Date post: | 03-Jan-2016 |
Category: |
Documents |
Upload: | ashlynn-higgins |
View: | 212 times |
Download: | 0 times |
August 2003
Perinatal Periods Of Risk
From Data to Action to Improve Women and Infants’ Health
A CityMatCH “How-to-Do” Workshop
August 2003
The “How to Do” PPOR Workshop will provide participants with the opportunity to:
1. Recognize and understand all components of the PPOR Approach
2. Assess “Analytic and Community readiness”3. Achieve a common understanding of what it takes
to conduct the first phase of analysis4. Learn how to shift focus from PPOR data to using
PPOR Approach for systems change
August 2003
Infant Mortality Rate,Urban County, 1990-2001
0
5
10
15
20
25
30
90 91 92 93 94 95 96 97 98 99 00 01
TotalWhite*Black
* White rate for 2001 is provisional
Source: DHHS
August 2003
2001 Infant Mortality Rate,Urban County vs. State
Source: DHHS
* Questionable due to small numbers
August 2003
Why Do We Need Another Way to Look at Infant
Mortality? Most current approaches do not
always identify gaps in community resources. Most current approaches do not target resources for prevention activities. Most current approaches do not use locally determined benchmarks to define disparities
August 2003
PPOR: From Data to Action
PPOR: From Data to Action
August 2003
PERINATAL PERIODS OF RISK PRACTICE COLLABORATIVE: 13 Participating U.S. Cities, 2000 - 2002
Baltimore ColumbusDurham
JacksonvilleKansas CityLouisvilleNashville
New HavenOrlando
PhiladelphiaPhoenixRaleigh
St. PetersburgPPOR-PC Partners
August 2003
PPOR – 2000-2002 Practice Collaborative
Our purpose was to determine and describe, together, the best practices in using the Perinatal Periods of Risk approach as a tool to improve maternal and infant health in communities… and, when necessary, to further develop, modify and strengthen the approach for its best use.
August 2003
Adding Adding new toolsnew tools to help solve to help solve
some very old problems some very old problems
Translating data intoTranslating data into actionaction
ChangingChanging the way we do the way we do
businessbusiness
“PPOR” is about :
August 2003
Headline News…Locally-defined disparities serve to target
further investigations and tailor preventionPhiladelphia PA
Successful integration of PPOR, FIMR, Healthy Start yields better prevention of feto-infant deaths
Louisville KY
Stronger local/state partnership builds better
data capacity to address health disparitiesColumbus OH
State-level “Practice Collaborative” model promotes consistent best uses of PPOR in
urban areasJacksonville FL
August 2003
The Value-Add of PPOR:…..from Knowing to Doing
Builds data and epi capacity Promotes effective data use Strengthens essential partnerships Fosters integration with other key efforts Localizes assessment to action process Encourages evidence-based interventions Helps leverage resources Enables systems change for perinatal health
August 2003
Perinatal Periods Of Risk… a comprehensive approach
1) Bring community partners together to build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
3) Focus on understanding the overall fetal-infant death rate.
4) Look for “opportunity gaps” between different groups.
5) Target further investigations and actions on the gaps.
6) Mobilize for sustainable systems change.
August 2003
Needs Assessment
Strategies
Plan
Implementation
Monitoring
Evaluation
Investment
Readiness
PPOR: a Tool for Planning PPOR: a Tool for Planning
August 2003
Community Foundations Cyclefor Change
Conceptual Framework for the Perinatal Periods of Risk Approach
Planning Cycle for
Action
PPOR Connections
August 2003
August 2003
6 Basic Steps: Perinatal Periods of Risk
Approach1) Bring community partners
together to build consensus, support, and partnership.
August 2003
Community Readiness:From Concepts to Tools
Partnership Leadership Commitment Change
RAISING THE ROOF FOR PPOR:What Shape Is Your Tent?
August 2003
RAISING THE ROOF FOR PPOR:
What Shape Is Your Tent?
August 2003
Louisville
June 2001 December 2002
August 2003
Community Readiness:From Concepts to ToolsRAISING THE ROOF FOR PPOR: What Shape Is Your Tent?
Tool for engaging partners Tool for reaching consensus Tool for identifying joint
assets Tool for revealing critical
gaps Tool for developing strategy
August 2003
6 Basic Steps: Perinatal Periods of Risk
Approach1) Bring community partners together to
build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
August 2003
Use linked infant birth – death file
Include fetal deaths
Building the PPOR “Map”: What data do we use?
August 2003
Fetal development is part of a continuum that runs from conception to the 1st birthday.
Fetal deaths may have similar causes as infant deaths.
The determination of “fetal” versus “infant” death is based on judgment.
Why include fetal deaths?
Including fetal deaths increases analytic power..
August 2003
PPOR Map of Fetal-Infant Mortality:
What events are not included?
Fetal deaths that occur before 24 wks Fetal deaths weighing under 500 grams
Live births weighing less than 500 grams Spontaneous and induced abortions
August 2003
Developing the “Map” of Feto-infant Mortality:
Cluster Analyses Used the 1995-1997 US fetal death and
linked birth & infant death files Clustered by both underlying cause of
death category & maternal risk factors Used near consensus findings of 8
hierarchal cluster methods: Average, Complete, Centroid, EVM, Flexible, McQuitty, Single, & Ward
Compared results to theoretical model
August 2003
Developing the “Map” of Feto-infant Mortality
<1000 g
1000-1499 g
1500-2499 g
2500+ g
Fetal Deaths
Early Neonatal
Post neonatal
Late Neonatal
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15 16
August 2003
Developing the “Map” of Feto-infant Mortality
Age at Death
Birth
weig
ht
500-1499 g
1500+ g
Fetal (24 wks)
Neonatal
Postneonatal
1 2
4 5
3
6
August 2003
Perinatal Periods Of RiskFetal-Infant Mortality Map
500-1499 g
1500+ g
Fetal Death Neonatal
Post- neonatal
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
August 2003
From Data to Potential Action
Maternal Maternal Health/ Health/
PrematurityPrematurity
Maternal Maternal CareCare
Newborn Newborn CareCare
Infant Infant HealthHealth
Preconceptional Health Health Behaviors Perinatal Care
Prenatal Care High Risk Referral Obstetric Care
Perinatal Management Neonatal Care Pediatric Surgery
Sleep Position Breast Feeding Injury Prevention
August 2003
What do we mean by “PPOR Analytic
Phases”? Phase 1: Identifies the populations with overly high numbers and rates of mortality. It examines the 4 components—Maternal Health/ Prematurity, Maternal Care, Newborn Care & Infant Health—for various populations and uses a comparison group to estimate “excess deaths.”
Phase 2: Explains the excess deaths. It examines reasons for the excess deaths through further epidemiologic studies, death reviews, program and policy reviews and other community assessments.
August 2003
Examines the four “Periods of Risk” — Maternal Health/ Prematurity, Maternal Care, Newborn Care & Infant Health — for various population groups
Identifies groups and periods of risk with the most deaths, highest rates.
Uses comparison groups to estimate “excess death”
PPOR Phase 1
August 2003
Phase I Example
What are Phase I Results for Douglas County?
August 2003
PPOR Map of Fetal-Infant Deaths
Douglas County, NE, All Races1997-2000
Maternal Health/ Maternal Health/ Prematurity Prematurity
119119
Maternal Maternal Care Care
7373
Newborn Newborn Care Care
5252
Infant Infant Health Health
5454
298 Total Fetal-Infant Deaths
28,956 Fetal Deaths & Live Births
August 2003
How Do We Calculate the Fetal-Infant Mortality Rate?
Douglas County, NE, All Races1997-2000
August 2003
How Do We Calculate the Fetal-Infant Mortality Rate?
Douglas County, NE, All Races1997-2000
116 Fetal Deaths 24+ wks.
182 Infant Deaths
298 Fetal-Infant Deaths
+ 116 Fetal Deaths 24+ wks.
28,840 Live Births
28,956 Live Births & Fetal Deaths
+
/
Numerator Denominator
= 10.3 Fetal-Infant Deaths
Per 1,000 Live Births & Fetal Deaths
August 2003
Map of Fetal-Infant Mortality Rates
4.14.1
2.52.5 1.81.8 1.91.9
Fetal-Infant Mortality Rate = 298 x 1,000
28,956
= 10.310.3 (4.1 +
2.52.5 + 1.81.8 + 1.91.9)
Douglas County, NE, All Races1997-2000
August 2003
6 Basic Steps: Perinatal Periods of Risk
Approach1) Bring community partners together
to build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
3) Focus on understanding the overall fetal-infant death rate.
August 2003
PPOR Map of Fetal-Infant Mortality Douglas County, Nebraska
All Races, 1990-2000
3.6
2.3 1.8 3.3
Fetal-Infant Rate=11.011.0
4.0
1.4 2.94.1
1.8 1.9
2.3
2.5
Fetal-Infant Rate=10.710.7
Fetal-Infant Rate=10.310.3
1990-1992
1993-1996
1997-2000
August 2003
White non-Hispanic Black non-Hispanic
3.53.5
2.42.4 1.51.5 1.41.4 2.72.7 4.94.93.23.2
7.17.1
White Fetal-Infant
Rate = 8.9Black Fetal-Infant
Rate =17.9
PPOR Map of Fetal-Infant Mortality Douglas County, NE,
by Race, 1997-2000
August 2003
From Data to Potential Action
Maternal Maternal Health/ Health/
PrematurityPrematurity
Maternal Maternal CareCare
Newborn Newborn CareCare
Infant Infant HealthHealth
Preconceptional Health Health Behaviors Perinatal Care
Prenatal Care High Risk Referral Obstetric Care
Perinatal Management Neonatal Care Pediatric Surgery
Sleep Position Breast Feeding Injury Prevention
August 2003
6 Basic Steps: Perinatal Periods of Risk
Approach1) Bring community partners together
to build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
3) Focus on understanding the overall fetal-infant death rate.
4)Look for “opportunity gaps” between different groups.
August 2003
Perinatal Periods of Risk:
What is the “Gap”? ASK: Which women/infants have the "best" outcomes?
ASSUME: all infants can have similar “best” outcomes
CHOOSE: a comparison group(s) (‘reference group’) who already has achieved “best” outcomes
COMPARE: fetal-infant mortality rates in your target group with those of the comparison group(s)
CALCULATE: excess deaths (= target – comparison groups). This is your community’s “Opportunity Gap.”
August 2003
Which “Comparison Group” should we use?
Which women and infants have “best”
outcomes?
Where should the “bar”be set?
August 2003
Defined by maternal characteristics 20 or more years of age 13 or more years of education Non-Hispanic white women
12 U.S. cities with adequate reporting Low (25th percentile) group-specific
death rates
National PPOR Initiative’s “External” Comparison Group
Source: NCHS Data, 1995-1997 Calculations by CDC/CityMatCH
August 2003
2.22.2
1.51.5 1.01.0 1.21.2
Total Fetal-Infant Mortality
Rate= 5.85.8
National External Comparison Group’s
Fetal-Infant Mortality Rates
Source: NCHS Data, 1995-1997 Calculations by CDC/CityMatCH
August 2003
Map of Fetal-Infant Mortality Rates
4.14.1
2.52.5 1.81.8 1.91.9
Total Fetal-Infant Mortality
Rate = 10.310.3
Douglas County, NE, All Races1997-2000
August 2003
Fetal-Infant Mortality Rates Douglas County, NE vs. External
Comparison
Douglas County
Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant
Health
Fetal-Infant Mortality
Total 4.1 2.5 1.8 1.9 10.3
External Comp'so
n
Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant
Health
Fetal-Infant Mortality
2.2 1.5 1.0 1.2 5.8
August 2003
ExcessExcess Fetal-Infant Mortality Rates
Douglas County, NE, 1997-2000
__
Douglas County
Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant
Health
Fetal-Infant Mortality
Total 4.1 2.5 1.8 1.9 10.3
External Comp'so
n
Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant
Health
Fetal-Infant Mortality
2.2 1.5 1.0 1.2 5.8
=Douglas County Excess
Mortality
Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant
Health
Fetal-Infant Mortality
Total 1.9 1.1 0.9 0.7 4.54.5
August 2003
Fetal-Infant Mortality Rates Douglas County, NE, Total and by
Race, 1997-2000
August 2003
Fetal-Infant Mortality Rates Douglas County, NE, Total and by Race,
1997-2000
August 2003
Excess Fetal-Infant Mortality Rates
Douglas County, NE, 1997-2000Groups Maternal
Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Feto-Infant Mortality
Total 11..99 11..11 00..99 00..77 44..55
White Race 11..33 11..00 00..55 00..22 33..11 Non-White Race
33..55 11..33 11..77 11..88 88..22
Black Race
44..99 11..77 11..77 33..77 1122..11
External Comp’son 00 00 00 00 00
August 2003
Number of Excess Fetal-Infant Deaths
Douglas County, NE, 1997-2000
Groups Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant Health
Feto-Infant
Mortality
Total 5566 3311 2255 1199 113311
White Race 2288 2211 1111 55 6655 Non-White Race
2288 1100 1144 1144 6666
Black Race
2200
77 77 1155 4499
External Comp’son 00 00 00 00 00
August 2003
Excess Fetal-Infant Mortality using External Comparison Group
Douglas County, NE, All Races, 1997-2000Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
131 excess deaths
65 excess White deaths
49 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Excess Fetal-Infant Mortality using External Comparison Group
Douglas County, NE, All Races, 1997-2000
42%
24%
19%
15%
100%
0%0%0%
100%
0%0%0%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
131 excess deaths
65 excess White deaths
49 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Excess Fetal-Infant Mortality using External Comparison Group
Douglas County, NE, All Races, 1997-2000
42%
24%
19%
15%
43%
32%
17%
8%
41%
14%
14%
31%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
131 excess deaths
65 excess White deaths
49 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
From Data to Potential Action
Maternal Maternal Health/ Health/
PrematurityPrematurity
Maternal Maternal CareCare
Newborn Newborn CareCare
Infant Infant HealthHealth
Preconceptional Health Health Behaviors Perinatal Care
Prenatal Care High Risk Referral Obstetric Care
Perinatal Management Neonatal Care Pediatric Surgery
Sleep Position Breast Feeding Injury Prevention
August 2003
What if we used a “Comparison Group” from within our own
community?
Which Douglas County women and infants have
“best” outcomes?
August 2003
“Internal” Douglas County Comparison Group
Defined by maternal characteristics 20 or more years of age 13 or more years of education Non-Hispanic White women Residents of Douglas County
August 2003
Number of Fetal-Infant Deaths in the Internal Comparison Group*
Douglas County, NE, 1997-2000
Maternal Health/ Maternal Health/ Prematurity Prematurity
3535
Maternal Care
32
Newborn Care
21
Infant Infant Health Health
1515
103 Total Fetal-Infant Deaths
14,173 Fetal Deaths & Live Births
* applying National PPOR Definition to Douglas County data
August 2003
2.52.5
2.32.3 1.51.5 1.11.1
Total Fetal-Infant
Rate= 7.3
Fetal-Infant Mortality Rates in the Internal Comparison Group
Douglas County, NE, 1997-2000
August 2003
Fetal-Infant Mortality Rates Douglas County, NE, 1997-2000
Groups Maternal Health/
Prematurity
Maternal Care
Newborn Care
Infant Health
Feto-Infant Mortality
Total 4.1 2.5 1.8 1.9 10.3
White Race 3.5 2.4 1.5 1.4 8.9 Non-White Race
5.7 2.7 2.6 3.0 14.0
Black Race 7.1 3.2 2.7 4.9 17.9
Internal Comp’son 2.5 2.3 1.5 1.1 7.3
August 2003
Excess Fetal-Infant Mortality Rates
Douglas County, NE, 1997-2000
August 2003
Number of Excess Fetal-Infant Deaths
Douglas County, NE, 1997-2000
August 2003
Excess Fetal-Infant Mortality using Internal Comparison Group
Douglas County, NE, All Races, 1997-2000Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
87 excess deaths
33 excess White deaths
44 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Excess Fetal-Infant Mortality using Internal Comparison Group
Douglas County, NE, All Races, 1997-2000
55%
9%
10%
26%
100%
0%0%
100%
0%0%0%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
87 excess deaths
33 excess White deaths
44 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Excess Fetal-Infant Mortality using Internal Comparison Group
Douglas County, NE, All Races, 1997-2000
55%
9%
10%
26%
64%12%
24%
44%
9%11%
36%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
87 excess deaths
33 excess White deaths
44 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Summary: Excess Fetal-Infant Mortality Rates, Using Internal and External
Comparison GroupsDouglas County, NE, 1997-2000
August 2003
Summary: Excess Fetal-Infant Deaths, Using Internal and External Comparison
GroupsDouglas County, NE, 1997-2000
August 2003
Questions? Comments? Observations?
August 2003
6 Basic Steps: Perinatal Periods of Risk Approach
1) Bring community partners together to build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
3) Focus on understanding the overall fetal-infant death rate.
4) Look for “opportunity gaps” between different groups.
5) Target further investigations and actions on the gaps.
August 2003
What do we mean by “PPOR Analytic
Phases”? Phase 1: Identifies the populations with overly high numbers of deaths. It examines the 4 death components—Maternal Health/ Prematurity, Maternal Care, Newborn Care & Infant Health—for various populations and uses a comparison group to estimate “excess death”.
Phase 2: Explains the excess deaths. It examines reasons for the excess deaths through further epidemiologic studies, death reviews, program and policy reviews, and other community assessments.
August 2003
Phase 2: Target Investigations & Prevention
Efforts on the Gaps Shift effort and attention to the group(s)
that contributes most to the gap. Conduct further studies or mortality
reviews on the group(s) that contribute(s) to the gap - Phase 2 studies.
Examine current prevention efforts on the group(s) that contribute(s) to the gap - Phase 2 policy/program reviews.
August 2003
PPOR – Douglas CountyInitial Phase 2 Analyses
Causes of Death: Newborn Care and Infant Health
Multiple Gestation: How big is its effect on fetal-infant mortality?
Birthweight Distribution vs. Birthweight-specific Mortality: How much mortality is from the number of very small babies vs. how many babies die at a given birth weight? (“Kitagawa Analysis”)
August 2003
Phase 2: Preliminary Results
Causes of Death: Newborn Care and Infant Health
August 2003
Excess Fetal-Infant Mortality using External Comparison Group
Douglas County, NE, All Races, 1997-2000
42%
24%
19%
15%
43%
32%
17%
8%
41%
14%
14%
31%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
131 excess deaths
65 excess White deaths
49 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Excess Fetal-Infant Mortality using Internal Comparison Group
Douglas County, NE, All Races, 1997-2000
55%
9%
10%
26%
64%12%
24%
44%
9%11%
36%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
87 excess deaths
33 excess White deaths
44 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Leading Causes of Death, by Race/Ethnicity, for Combined Newborn Care and Infant Health PPOR Components, Douglas County, 1997-2000
144.0121.7
176.2
126.5107.1101.9
68.1
276.9
327.2
0
50
100
150
200
250
300
350
All White Black
Death
s per
100,0
00
Birth Defects SIDS All Other Causes
Major "other causes" include perinatal conditions, injury and infection.
August 2003
Major Causes of Death (Infants only), by PPOR Component, Douglas County, 1997-
2000 Maternal Health/ Prematurity
Newborn Care
Infant Health
Perinatal Conditions
Congenital Anomalies
SIDS
August 2003
Phase 2: Preliminary Analyses
Causes of Death: Newborn Care and Infant Health
Birthweight Distribution vs. Birthweight-specific Mortality: How much mortality is from the number of very small babies vs. how many babies die at a given birth weight once they are born?
(“Kitagawa Analysis”) Multiple Gestation: How big is its effect on fetal-
infant mortality?
August 2003
Feto-Infant Mortality
Birthweight Distribution
Birthweight Specific Mortality
Risk Factors
Interventions
Access
Socio-Economic Smoking Race Medical Conditions
Gender Gestational age Race Medical Conditions
Prenatal Care Smoking Cessation Tocolytics
Perinatal Care Quality Care Referrals
Health Insurance Primary Care Content Availability
Referral Systems Transport Systems Expertise
August 2003
A. Total Excess (All Birthweight Categories)
39.5%
60.5%
Birthweight Mortality67.0%
33.0%
Birthweight Mortality
B. Maternal Health/ Prematurity Excess
Kitagawa AnalysisDouglas County, 1997-2000
August 2003
Phase 2: Preliminary Analyses
Causes of Death: Newborn Care and Infant Health
Birthweight Distribution vs. Birthweight-specific Mortality: How much mortality is from the number of very small babies vs. how many babies die at a given birth weight once they are born? (“Kitagawa Analysis”)
Multiple Gestation: How big is its effect on fetal-infant mortality?
August 2003
Examining the Impact of Multiple Gestations in Douglas County,
Nebraska1. What is the prevalence of multiple
gestations in Douglas County?
2. What is the prevalence of multiple gestations by race/ethnicity, and over time?
3. What is the mortality experience for multiple gestations?
4. How much of overall fetal-infant mortality is explained by multiple gestations?
August 2003
Examining the Impact of Multiple Gestations in Douglas County,
Nebraska1. What is the prevalence of multiple
gestations in Douglas County?
2. What is the prevalence of multiple gestations by race/ethnicity, and over time?
3. What is the mortality experience for multiple gestations?
4. How much of overall fetal-infant mortality is explained by multiple gestations?
August 2003
Prevalence of Multiple Gestations
among Fetal Deaths and Live Births
**The percentage of multiple gestations is significantly higher in Douglas County than in the US and in Midwest Cities, although the significance between Douglas County and Midwest Cities decreases after adjusting for maternal race, age and education.
* Midwest Cities are Kansas City, Wichita, St. Louis, Toledo and Cincinnati.
August 2003
Examining the Impact of Multiple Gestations in Douglas County,
Nebraska1. What is the prevalence of multiple
gestations in Douglas County?
2. What is the prevalence of multiple gestations by race/ethnicity, and over time?
3. What is the mortality experience for multiple gestations?
4. How much of overall fetal-infant mortality is explained by multiple gestations?
August 2003
Prevalence of Multiple Gestations,Douglas County, NE, 1990 - 2000
1990-1992
1997-2000
% Multiple Gestation Births
*The increase in multiple gestations over the three time periods is significant.
1993-1996
August 2003
Examining the Impact of Multiple Gestations in Douglas County,
Nebraska1. What is the prevalence of multiple
gestations in Douglas County?
2. What is the prevalence of multiple gestations by race/ethnicity, and over time?
3. What is the mortality experience for multiple gestations in Douglas County?
4. How much of overall fetal-infant mortality is explained by multiple gestations?
August 2003
Fetal-Infant Mortality Rates for Single Gestations, Douglas County and the
U.S.
*Midwestern cities are the only significant difference with Douglas County (11.2/100,000 vs. 9.4/100,000).
August 2003
Fetal-Infant Mortality Rates for Multiple Gestations, Douglas County and the
U.S.
•There are no significant differences for comparisons with Douglas County.
•There are too few non-White multiple gestations to give stable rates.
August 2003
Summary: Plurality-Specific Fetal-Infant Mortality Rates
Mortality rates for single gestations are significantly lower in Douglas County than in selected Midwestern cities. There are no significant differences in mortality rates for multiple gestations in Douglas County compared to the U.S. and selected Midwestern cities.
August 2003
Examining the Impact of Multiple Gestations in Douglas County,
Nebraska1. What is the prevalence of multiple
gestations in Douglas County?
2. What is the prevalence of multiple gestations by race/ethnicity, and over time?
3. What is the mortality experience for multiple gestations?
4. How much of overall fetal-infant mortality is explained by multiple gestations?
August 2003
A Different Way to Look at the Question: Population Attributable
Risk
Population Attributable Risk (PAR)
= risk population - risk unexposed
PAR measures the amount by which the overall frequency of the disease in the population would be reduced, if the exposure of interest were removed.
“What is the effect of the exposure on the overall population ?”
August 2003
Population Attributable Risk for Multiple Gestations, Douglas
County and Midwest Cities
Douglas County
Midwest cities
Population Attributable Risk
•Midwest cities data are from 97-98. Douglas County data are from 1997-2000.
August 2003
Fetal-Infant Mortality
Birthweight Distribution
Birthweight Specific Mortality
Risk Factors
Interventions
Access
Socio-Economic Smoking Race Medical Conditions
Gender Gestational age Race Medical Conditions
Prenatal Care Smoking Cessation Tocolytics
Perinatal Care Quality Care Referrals
Health Insurance Primary Care Content Availability
Referral Systems Transport Systems Expertise
How much mortality is from the number of very small babies vs. how many babies die at a given birth weight once they are born? (“Kitagawa Analysis”)
August 2003
A. Maternal Health/ Prematurity Excess Compared to External Comparison
67%
33%
66%
34%
Kitagawa Analysis: All RacesDouglas County, 1997-2000
B. Maternal Health/ Prematurity Excess Compared to Internal Comparison
Birthweight Distribution
Birthweight-Specific Mortality
Birthweight Distribution vs. Birthweight-specific Mortality: How much mortality is from the number of very small babies vs. how many babies die at a given birth weight once they are born?
August 2003
A. Maternal Health/ Prematurity White Mothers
62%
38%
83%
17%
Kitagawa Analysis: By RaceDouglas County, 1997-2000External Comparison Group
B. Maternal Health/ Prematurity Black Mothers
Birthweight Distribution
Birthweight-Specific Mortality
August 2003
Douglas County Feto-Infant Mortality Rates by PPOR Component, 1990-2001
0
1
2
3
4
5
6
90-93 91-94 92-95 93-96 94-97 95-98 96-99 97-00 98-01
Rate
Per
1,0
00
MH
MC
NC
IH
August 2003
Douglas County Feto-Infant Mortality Rates by PPOR Component - White, 1990-2001
0
1
2
3
4
5
6
90-93 91-94 92-95 93-96 94-97 95-98 96-99 97-00 98-01
MH
MC
NC
IH
August 2003
Douglas County Feto-Infant Mortality Rates by PPOR Component - Black, 1990-2001
0
1
2
3
4
5
6
7
8
9
10
90-93 91-94 92-95 93-96 94-97 95-98 96-99 97-00 98-01
Rate
Per
1,0
00
MH
MC
NC
IH
August 2003
Excess Fetal-Infant Mortality using External Comparison GroupDouglas County, NE, All Races, 1997-2000
42%
24%
19%
15%
43%
32%
17%
8%
41%
14%
14%
31%
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Total
Whites Blacks
131 excess deaths
65 excess White deaths
49 excess Black deaths
298 Total Fetal-Infant Deaths
August 2003
Philadelphia’s PPOR
Phase 2 Analysis: Combine PPOR methodology with Geographical Information Systems (GIS).Benefits: 1) Provides information for fine tuning existing programs. 2) Provides information on where new programs are needed.3) Provides information for specific communities4) Serves as a tool for epidemiological investigations
August 2003
Infant Mortality 1998-2000 Density Analysis
West Oak Lane
HS West/SW
HS North
August 2003
Philadelphia PPOR Summary
PPOR analysis is starting point not the ending point
Provides a framework for discussing the problem
Provides a framework for further investigation of the problem
August 2003
Louisville’s Lessons Learned
Improve existing data and/or develop other data sets as necessary: better data for better information
PPOR integration into the existing community initiatives enhanced the MCH/women’s health capacity/efforts
Be flexible, adjust the system by using the evidence-based findings
Need right stakeholders and political will to be successful
Work as a team, build partnership and collaboration
August 2003
RecommendationsRecommendations
PPOR Phase 1Link births with deaths
Identify the groups with gaps
FIMRHome interviews + medical records
PPOR Phase 2Vital Statistics data
Data + stories(paint faces behind the numbers)
Identify problems/gaps in services
Statistical data analysis Analyze the impact of different
risk factors
Develop evidence-based prevention strategies (preconceptional, during pregnancy and interconceptional) e.g. Healthy Start
Develop evidence-based prevention strategies (preconceptional, during pregnancy and interconceptional) e.g. Healthy Start
Improve women and children’s health
Reduce the existing racial disparities
Improve women and children’s health
Reduce the existing racial disparities
MCH Initiative : “Healthy women, children and families”
August 2003
Perinatal Periods Of Risk Approach
…not just data.1) Bring community partners together
to build consensus, support, and partnership.
2) “Map” fetal & infant deaths by birth weight & age at death.
3) Focus on understanding the overall fetal-infant death rate.
4) Look for “opportunity gaps” between different groups.
5) Target further investigations and actions on the gaps.
6) Mobilize for sustainable systems change.
August 2003
Perinatal Periods of Risk: For More Information: www.citymatch.org