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Promising Tools to Improve Birth Outcomes:
PPOR, FIMR, and LAMB Project
Shin Margaret Chao, MPH, PhD Kevin Donovan MPH, Cathleen Bemis, MS, Sungching Glenn,
MSAngel Hopson, MSN, MPH, RN, Cynthia Harding, MPH
Los Angeles County Department of Public Health Maternal, Child and Adolescent Health
Today’s Presentation
I. What is the problem?II. Our Response:
- Perinatal Periods of Risk (PPOR)- Fetal & Infant Mortality Review (FIMR)
- Los Angeles Mommy and Baby (LAMB)Survey
III. Findings IV. From Data to Action
I. What is the problem ?
Antelope Valley? Health Service Planning Area
(SPA 1)
Relatively isolated from much of LAC
Population size— 4,903 live births in 2002 Live births by mother’s
race/ethnicity: 17% African American 46% Hispanic 33% White
Poverty: 12% population with household income less than 100% of the federal poverty (vs. 20.1% in LAC)
Antelope Valley (SPA 1)
Increasing Infant Death Rates in AV
1999-2002
4.95.4 5.5
5.4
5.0
6.2
9.4
10.6
0
2
4
6
8
10
12
1999 2000 2001 2002
per
1,00
0 L
ive
Bir
ths
LAC Overall Rate
AV Rate
The overall IM rates in LA county
in 1999-2002 were 4.9 to 5.5
The infant mortality rate in AV more than doubled between 1999 and 2002
In 2002, there were 4903 live births and 53 infant deaths* in AV
* Caution: Small numbers cause large changes in rates
The highest IM rate was experienced by African American mothers
African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002
19.0
28.4
32.7
5.7 5.6
7.7
3.5
5.5
11.0
6.6
2.7 2.2
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1999 2000 2001 2002
Per 1
,000 L
ive Bi
rths
African American Hispanic
White (Non-Hispanic) Antelope Valley Rate
Source: California Department of Health Services, Center for Health Statistics, Vital Statistics, 1999 to 2002
Our Responses
Promising Approaches
Three promising approaches:
PPOR Fetal Infant Mortality Review (FIMR) LAMB
PPOR/FIMR
PPOR: Map Fetal-infant Mortality Calculate the excess Fetal-infant Mortality Rates
FIMR: Used National FIMR forms to review 53 infant deaths that
occurred in AV in 2002 PHNs conducted home interviews, abstracted prenatal
care, labor and delivery, newborn records, etc. from hospitals and provider offices
Findings are summarized according to each infant’s birth weight and age at death-PPOR
Population-based survey of women who recently Population-based survey of women who recently delivered and resided in AVdelivered and resided in AV
Identifies factors associated with poor birth Identifies factors associated with poor birth outcomesoutcomes
Self-administered survey on experiences before, Self-administered survey on experiences before, during, and after pregnancy:during, and after pregnancy:
– Pre- and inter-conception carePre- and inter-conception care– Prenatal carePrenatal care– Maternal medical conditionsMaternal medical conditions– Psychosocial factorsPsychosocial factors– Risk taking behaviorsRisk taking behaviors
Los Angeles Mommy and Baby(LAMB) ProjectLos Angeles Mommy and Baby(LAMB) Project
III. Findings
PPOR Findings
Fetal NeonatalPost-
NeonatalFetal Neonatal
Post-Neonatal
Fetal NeonatalPost-
Neonatal
3.4 5.5 0.8 2.2 1.5 0.4(N=17) (N=27) (N=4)
-(N=45) (N=30) (N=7) =
2.8 1.8 2.6 1.2 0.8 0.6(N=14) (N=9) (N=13) (N=25) (N=17) (N=12)
Total Births = 4,934 Total Births = 20,139
Total Fetal-Infant Mortality Rate = 17.0 Total Fetal-Infant Mortality Rate = 6.8 Total Excess Rate = 10.3
1.
2.
3.Data Source: Birth Cohort data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
Fetal-Infant Mortality Rate is defined as death per 1,000 live births plus fetal deaths (Total Births).
<1500 g
1500+ g
1.2
SPA 12 Comparison Group3 Excess Rate
The Comparison Group is defined as non-Hispanic w hite mother aged 20 and above w ith more than 12 years of education and resided in Los Angeles County.
Data Source: Birth, Fetal Death, and Death data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.
4.0 0.5
1.6 1.0 2.0
FIMR/PPOR FindingsFIMR/PPOR Findings
27 Neonatal Deaths (<1500 g27 Neonatal Deaths (<1500 g, 0-28 days)0-28 days)
Mother:• All had at least one risk factor for poor birth outcome• 65% had psychosocial issues• 54% had an infection – most common were UTI and
STD• 35% started prenatal care after 12th week
Infant:• 22% had a documented infection• 15% had congenital birth defect
FIMR Findings -continued-FIMR Findings -continued-13 Infant Deaths (> 1500 g, 29-365 days):13 Infant Deaths (> 1500 g, 29-365 days):
Mother:•85% had at least one risk factor for poor birth outcome•77% had psychosocial issues•54% started prenatal care after 12th week
Infant:•54% had issues related to safety, including injury,
co-sleeping, and lack of supervision•46% had a congenital birth defect
LAMB Findings:
Results from 366 moms who gave birth in AV between May-July 2004 (response rate 54%):
Moms with poor birth outcomes tend to have: No insurance before pregnancy (OR=2.3; p = 0.004)
Previous low birth weight/preterm infant (OR=3.67; p = 0.0003)
High blood pressure during pregnancy) (OR=3.44; p=0.06)
Inadequate prenatal care (OR=2.34; p= 0.01)
Early labor pain, water broke early (OR=2.54/10.93; p <0.001)
Reported feeling less happy during pregnancy (OR=1.92; p= 0.02)
Smoked during pregnancy (OR=3.19; p= 0.005)
Described their neighborhood as unsafe (OR=2.45; p= 0.02)
IV. From Data to Action
Antelope Valley Best Babies Collaborative Meeting
More than 50 community partners attended to review
the findings and identify intervention strategies
Findings from FIMR/PPOR/LAMB were presented
12 short-term interventions and 4 long-term
interventions were identified
Maternal Health/
Prematurity
1. Preconception care
2. Interconception care
3. Prenatal care
4. High risk Ob care
Infant Health
1. Safety issues
(sleep position, injury
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
?
?
Maternal Health/
Prematurity
1. Preconception care
2. Interconception care
3. Prenatal care
4. High risk Ob care
Infant Health
1. Safety issues
(sleep position, injury
prevention, etc)
2. Breast-feeding
3. Family and parenting
issues
12 Short-term Interventions
1. Increase access to high-risk Ob care and related ancillary services, such as labs; access is particularly difficult for Medi-Cal recipients.
2. Arrange faith-based youth services to provide health services.
3. Promote “100 Acts Kindness” for pregnant women.
4. Increase access to transportation for pregnant moms and advocate politically for trans. improvement.
5. Arrange male support groups to address the ”Role of Men”.
6. Present this data to local Ob and pediatric providers and staff to increase awareness.
7. Provide comprehensive assessment for newborns, especially for high risk ones.
8. Provide immediate information and planned follow-up for high-risk infants/moms.
9. Provide newborn infant care classes to new moms before they are discharged from the hospital.
10.Establish a 24-hour lactation team.11.Provide education for
breastfeeding and infant care during prenatal care.
12.Bring providers and volunteers together to identify best practices.
Interconnection between PPOR, Infant Death Review, and LAMB
PPOR Link births with deaths
Identify groups with gap in mortality
Infant Death Review Maternal interviews + Medical Chart abstraction
LAMB Project
Data Analysis Calculate the prevalence of specific problems
Data Analysis Identified risk factors associated with
LBW/PT
Disseminated findings to the local community meetings
In collaboration with community, developed short and
Improve women and children’s health
Conduct population-based case-control study
Long term prevention strategies
Post Script From 2002 to 2004, the infant mortality rate
in the Antelope Valley decreased, from 10.6 to 5.6 per thousand live births
Community efforts, such as the resources/efforts funded by First Five, AV HBLC, the implementation of the BIH Program (2002), etc. will continue to improve the birth outcomes in the AV.
In 2006, LAC Preconception Health Collaborative was formed to promote the integration of preconception health policies and practices into public health programs
Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2004
15.1
17.619.1
11.0
19.0
28.4
32.7
16.5
14.3
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Infa
nt D
eath
s p
er
1,0
00 L
ive B
irth
s
African American Asian/Pacific Islander Hispanic White Total
Infant Death Rate by Race/Ethnicity LA County, 1996-2004
12.211.8
13.5
10.5
12.8
11.4
13.112.2
11.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Infa
nt D
eath
s p
er
1,0
00 L
ive B
irth
s
African American Asian/Pacific Islander Hispanic White Total