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Perinatal Periods of Risk-A Tool for Improving the Health
of Mothers and Infants
Carolyn Slack, MS, RN
Columbus (OH) Health Department
Map of Feto-Infant Mortality
500-1499 g
1500+ g
Fetal Deaths Neonatal
Post neonatal
1 2 3
4 5 6
Map of Feto-Infant Mortality
500-1499 g
1500+ g
Fetal Deaths Neonatal
Post neonatal
Maternal Health/ Maternal Health/ PrematurityPrematurity
Maternal Maternal CareCare
Newborn Newborn CareCare
Infant Infant HealthHealth
Feto-Infant MortalityFranklin County, Ohio, All Races
1997-1998
Maternal Health/ Maternal Health/ Prematurity Prematurity
123123
Maternal Maternal Care Care
7171
Newborn Newborn Care Care
4343
Infant Infant Health Health
8282
319 Feto-Infant Deaths
32,673 Fetal Deaths & Live Births
Background
WHO and Dr. Brian McCarthy
CityMatCH PPOR Work Group
Why a new approach to infant mortality?
National Practice Collaborative
Description of the PPOR Practice Collaborative
Application Process Practice Collaborative Curriculum Participating Cities
– Baltimore, MD, Columbus, OH, Durham, NC, Jacksonville, FL, Kansas City, MO, Louisville, KY, Nashville, TN, New Haven, CT, Orlando, FL, Philadelphia, PA, Phoenix, AZ, Portland, OR, Raleigh, NC, and St. Petersburg, FL.
Perinatal Periods of Risk Approach:5 Major Principles
1) Engage community partners early to gain consensus and support
2) Map feto-infant mortality by birthweight &
age at death
3) Focus on reducing the overall feto-infant mortality rate
4) Examine potential opportunity gaps between population groups
5) Target further investigations and prevention efforts on the gaps
Community Readiness: From Concepts to Tools
Tool for engaging partners Tool for reaching consensus Tool for identifying joint assets Tool for revealing critical gaps Tool for developing strategy
What shape is your tent?
Raising the roof for PPOR:
5 4 3 2 1 2 3 4 5
5
4
3
2 2
3
4
5
23
4
5
Reasoning
RolesResources
Risk/Rewards
Results
What shape is your tent?
PPOR Community Readiness“5 Tent Poles”
1. Reasoning: partners can communicate clear, compelling case for PPOR based on its value-add
2. Results: partners can articulate what measurable results are expected from doing PPOR, and by when
3. Roles: partners are willing and able to champion PPOR over a time in their various roles in the community
4. Risks/Rewards: sufficient strategic balance exist between benefits and consequences for essential stakeholders to support PPOR implementation
5. Resources: sufficient systems and resources to support full implementation
PPOR Partnerships in ColumbusLead Partners
&Columbus Health Department
Caring for 2 (Healthy Start)
Other Partners
Child Death Review Team
WIC/CFHS (Title V) Advisory Council
Council onHealthy Mothers andBabies
Ohio Dept. of Health
2. Map of Feto-Infant Mortality
Age at Death
Birth
weig
ht
Linked Birth & Death Certificates
Infant Deaths
Live BirthCertificate
Birth Characteristics
Infant DeathCertificate
Death Characteristics
FetalDeaths
Fetal Death Certificate
Birth Versus Death Cohort
Birth Cohort
Births
Deaths
1999 2000
Death Cohort
Births
Deaths
1999 2000
Data Recommendations
Need at least 60 deaths in every population you want to study
No more than 5 years of data due to changes in medical practice
Assess data quality – Missing birth weight and gestational age– Missing education and race
Map of Feto-Infant Mortality
Age at Death
Birth
weig
ht
500-1499 g
1500+ g
Fetal
(24
wks
)
Neonat
al
Postneo
natal
1 2 3
54 6
Map of Feto -Infant MortalityWhat Is Missing in the 6 Cells?
Fetal deaths restricted to
>500 gLive births restricted to
Spontaneous abortions
Induced abortions
24 wks and 500 g
Map of Feto-Infant Mortality
500-1499 g
1500+ g
Fetal Deaths Neonatal
Post neonatal
Maternal Health/ Maternal Health/ PrematurityPrematurity
Maternal Maternal CareCare
Newborn Newborn CareCare
Infant Infant HealthHealth
3. Focus on Reducing the Overall Feto-Infant Mortality Rate
The overall rate includes fetal deaths which are often excluded
Cell or group specific mortality rates are calculated such that they add up to the total feto-infant mortality rate
Excess mortality rates and numbers are also calculated such that they relate to the total feto-infant rate
Focus on Overall MortalityMap of Feto-Infant Mortality
Compare within feto-infant mortality rates by examining the 4 group rates
Compare overall and group rates over time
Compare overall and group rates between different population groups
4. Examine the “Opportunity Gap” Between Population Groups
Identify the potential for reduction in the community
Decide on internal reference groups for comparison
Consider external reference groups for comparison
Calculate excess mortality rates by components
Examine the “Opportunity Gap”Reference Groups
20 or more years of age
13 or more years of education
Non-hispanic white women
Attempt to choose a simple optimal group; at least 15% of the population
US studies:
Examine the “Opportunity Gap”
Examine excess overall mortality, both rate and number
Examine excess mortality across the 4 groups
Calculate the percentage of excess mortality by racial and socio-economic
5. Target Investigations & Prevention Efforts on the Gap
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 contributes to the gap (Phase 2 studies)
Examine current prevention efforts on the group(s) that contributes to the gap (Phase 2 policy/program reviews)
Map of Feto-Infant MortalityMaternal 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
Feto-Infant MortalityFranklin County, Ohio, All Races
1997-1998
Maternal Health/ Maternal Health/ Prematurity Prematurity
123123
Maternal Maternal Care Care
7171
Newborn Newborn Care Care
4343
Infant Infant Health Health
8282
319 Feto-Infant Deaths
32,673 Fetal Deaths & Live Births
Feto-Infant Mortality RatesFranklin County, Ohio, All Races
1997-1998
Maternal Health/ Maternal Health/ Prematurity Prematurity
3.83.8
Maternal Maternal Care Care
2.22.2
Newborn Newborn Care Care
1.31.3
Infant Infant Health Health
2.52.5
Feto-Infant Mortality Rate =
319 x 1,000 32,673
= 9.8 deaths per 1,000 births
& fetal deaths
Excess Feto-Infant Mortality Franklin County, Ohio, 1997-1998
- =
Franklin Co. All Races
U.S. Reference Excess
3.83.8
2.22.2 1.31.3 2.52.5
9.8
2.22.2
1.51.5 1.01.0 1.21.2
5.8
1.61.6
0.7 0.30.3 1.31.3
4.0
Feto-Infant Mortality RatesFranklin County, Ohio, Black
1997-1998
Maternal Health/ Maternal Health/ Prematurity Prematurity
5.85.8
Maternal Maternal Care Care
3.83.8
Newborn Newborn Care Care
1.61.6
Infant Infant Health Health
5.55.5
Feto-Infant Mortality Rate =
106 x 1,000 6,349
= 16.7 deaths per 1,000 births
& fetal deaths
Excess Black Feto-Infant Mortality
Franklin County, Ohio, 1997-1998
- =
Franklin Co. Black
U.S. Reference Excess
5.85.8
3.83.8 1.61.6 5.55.5
16.7
2.22.2
1.51.5 1.01.0 1.21.2
5.8
3.63.6
2.3 0.60.6 4.34.3
10.9
Excess Feto-Infant MortalityOverall and Black
Franklin County, Ohio, 1997-1998
Franklin County Overall Excess
Black Excess
1.61.6
0.70.7 0.30.3 1.31.3
3.63.6
2.3 0.60.6 4.34.3
Infant Health – Phase IIFranklin County, 1997-98
Postneonatal deaths of birth weight of 1500 grams or above
Race of Mother
# of deaths
% of black
deaths# of
deaths
% of white
deaths# of
deaths
% of all B & W deaths
Causes of Deathcongenital anomalies 12 33% 11 25% 23 29%prematurity (<26 wks) 0 0% 0 0% 0 0%SIDS 12 33% 24 55% 36 45%illness 10 28% 3 7% 13 16%injury 2 6% 2 5% 4 5%infection 0 0% 0 0% 0 0%undetermined 0 0% 1 2% 1 1%unknown 0 0% 3 7% 3 4%
1997-1998 subtotals 36 44 80
BLACK WHITE B & W total
Prevalence of Selected Risk FactorsFranklin County, 1997-98
*Postneonatal deaths of birth weight of 1500 grams or above
Infant Health deaths*
SIDS deaths*
Live births
(>=500 g)
Characteristics & (n=80) (n=36) (n=32,342)Risk Factors % % %
education <13 years 72.1% 80.0% 45.6%unmarried 53.5% 50.0% 35.3%
late prenatal care (after 1st trimester) 14.3% 20.0% 16.9%
smoking 26.3% 36.1% 16.4%age <20 years 21.3% 13.9% 12.3%
alcohol use 2.5% 2.8% 0.1%male child 55.0% 55.6% 50.1%
Issues and PlansVital Statistics - Statewide
Availability of matched certificatesStreet address vs. census tractsCompleteness of dataSource of congenital anomalies
dataNCHS perinatal mortality data filesEBC plans and access
Issues and PlansVital Statistics - Local
Completeness of data– Follow-up and training of VS staff,
hospital and other medical personnelCause of death problemsMissing certificates
Issues and PlansOur Response
Create our own electronic database– Using Child Death Review data
Improve process to get out of county certificates
Continue to work with fetal death data
Issues and PlansOther Stuff
Focus on singletonsUse of other data sets for next level
of analysis– e.g., programs: STD, CFHS, NHCs
– e.g., surveillance: PRAMS, BRFSS
Issues and PlansOther Stuff
Talk in terms of excess deaths, rather than rates
Power of selecting an internal reference group (must be at least 15% of population)
Examine PTB and C-section rates Multiracial moms
Issues and PlansOne Parting Thought…
An Ohio MCH/PPOR Collaborative– Based on national (City MatCH) model– Possible funding through MOD
Acknowledgements
Kelly Welch Williams, MS, Caring for 2 Project Director
Kathleen Cowen, MS, Senior Epidemiologist – Columbus Health Department
For Further Information, visit the CityMatCH website:www.citymatch.org