surprise. I never would have guessed that," said one of the study's authors, Dr. Russell Moy, director of the Office of Maternal Health and Family Planning at the state Department of Health and Mental Hygiene.
The report found that a third of the multiple births were conceived with the assistance of fertility therapy. Investigators suspect that more of the mothers got fertility treatment, but that information was missing from medical records.
The higher the number of fetuses a woman carries, the higher the risk of early delivery and its attendant problems.
Nationwide, there was a 20 percent increase in higher-order multiple births between 1996 and 1997. Along with that, doctors said, more African-American women may be seeking fertility treatment.
One possible explanation for the rise in deaths may be cuts in insurance coverage for fertility services, said Dr. Eugene Katz, director of the Greater Baltimore Medical Center's fertility center.
GBMC, the area's largest fertility center, hasn't seen an increase in multiple births among African-Americans, Katz said. But he suggested that perhaps the explanation for the increased deaths lies in insurance cutbacks that cover only one in-vitro fertilization attempt, where "both physician and patient are forced into more aggressive treatment."
That means implanting more embryos and may result in a higher number of babies.
About a third of in-vitro births are multiple.
In any case, the Baltimore-area deaths are a cautionary note for women -- and the physicians who treat them -- about getting pregnant at any cost, without considering the potentially fatal risks to the babies, said Dr. Frank R. Witter, director of labor and delivery at Johns Hopkins Hospital.
Sexually transmitted diseases were another major factor in the rise in infant deaths. These conditions include chlamydia, syphilis, gonorrhea, Group B strep and bacterial vaginosis.
For some diseases, such as syphilis, state law requires every pregnant woman to be screened. In other cases, such as bacterial vaginosis, universal screening is still being debated.
African-American women have a higher incidence of these infections, as well as such chronic conditions as gestational diabetes and hypertension, said Dr. Bernard Guyer, outgoing chairman of the Maryland Commission on Infant Mortality Prevention and a professor of maternal and child health at Johns Hopkins School of Public Health.
These infections can also lead to chorioamnionitis, an inflammation and infection of the membranes around the fetus. Investigators said this was a factor in about a quarter of the infant deaths.
Most of these conditions can lead to premature birth. But doctors say that, mostly, this doesn't have to happen.
"The vast majority of STD-related infant mortality cases should be able to be prevented through early detection and treatment," said Dr. Peter Beilenson, city health commissioner. In response to the findings, state health officials are going to educate doctors and midwives to do more aggressive screening and treatment of infections and sexually transmitted diseases.
Doctors also want to reach women. According to hospital medical records, postpartum family counseling and services, particularly important for these women, were offered to only about 45 percent of the women studied.
Because so much information was missing from records, Moy said his office also plans to require hospitals to review their birth and death certificates and be held accountable for filling them out completely and accurately.
For instance, chorioamnionitis was implicated in 24 percent of the deaths. But the diagnosis appeared on the death certificate in just eight cases, even though a review of pathology and clinical notes showed the condition was significant in many other cases.
Health officials also want to establish a "multifetal pregnancy" pilot project, to heighten awareness among doctors and consumers about the dangers associated with multiple births. There are plans to set up support groups for parents expecting triplets or quadruplets.
But perhaps the biggest obstacle is figuring a way to bridge the gulf between African-American women and the places they go for health care, said Dan Timmel, Maryland's coordinator of Fetal and Infant Mortality Review, a federal program.
Roughly 21 percent of the cases showed late or no prenatal care at all. Officials suspect the proportion may be much higher, since this element was the most poorly completed field in both the birth certificate and medical records.
"Prenatal care is available," Gewolb said, referring to Medicaid and the new state health insurance program for women and children.
"If they're available and people aren't using them, what can we do to win the hearts and minds of people so they come?"
Pub Date: 11/13/98