World Health OrganizationCollaborating Center in Reproductive

HealthPromoting Healthy Birth Outcomes

October 27-28, 2009

Emory UniversityWoodruff Health Sciences Center

The National Centers for Disease Control and Prevention (CDC)Georgia Department of Human Resources

Division of Public Health

Alfred W. Brann, Jr., MD, DirectorWoodruff Health Sciences CenterEmory University

Brian McCarthy, MD, Principal InvestigatorThe National Centers for Disease Control

and Prevention

WHO Collaborating CenterCountries Receiving HSR Support

AFRO• Kenya• Madagascar• Tanzania• Uganda

EMRO• Afghanistan• Egypt• Jordan• Sudan

ERO• Armenia• Kazakstan• Moldova• Republic of Georgia• Russia• Bosnia• Czech Republic• Poland• Romania• Yugoslavia• Cypress• Greece• Turkey

PAHO• Guatemala• Honduras• Mexico• Cuba• Grenada• Argentina• Columbia• Ecuador• United States - Georgia - Mississippi

SEARO• India• Indonesia• South Korea

WPRO• China• Philippines

UNRWA For Palestinian Refugees• Gaza• West Bank

The systematic study of whether current medical and other relevant knowledge has been brought to bear to improve the health of a community under a set of existing conditions.

Health Services Research

Expertise required-*Clinical Practice *P.H. Program Management *Epidemiology *Cultural and Social

*Behavioral Science Aspects of Health*Public Policy *Country or state-specific Knowledge

Infant Mortality and Per Capita GNP

Objectives• Objective 1 – List the largest contributor to infant

mortality.

• Objective 2 – Describe a new indicator for the status of health of a community.

• Objective 3 – Describe an approach to a quantified recurrent public health risk.

• Objective 4 – Describe four critical questions that are critical for reproductive-aged women.

Georgia Perinatal Surveillance

• Total cohort accountability begins with the reporting of all products of

conception.

Georgia Perinatal Surveillance

• Feto-infant mortality (FIMR) is used as the measure of mortality rather than infant mortality.

Georgia Perinatal Surveillance

• Five hundred grams (500gm) or twenty week gestation is used as the starting point for counting feto-infant deaths.

Georgia Perinatal Surveillance

• Birth weight and age of death are used to classify each death two-dimensionally in order to identify pockets of excess feto-infant deaths, along with the most effective strategies for reducing these excess deaths.

Georgia Perinatal Surveillance

• Sociodemographic (SD) groups are used to identify disparities as follows:

Group 1: ≥ 20 years of age, ≥13 years of education

Group 2: ≥ 20 years of age, <13 years of education

Group 3: < 20 years of age, <13 years of education

Georgia Perinatal Surveillance

• The opportunity gap is based on a comparison between the “standard” feto-infant mortality in Georgia (the lowest rate achieved by one SD group in a defined geographical area) with the rates experienced by the remaining SD groups.

Georgia’s Six Perinatal Regions

Hospital

Perinatal Center

TotalDeaths

3936

Number of Feto-Infant Deaths

Data Rich, Information Poor

TotalDeaths

3936

Number of Feto-Infant DeathsData Rich, Information Poor

Age at Death

BirthWeight

1

5

9

13

2

6

10

14

3

7

4

8

1211

15 16

Birthweight and Age at DeathLate

Fetal Death

(28+ wks)

Early Neontal Death

(<7 days)

Late Neonatal

Death(7-27days)

Post Neonatal

Death(28+ days)

VVLBW(500 - 999gms)

VLBW(999-1499 gms)

IBW(1499-2499 gms)

NBW(2500+ gms)

Interventions for Reducing Mortality

Women’s and Maternal Health

Maternal and Fetal Care

Neonatal Care

Infant Care

W & MHealth

1

W & MHealth

5

M & FCare

9

M & FCare13

W & MHealth

2

W & MHealth

6

NewbornCare10

NewbornCare14

W & MHealth

3

W & MHealth

7

W & MHealth

4

W & MHealth

8

InfantCare12

NewbornCare11

InfantCare15

InfantCare16

Birthweight and Age at DeathLate

Fetal Death

(28+ wks)

Early Neontal Death

(<7 days)

Late Neonatal

Death(7-27days)

Post Neonatal

Death(28+ days)

VVLBW(0-999gms)

VLBW(999-1499 gms)

IBW(1499-2499 gms)

NBW(2500+ gms)

Summary of Perinatal Health Care Interventions

• Reproductive Awareness• Preconception Care• Child Spacing• Nutrition• Micronutrients• STDs• Substance Abuse• Domestic Violence•

• Pregnancy Identification• Prenatal Surveillance & Care• Anticipatory Guidance• Intrapartum Monitoring• “ART” for complications • Surgical Services• High Risk Maternal Followup

Women’s & Maternal HealthInterventions:

Maternal & Fetal CareInterventions:

Newborn CareInterventions:

• Clean Delivery• Resuscitation• Thermal Control• Breast Feeding• “ART” for the At-Risk-Infant• “Baby Friendly” Concept• Parenting Skill Education

Infant CareInterventions:

• Parenting Skill Education• Child Health Supervision Breastfeeding/nutrition Immunization Growth/Development Monitoring Anticipatory Guidance A.R.I. D.D. Injury Control “ART” for the At-Risk-Infant

•Community Services

Georgia’s Six Perinatal Regions

Hospital

Perinatal Center

4.3

3.2

4.6

4.2

4.1

7.4

Atlanta Augusta Macon

Columbus Savannah Albany

1.40.3

0.7 1.01.2

1.80.5

1.0

2.5

2.4

1.11.02.6

0.80.3

1.5

0.90.6

Total=5.6 Total=8.2 Total=11.4

Total=7.3 Total=8.3 Total=8.6

Excessive Mortality Rate by RegionGeorgia, 1991-1993

What do Current Data Show?

• Excess fetal and infant death rates occur in all six perinatal regions, with the highest death rate in the Macon region followed by Albany, Savannah, Augusta, Columbus and Atlanta.

• The “standard woman” has excess fetal and infant mortality when compared to the same woman who lives in Connecticut.

The “Opportunity Gap”- The potential for reduction in excessive mortality based on a comparison between rates already achieved by one sub-population in a defined geographical area with those experienced by the remaining population.

Analysis of Sociodemographic Risks

Sub-group Age Education DeathRate

ExcessRate

White Group 1 >20 >13 years 5.7 .7

White Group 2 >20 <13 years 9.0 4.1

White Group 3 ≤19 <13 years 13.3 8.3

Black Group 1 >20 >13 years 14.0 9.0

Black Group 2 >20 <13 years 19.0 14.0

Black Group 3 ≤19 <13 years 19.6 14.6

Deaths per 1,000 live births

Calculating “The Opportunity Gap” = Excess Mortality

Excess Mortality = BWPR TARGETPOPULATION

- BWPRSTANDARD

Birthweight Proportionate Rate (BWPR)

BWPR =Number of deaths in a given weight group

Total Number of births in all weight groupsx 1000

ORMaternalHealth# of

Deaths

W & MHealth

W & MHealth

M & FCare

M & FCare

W & MHealth

W & MHealth

NewbornCare

NewbornCare

W & MHealth

W & MHealth

W & MHealth

W & MHealth

InfantCare

NewbornCare

InfantCare

InfantCare

(# in cells)

(# in entire table)

x 1000

Analysis of Sociodemographic Risks

Sub-group Age Education DeathRate

ExcessRate

White Group 1 >20 >13 years 5.7 .7

White Group 2 >20 <13 years 9.0 4.1

White Group 3 ≤19 <13 years 13.3 8.3

Black Group 1 >20 >13 years 14.0 9.0

Black Group 2 >20 <13 years 19.0 14.0

Black Group 3 ≤19 <13 years 19.6 14.6

Deaths per 1,000 live births

TotalFeto-Infant

Deaths

3936ExcessiveFeto-Infant

Deaths

2314

Calculating “The Opportunity Gap” = Excess Mortality

Excess Mortality = BWPR TARGETPOPULATION

- BWPRSTANDARD

Birthweight Proportionate Rate (BWPR)

BWPR =Number of deaths in a given weight group

Total Number of births in all weight groupsx 1000

ORMaternalHealth# of

Deaths

W & MHealth

W & MHealth

M & FCare

M & FCare

W & MHealth

W & MHealth

NewbornCare

NewbornCare

W & MHealth

W & MHealth

W & MHealth

W & MHealth

InfantCare

NewbornCare

InfantCare

InfantCare

(# in cells)

(# in entire table)

x 1000

2.1

0.8

1.20.9

Total = 5.0

Feto-Infant Mortality RateWhite Group I, Atlanta Region

7.2

0.3

8.3

1.6

8.7

3.6

Excessive Mortality Rate by Sociodemographic GroupGeorgia, 1991-1993

White Group 1 White Group 2 White Group 3

Black Group 1 Black Group 2 Black Group 3

0.20.1

0.1 0.40.5

1.50.4

0.9

3.4

3.3

1.11.42.8

1.21.7

0.8

0.50.5

Total=0.7 Total=4.0 Total=8.3

Total=9.0 Total=14.0 Total=14.5

Interventions for Reducing Mortality

Women’s and Maternal Health

Maternal and Fetal Care

Neonatal Care

Infant Care

Georgia’s Six Perinatal Regions

Hospital

Perinatal Center

Areas of Concentration to Reduce Infant Mortality

Area Potential for Improvement

WOMEN’S & MATERNAL HEALTH 60%

Maternal Fetal Care 10%

Neonatal Intensive Care 9%

POSTNATAL CARE 21%

LOW HIGH

Figure 1: Percent of Births According to Sociodemographic group for Georgia, 1981-83, 1991-93, 2001-03

0%

5%

10%

15%

20%

25%

30%

35%

40%

Age 20+, Educ.13+ yrs.

Age 20+, Educ.<13 yrs.

Age <20, Educ.<13 yrs.

Age 20+, Educ.13+ yrs.

Age 20+, Educ.<13 yrs.

Age <20, Educ.<13 yrs.

White NH Grp 1 White NH Grp 2 White NH Grp 3 Black NH Grp 1 Black NH Grp 2 Black NH Grp 3

Sociodemographic Group

Perc

ent o

f birt

hing

pop

ulat

ion

1981 - 1983

1991 - 1993

2001 - 2003

Time Period:

Figure 2: Comparison of Sociodemographic Group Specific Feto-Infant (20+ Weeks) Moratlity Rates for Georgia, 1981-83, 1991-93, 2001-03

12.8

18.8

26.228.4

35.739.1

24.6

7.711.9

18.122.1

26.028.7

16.7

5.19.8

12.3 11.5

18.0 17.9

10.5

0

5

10

15

20

25

30

35

40

45

50

Age 20+, Educ.13+ yrs.

Age 20+, Educ.<13 yrs.

Age <20, Educ.<13 yrs.

Age 20+, Educ.13+ yrs.

Age 20+, Educ.<13 yrs.

Age <20, Educ.<13 yrs.

White NH Grp 1 White NH Grp 2 White NH Grp 3 Black NH Grp 1 Black NH Grp 2 Black NH Grp 3 Total

Sociodemographic Group

FIM

R pe

r 100

0

1981-83

1991-93

2001-03

Figure 4: Sociodemographic Group Specific LBWR/TB for Georgia 1981-83, 1991-93, 2001-03

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

White NHGrp 1

White NHGrp 2

White NHGrp 3

Black NHGrp 1

Black NHGrp 2

Black NHGrp 3

Sociodemographic Group

% L

BW

R/T

B 1981-831991-932001-03

Figure 4: SES Group Specific Birthweight Specific Mortality Rates

800.8639.9

425.2

218.9

135.2112.0

50.2

31.0 26.4

7.04.6

3.7

1

10

100

1000

1981-83 1991-93 2001-03

Time Period

BW

SM

R p

er

10

00

TB

< 1000

1000-1499

1500-2499

2500+

Linear (< 1000)

Summary of Perinatal Health Care Interventions

• Reproductive Awareness• Preconception Care• Child Spacing• Nutrition• Micronutrients• STDs• Substance Abuse• Domestic Violence•

• Pregnancy Identification• Prenatal Surveillance & Care• Anticipatory Guidance• Intrapartum Monitoring• “ART” for complications • Surgical Services• High Risk Maternal Followup

Women’s & Maternal HealthInterventions:

Maternal & Fetal CareInterventions:

Newborn CareInterventions:

• Clean Delivery• Resuscitation• Thermal Control• Breast Feeding• “ART” for the At-Risk-Infant• “Baby Friendly” Concept• Parenting Skill Education

Infant CareInterventions:

• Parenting Skill Education• Child Health Supervision Breastfeeding/nutrition Immunization Growth/Development Monitoring Anticipatory Guidance A.R.I. D.D. Injury Control “ART” for the At-Risk-Infant

•Community Services

Background

• Georgia’s infant mortality declined by 50% from 1975 to 1996, primarily due to improved survival of low birth weight (LBW; < 2500 gm) infants;

• The largest contributor to Georgia’s infant mortality rate is the birth of LBW and VLBW (< 1500 gm) infants:

% of Births % of Infant Deaths

< 2500 g 11% 70%

< 1500 g 2% (~2500 births) 50%

Background

• African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality (1).

• Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.

Background

• No obstetrical or prenatal assessment or intervention has been successful in predicting or preventing a woman’s first preterm/LBW delivery (4);

• The single best predictor of a preterm/VLBW delivery is a history of a previous preterm/VLBW delivery (5).

• White women – 8%

• African-American women – 13%

Background

• Experience and a growing body of evidence link the delivery of a VLBW infant to aspects of a woman's health status, including (1):

– Unrecognized and poorly-controlled medical problems;

– Reproductive tract infections (including BV and STI’s);

– Substance abuse disorders;– Periodontal disease;– Psychosocial factors including psychological stress

and domestic violence.

Background

• Short interpregnancy intervals increase the risk of preterm/LBW delivery (2, 3),

• the critical interval varies by race (4):

– 9 months for African-American women;

– 3 months for white women.

Background

• Pregnancy is too late to initiate

prenatal care if the mother has had

a previous VLBW infant.

Interpregnancy Care

• Primary health care from delivery of one child until conception of the next.

The Interpregnancy Care ProgramThe Interpregnancy Care Program

Interpregnancy Primary Care and Social Support for African-American Women at risk for recurrent

very-low-birthweight delivery:A Pilot Evaluation

Accepted for Publication - July, 2007 in

Maternal and Child Health Journal