GBI Special Agent Trebor Randle remembers a particularly tough day that she had early last month. The Labor Day weekend was over, and there were three babies in the morgue requiring autopsies.
When an infant dies, the Georgia Bureau of Investigation steps in with a forensic investigation. That includes an autopsy and a medical report, as well as a close look at the death scene.
“We need to know exactly what happened to be able to prevent future unexplained deaths of infants,” says Randle, the investigator in charge of Georgia’s Child Fatality Review Unit.
These reviews have been done in Georgia since 1990, and since last year they have been administered by the GBI.
Working such a case is an especially sad duty.
“We have to deal with a parent who has just lost a child,” says Randle, “and that’s very difficult.”
Investigating individual fatalities is part of a multipronged strategy to lower the number of infant deaths in Georgia, The state historically has had a high infant mortality rate.
The GBI’s information-gathering role is to try to learn what happened in each case and help prevent infant deaths. “One thing we see are too many unsafe cribs,” she says.
A lot can go wrong
Causes of unexpected deaths of sleeping babies run the gamut. Some children are suffocated by overly soft bedding that envelops there noses and mouths. Some die in “overlay” incidents, meaning that a parent sleeping in the same bed as the infant accidentally rolled over onto the child.
Some babies die when they become wedged, or “entrapped,” between objects that are too hard for their fragile bodies. Some suffer accidental strangulation, when their heads get caught between crib railings and their breathing is cut off.
In addition to accurate identification and reporting of infant and child fatalities, the GBI is training other professionals across the state. Working with community partners, the GBI reaches out to local law enforcement agencies, local coroners and Georgia’s Division of Children and Family Services.
“One of many tools we use to help with these emotional situations is our child death re-enactment doll,” says Randle. It’s used in all sleep-related death investigations in Georgia. “The doll weighs about eight pounds, and is built in such a way that allows agents to re-enact what happened.”
Having to go through a re-enactment of the fatal event is generally painful for the parent or caretaker. But for law enforcement, it’s a critical part of understanding what happened, Randle explains.
Co-sleeping, the practice of adults and infants sharing beds, has long been recognized as a cause of childhood fatalities. But it still goes on, with many well-meaning parents unaware of the danger.
“Unfortunately, co-sleeping accidents still happen, and they’re a terrible tragedy,” Randle says.
Born too soon?
“Infant mortality has been a serious Georgia problem for decades,” says the state’s commissioner of Public Health, Dr. Brenda Fitzgerald.
But there has been progress. In fact, Georgia’s infant mortality has decreased 48 percent since 1990, Fitzgerald says.
“As we addressed low birth weight and sudden unexpected [or unexplained] death, we changed Georgia’s 44th place among the states in 2012” to 31st today, says Fitzgerald.
Low birth weight is usually related to preterm birth, often called premature birth. And preterm babies tend to have worse health than babies who were carried to term.
In a review of Georgia’s data for 2002 to 2006, disorders related to short gestation periods and low birth weight stood out as the leading causes of infant mortality, Fitzgerald said. When she and other experts considered these statistics, they looked for positive changes that could be made.
The issue of early delivery
One problem the experts found was the number of “early elective deliveries,” decisions to deliver babies early for non-medical reasons, says Fitzgerald.
The average human pregnancy is about 40 weeks. Some of the elective deliveries have been carried out before 39 weeks.
Infants born at 37 or 38 weeks have long technically been considered born “at term,” even if a little earlier than average. But studies in recent years have shown that these infants could be at risk because of the shortened pregnancy.
The time from Week 37 to Week 39 is now considered critical to the baby’s development in the womb, Fitzgerald says.
“Clinical evidence shows that a fetus goes through a significant amount of development and growth in several key organ systems [including the brain] between 37 and 39 weeks of gestation,” explains Fitzgerald. And infants born prior to 39 weeks face a 20 percent greater risk of significant medical consequences, according to NIH.
As recently as 2009, 65 percent of the babies in Georgia were delivered by early elective surgery, and that was one thing that needed to change, health officials concluded.
Working with Georgia physicians in a variety of ways, such as seminars, conferences, and continuing education, the state has been able to turn around the number of elective deliveries.
Today, the number of early elective deliveries in Georgia is under 1 percent, and for the past 21 months, the number has remained below the national average of 2 percent, says Fitzgerald.
Public Health’s efforts haven’t prevented every birth problem. Congenital malformations, deformities and other abnormalities are not necessarily preventable through current methods. “We probably can’t make those things better,” says Fitzgerald.
But she adds, “What we are doing in Georgia, is continuously looking at things that we can fix. And there’s still plenty of work to do.”
Other tactics in improving birth outcomes include community-based home visitation programs for at-risk newborns, tobacco cessation programs for women, baby-friendly hospital programs, and business breastfeeding initiatives.
Birth before 37 completed weeks of pregnancy, preterm birth, costs the United States more than $26 billion annually, according to an Institute of Medicine 2006 report. Prolonged hospitalizations and neonatal stays in intensive care contribute to this enormous expense, says Dr. Melissa Kottke, Associate Professor of Gynecology and Obstetrics at Emory University.
“We also know that prematurity and low birth weight are major risk factors for infant mortality,” says Kottke.
In 2013, more than 16,000 babies were born prematurely in Georgia. That was almost 13 percent of all the babies born that year , Kottke notes.
“What many don’t know is that women who experience a premature delivery the first time are three times more likely to have a subsequent preterm birth than women who carried to full term ,” Kottke says. “Plus having births really close together is also linked to prematurity, low birth weight and infant mortality.”
Georgia’s recent approach to achieving an effective reduction in infant mortality offers strategies to reduce premature births, says Kottke.
One idea that is being tried is contraception for new mothers, so the women will not become pregnant again sooner than they wish. Research and credible data suggest that implanting an IUD immediately after delivery not only means better child spacing for the parents, but also fills an important gap in postpartum contraceptive needs.
Kottke, who also directs Jane Fonda’s Center for Adolescent Reproductive Health, says “women may be at risk for pregnancy and may not be able to access the birth control they need.”
Doing this under the Medicaid program required some administrative changes. “First, we had to ‘unbundle’ Medicaid to change the situation,” says Fitzgerald.
Kottke explains: “At the time, there was one global reimbursement for pregnancy and delivery.” In order for hospitals or clinicians to be reimbursed for the device and its placement, that system had to change.
“In 2014, Georgia joined South Carolina, New Mexico, Colorado and Iowa as early adopters of this innovative and important practice,” says Kottke.
“Medicaid was supportive and excited about the potential this had to impact families in Georgia,” she says, “as they worked on fixing the problem with us.”
Today, 13 states have final or proposed guidance regarding reimbursement for postpartum contraception programs, according to the American Congress of Obstetricians and Gynecologists.
“This particular medical procedure wouldn’t have been paid for outside of the reimbursement for the delivery itself. So this recent policy change lifted a huge financial burden off our state and offered a clinical service that was convenient for women and their providers,“ says Kottke.
“I look forward to seeing Georgia’s trend continue and outcomes improve for our mothers and infants,” Kottke adds.
Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.