1 The Perinatal Periods of Risk CityMatCH

11

The Perinatal Periods of RiskThe Perinatal Periods of Risk

CityMatCH http://www.citymatch.org/

22

PPOR PPOR MapsMaps Fetal & Infant Fetal & Infant Deaths Deaths

500-1499 g

1500+ g

Fetal Death Neonatal

Post- neonatal

Maternal Health/ Prematurity

Maternal Care

Newborn Care

Infant Health

Birth

weig

ht

Age at Death

33

PPOR analytic methodsPPOR analytic methods Analytic Preparation Analytic Preparation

http://www.citymatch.org/PPOR/HowTo/Content/AnalyticReadinessWKSHOhttp://www.citymatch.org/PPOR/HowTo/Content/AnalyticReadinessWKSHOP.pptP.ppt

Acquire access to three required Acquire access to three required vital records computer filesvital records computer files

Prepare vital records files and Prepare vital records files and required data elementsrequired data elements

Assess data qualityAssess data quality Assess study sample sizeAssess study sample size

44

PPOR analytic methodsPPOR analytic methodsPhase I:THE MAPSPhase I:THE MAPS

http://www.citymatch.org/PPOR/HowTo/HowToDo.http://www.citymatch.org/PPOR/HowTo/HowToDo.htmhtm Define study populationDefine study population

Restrict study population by Restrict study population by birthweight and gestational agebirthweight and gestational age

Calculate numbers and rates for Calculate numbers and rates for the feto-infant mortality mapthe feto-infant mortality map

Compare different time periods, Compare different time periods, subpopulations and geographic subpopulations and geographic areasareas

55

PPOR analytic methodsPPOR analytic methodsPhase I, continued: THE GAPSPhase I, continued: THE GAPS

Select reference populationSelect reference population Calculate excess mortality rates Calculate excess mortality rates

and numbers of deathsand numbers of deaths Identify excess mortality gapsIdentify excess mortality gaps

66

PPOR Analytic MethodsPPOR Analytic Methods——

Phase 2 AnalysisPhase 2 Analysis Explains Explains whywhy the excess deaths the excess deaths

occurred so that appropriate occurred so that appropriate action can be taken.action can be taken.

77

PPOR is aboutPPOR is about ACTIONACTIONMaternal Health/

Prematurity

Maternal Care

Newborn Care

Infant Health

Preconception Health Health Behaviors Perinatal Care

Prenatal Care High Risk Referral Obstetric Care

Perinatal Management Neonatal Care Pediatric Surgery

Sleep Position Breast Feeding Injury Prevention

88

Three Phase 2 DirectionsThree Phase 2 Directions Community health and health Community health and health

systems assessmentsystems assessment Fetal Infant Mortality Reviews Fetal Infant Mortality Reviews

(FIMR)(FIMR) Further epidemiologic studyFurther epidemiologic study

PPOR Analytic Methods PPOR Analytic Methods ——

99


Phase 2 AnalysisPhase 2 Analysis

The third direction is the focus of The third direction is the focus of this presentation:this presentation:

Epidemiologically investigate Epidemiologically investigate the reasons for excess the reasons for excess mortalitymortality

1010


Steps of Phase 2 Analysis : Steps of Phase 2 Analysis :

Identify Identify causal pathwayscausal pathways or or biologic mechanisms for biologic mechanisms for excess mortalityexcess mortality

Estimate Estimate prevalenceprevalence of risk and of risk and preventive factors by type of preventive factors by type of mechanismmechanism

Estimate the Estimate the impactimpact of the risk of the risk and preventive factors.and preventive factors.

1111

PPOR Phase 2 AnalysesPPOR Phase 2 AnalysesLimitationsLimitations

Large number of deaths neededLarge number of deaths needed to obtain to obtain statistically significant because models are statistically significant because models are complex and effect sizes are small.complex and effect sizes are small.

Unlikely to identify new causesUnlikely to identify new causes because an because an observational study using vital records and observational study using vital records and existing data. existing data.

Unlikely to find a single cause for excess Unlikely to find a single cause for excess mortalitymortality because the feto-infant mortality it because the feto-infant mortality it is a multifactorial problemis a multifactorial problem

1212

How can we most How can we most effectively determine effectively determine the likely causes of the likely causes of excess deaths in our excess deaths in our

community?community?

1313

PPOR Phase 2 AnalysesPPOR Phase 2 Analyses StrategyStrategy

Eliminate factors unlikely to be Eliminate factors unlikely to be contributingcontributing

Find and target factors likely to be Find and target factors likely to be contributingcontributing

1414

PPOR Phase 2 AnalysesPPOR Phase 2 Analyses StrategyStrategy

A factor is a likely contributor if:A factor is a likely contributor if:

1.1. KNOWNKNOWN cause of death based on cause of death based on scientific literature.scientific literature.

2.2. MORE PREVALENTMORE PREVALENT among the among the population with excess deathspopulation with excess deaths

Impact analysis helps prioritize among Impact analysis helps prioritize among likely contributorslikely contributors

1515

Phase 2 Analysis PlanPhase 2 Analysis Plan

Depends on:Depends on:

Phase 1 Analysis resultsPhase 1 Analysis results

Availability of dataAvailability of data

Community prioritiesCommunity priorities

1616

Phase 2 Analysis PlanPhase 2 Analysis Plan

Guidelines Developed for :Guidelines Developed for :

Infant HealthInfant Health

Maternal Health/PrematurityMaternal Health/Prematurity

Recommendations for :Recommendations for :

Maternal CareMaternal Care

1717

Phase 2 Analyses Phase 2 Analyses Preparation Preparation

The The DEATH CERTIFICATEDEATH CERTIFICATE is the source of is the source of Age at deathAge at death Cause of deathCause of deathThe The BIRTH CERTIFICATEBIRTH CERTIFICATE is the source for is the source for Maternal characteristics & risk factorsMaternal characteristics & risk factors Circumstances of the birthCircumstances of the birth Infant risk factors & conditionsInfant risk factors & conditions Geo-coding (mother’s residence)Geo-coding (mother’s residence)

1818

Phase 2 Analyses Phase 2 Analyses Preparation of data for impact Preparation of data for impact

estimationestimation

o Use a birth cohort file of live births and Use a birth cohort file of live births and fetal deaths with linked deaths. fetal deaths with linked deaths.

o Convert death cohort files to a single Convert death cohort files to a single birth cohort file Combine linkedbirth cohort file Combine linked

o Add fetal deaths for the same year with Add fetal deaths for the same year with a variable indicating the outcome.a variable indicating the outcome.

1919

Preparation of data for impact estimationPreparation of data for impact estimation Converting 2000 and 2001 Converting 2000 and 2001 Period Files to a 2000 Birth Period Files to a 2000 Birth

Cohort FileCohort File Linked Linked FileFile

Year Year BornBorn

Year DiedYear Died ActionAction

20002000 19991999 20002000 OmitOmit

20002000 20002000 20002000 KeepKeep

20012001 20002000 20012001 KeepKeep

20012001 20012001 20012001 OmitOmit

2020

Data Source>Data Source> Birth/Fetal Birth/Fetal CertificateCertificate

Death Cert.Death Cert.

IDID OutcomeOutcome Birth-Birth-weightweight

Maternal Maternal AgeAge

Cause of Cause of DeathDeath

Fet01Fet01 Fetal Fetal DeathDeath

798798 1717 InfectionInfection

Fet02Fet02 Fetal Fetal DeathDeath

25372537 3434 Cong. Cong. AnomalyAnomaly

LB01LB01 SurviveSurvive 35113511 2222

LB02LB02 Infant Infant DeathDeath

23142314 2525 SIDSSIDS

LB03LB03 SurviveSurvive 12931293 2121

LB04LB04 Infant Infant DeathDeath

631631 2626 InfectionInfection

Preparation of data for impact Preparation of data for impact

estimationestimation Portion of birth cohort data Portion of birth cohort data

filefile

2121

Phase 2 Data Phase 2 Data PreparationPreparation

o Other files can be also now be linked to Other files can be also now be linked to the combined study filethe combined study file

o If geocoded according to street If geocoded according to street address, census tract or zip code (e.g.), address, census tract or zip code (e.g.), GIS analysis including neighborhood GIS analysis including neighborhood and community factors, census, crime, and community factors, census, crime, housing, etc. housing, etc.

2222

Phase 2 Analyses Phase 2 Analyses Preparation Preparation

OTHER DATA SETSOTHER DATA SETS to consider: to consider: Hospital discharge systemHospital discharge system PRAMSPRAMS Birth defects surveillanceBirth defects surveillance Pregnancy/Pediatric Nutrition Surveillance Pregnancy/Pediatric Nutrition Surveillance Injury surveillanceInjury surveillance STD reportsSTD reports Child abuse reporting systemsChild abuse reporting systems Program files (Medicaid, WIC, etc)Program files (Medicaid, WIC, etc) Linked program filesLinked program files

2323

When linked to birth certificates,other datasets can be used to estimate the impact of risk factors on mortality.

2424

INFANT HEALTH INFANT HEALTH PERIODPERIOD

Protocol is on the web atProtocol is on the web at http://www.citymatch.org/PPOR/HowTo/Content/PHAS2IH.dochttp://www.citymatch.org/PPOR/HowTo/Content/PHAS2IH.doc

2525

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod Identify causal pathways or Identify causal pathways or

biologic mechanisms for excess biologic mechanisms for excess mortalitymortality

Use Underlying Cause of Death Use Underlying Cause of Death

Categorize by CDC’s Postneonatal Categorize by CDC’s Postneonatal Mortality Surveillance System Mortality Surveillance System

birth defectsbirth defects infectionsinfections injuriesinjuries perinatal conditionsperinatal conditions SIDSSIDS other causesother causes

2626

Infant HealthInfant Health

SIDS

Injury

Infection

Anomalies

Each category has its

own set of risk

factorsPerinatal

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod

Identify causal pathways or biologic Identify causal pathways or biologic mechanisms for excess mortalitymechanisms for excess mortality

2727

Cause-specific mortality rate (CSMR)Cause-specific mortality rate (CSMR)

the number of deaths in each category the number of deaths in each category

number of live births>=1500gnumber of live births>=1500g

ExcessExcess Cause-specific mortality rate Cause-specific mortality rate

= Study Pop. CSMR – Ref. Pop. CSMR= Study Pop. CSMR – Ref. Pop. CSMR



2828

Example City

Number of IH

Deaths

IH Death Rate

Ref. IH Death

RateExcess CSMR

Congenital Anomaly 11 0.179 0.16 0.019

Infection 13 0.211 0.14 0.071

SIDS 75 1.219 0.84 0.379

Perinatal Conditions 31 0.504 0.25 0.254

Other/Undefined 16 0.260 0.27 -0.010

total IH 146 2.372 1.66 0.712

Live Births >= 1500g 61,540



2929

Cause-Specific Contribution to Excess Infant Health Deaths

Congenital Anomaly

3%

SIDS52%

Perinatal Conditions

35%

Infection10%

Example CityExample City

Excess Infant Health Mortality Rate=0.712 per 1000 live births

3030

Passive smokePassive smoke Sleep positionSleep position Breast-feedingBreast-feeding BeddingBedding Co-sleepCo-sleep Maternal ageMaternal age Death scene Death scene

investigationinvestigation

Folic acid intakeFolic acid intake Alpha-feto Alpha-feto

proteinprotein AlcoholAlcohol Drug abuseDrug abuse DiabetesDiabetes UltrasoundUltrasound Delivery siteDelivery site

SIDS Anomalies

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod Estimate prevalence of risk and Estimate prevalence of risk and

preventive factors by type of mechanismpreventive factors by type of mechanism

3131

Medical homeMedical home ImmunizationsImmunizations Breast-feedingBreast-feeding Passive smokePassive smoke Prenatal carePrenatal care Maternal ageMaternal age Infection typeInfection type

BeddingBedding SupervisionSupervision EnvironmentEnvironment Injury typeInjury type

InjuryInfection

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod Estimate prevalence of risk and Estimate prevalence of risk and

preventive factors by type of mechanismpreventive factors by type of mechanism

3232

SIDS—major contributor to excess SIDS—major contributor to excess deathsdeaths

Examine risk factor disparity for SIDSExamine risk factor disparity for SIDS Compare prevalence between study Compare prevalence between study

population to reference populationpopulation to reference population Denominator is all live birthsDenominator is all live births

Estimate prevalence of risk and Estimate prevalence of risk and preventive factors by type of mechanismpreventive factors by type of mechanism

3333

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod OTHER DATA SETSOTHER DATA SETS to consider: to consider:

Hospital discharge systemHospital discharge system PRAMSPRAMS Birth defects surveillanceBirth defects surveillance Pregnancy/Pediatric Nutrition Surveillance Pregnancy/Pediatric Nutrition Surveillance Injury surveillanceInjury surveillance STD reportsSTD reports Child abuse reporting systemsChild abuse reporting systems Program files (Medicaid, WIC, etc)Program files (Medicaid, WIC, etc) Linked program filesLinked program files

3434

Phase 2 Analyses-Infant Health PeriodPhase 2 Analyses-Infant Health Period

Example CityExample CityPrevalence of SIDS Risk Factors Among Live Prevalence of SIDS Risk Factors Among Live Births Study versus Reference PopulationsBirths Study versus Reference Populations

20.4

15.4

8

11.2 10.1 10

0

5

10

15

20

25

TeenMothers

Sleepingon

Stomach

Smoking

Study PopReference Pop

3535

Phase 2 Analyses-Infant Health Phase 2 Analyses-Infant Health PeriodPeriod Estimate the impact of the risk Estimate the impact of the risk

and preventive factorsand preventive factors

Risk Ratio or Relative RiskRisk Ratio or Relative Risk Probability of disease Probability of disease

in the exposed in the exposed population divided by population divided by the probability of the probability of disease in the disease in the unexposed unexposed populationpopulation

A/(A+B)A/(A+B)RR= RR=

C/(C+D)C/(C+D)

OutcomOutcome Yese Yes

OutcomOutcomee

NoNo

Risk Risk FactorFactor

YesYes

AA BB

Risk Risk Factor Factor NoNo

CC DD

3636

Population Attributable Risk Population Attributable Risk PercentPercent

Compares the rate for the whole population Compares the rate for the whole population to the rate for those WITHOUT the risk factorto the rate for those WITHOUT the risk factor

Based on the relative risk and the prevalence Based on the relative risk and the prevalence of the exposure for the whole population.of the exposure for the whole population.

Has a meaningful interpretation: Has a meaningful interpretation: “Percent of “Percent of the population that would be prevented from the population that would be prevented from the poor outcome if the risk factor were the poor outcome if the risk factor were eliminated from the entire population.”eliminated from the entire population.”

Relevant to overall impact and cost.Relevant to overall impact and cost.


Estimate the impact of the risk and preventive factorsEstimate the impact of the risk and preventive factors

3737

Population Attributable RiskPopulation Attributable RiskDeb Rosenberg recommends using the formulaDeb Rosenberg recommends using the formula

PAR = PPAR = P0 0 – P– P22

Where Where PP00 is the proportion of the whole population that have the bad is the proportion of the whole population that have the bad

outcomeoutcomePP2 2 is the proportion of those without the risk factor that have the bad is the proportion of those without the risk factor that have the bad

outcome.outcome.

The difference is interpreted as the proportion of bad outcomes that The difference is interpreted as the proportion of bad outcomes that would be eliminated if no-one in the population had the risk would be eliminated if no-one in the population had the risk factor. This is the proportion of bad outcomes that can be factor. This is the proportion of bad outcomes that can be “attributed” to the factor.“attributed” to the factor.



3838

Population Attributable Risk Percent Population Attributable Risk Percent (PAR%)(PAR%)

PAR% = {P (RR-1) /1+P (RR-1)} x 100PAR% = {P (RR-1) /1+P (RR-1)} x 100

WhereWhere P P = proportion of the population with a = proportion of the population with a particular risk factor, and particular risk factor, and

RRRR = Risk Ratio = Risk Ratio (can substitute Adjusted Odds Ratio or (can substitute Adjusted Odds Ratio or RR from logistic regression or published literature)RR from logistic regression or published literature)



3939

PAR ResourcesPAR Resources

http://www.soph.uab.edu/mch-imrm/stats.htm,

LEVIN 1953, Fleiss 1981 p76 Calculator at : http://

www.urmc.rochester.edu/cpm/education/mach/PARC.xls

4040

Phase 2 Analyses-Infant Health PeriodPhase 2 Analyses-Infant Health Period PAR% EXAMPLE: PAR% EXAMPLE: EXAMPLEEXAMPLE INFANT INFANT MORTALITY ATTRIBUTABLE TO TEEN MORTALITY ATTRIBUTABLE TO TEEN

MATERNAL AGEMATERNAL AGE Example:Example: RR=1.998RR=1.998 PAR%=8.94PAR%=8.94

Maternal Age

Infant Deaths

Infants Surviving

<=19 35 3082

>=20 159 27897

If no teen births occurred, 8.94% fewer babies If no teen births occurred, 8.94% fewer babies would die in Example. This translates to 17 fewer would die in Example. This translates to 17 fewer deaths, or a reduction in IMR from 6.2 to 5.7 per deaths, or a reduction in IMR from 6.2 to 5.7 per thousand live births.thousand live births.

4141

MATERNAL HEALTH / MATERNAL HEALTH / PREMATURITY PREMATURITY

PERIODPERIODProtocol is on the web atProtocol is on the web at

http://www.citymatch.org/PPOR/HowTo/Content/PHAS2MH.dhttp://www.citymatch.org/PPOR/HowTo/Content/PHAS2MH.dococ

4242

Causes for 500-1,499g areCauses for 500-1,499g are MultifactorialMultifactorial ComplexComplex InconsistentInconsistent Varies by trainingVaries by training

Phase 2 Analyses-Mat. Phase 2 Analyses-Mat. Health/Prem.Health/Prem.


4343

Kitagawa’sKitagawa’s formula algebraically formula algebraically partitions excess mortality into 2 partitions excess mortality into 2 stratastrata

portion to portion to birthweight distributionbirthweight distribution portion to portion to birthweight specific birthweight specific

mortalitymortality



4444

KitagawaKitagawa



Maternal Health/ Maternal Health/ PrematurityPrematurity

Birthweight Distribution

Birthweight- Specific Mortality

4545

n

nnnn

nnnn PP

MMMM

PP1 21

2121

21 )(2

)()(

2

)(



The Kitagawa FormulaThe Kitagawa Formula

Where “P” stands for birthweight distribution (proportion of births in stratum n)

And “M” stands for specific mortality (the mortality rate in stratum n)

http://www.citymatch.org/PPOR/HowTo/Content/kitgawa_updated_98_00.xls

(save the spreadsheet on your own computer)

4646

Contribution to Mortality Contribution to Mortality DifferenceDifference

Birth Birth weightweight

Bwt Bwt Dist.Dist.

Mort. Mort. RateRate

Bwt Bwt Dist.Dist.

Mort.Mort.

RateRate

500-749500-749 0.4%0.4% 612.5612.5 0.2%0.2% 573.5573.5

750-999750-999 0.4%0.4% 205.5205.5 0.2%0.2% 244.3244.3

1000-12491000-1249 0.3%0.3% 166.7166.7 0.2%0.2% 134.6134.6

1250-14991250-1499 0.5%0.5% 117.0117.0 0.3%0.3% 98.098.0

1500-19991500-1999 1.9%1.9% 66.966.9 1.1%1.1% 50.450.4

2000-24992000-2499 4.9%4.9% 20.120.1 3.4%3.4% 19.919.9

2500+2500+ 91.691.6 3.63.6 94.5%94.5% 2.72.7

TotalTotal 100%100% 10.010.0 100%100% 6.06.0

Pinellas County National Reference Group

4747

Contribution to Mortality Contribution to Mortality DifferenceDifference

Pinellas County vs National Reference GroupPinellas County vs National Reference Group

Birth Birth WeightWeight

Birthweight Birthweight DistributionDistribution

MortalitMortality Ratey Rate

CombinedCombined

500-749500-749 1.41.4 0.10.1 1.51.5

750-999750-999 0.40.4 -0.1-0.1 0.30.3

1000-12491000-1249 0.10.1 0.10.1 0.20.2

1250-14991250-1499 0.20.2 0.10.1 0.30.3

1500-19991500-1999 0.40.4 0.20.2 0.70.7

2000-24992000-2499 0.30.3 0.00.0 0.30.3

2500+2500+ -0.1-0.1 0.80.8 0.70.7

TotalTotal 2.82.8 1.21.2 4.04.0

4848

Feto-Infant Mortality Feto-Infant Mortality Contribution to MortalityContribution to Mortality

Pinellas County vs National Reference Pinellas County vs National Reference GroupGroup

70%

30%

91%

9%

Distribution Mortality Rates

Total Fetal Infant Mortality

Maternal Health/ Prematurity

Mortality

4949

Presenting kitagawa resultsPresenting kitagawa resultsKitagawa: Most Common Kitagawa: Most Common

ConclusionConclusion ““The predominant cause of death for VLBW The predominant cause of death for VLBW

babies is birthweight distribution: too many babies is birthweight distribution: too many babies are born at very low weights. Our babies are born at very low weights. Our community will benefit most by preventing community will benefit most by preventing prematurity”prematurity”

““Birthweight-specific mortality nearly Birthweight-specific mortality nearly matches that of the reference group. Babies matches that of the reference group. Babies born too small are surviving nearly as well as born too small are surviving nearly as well as babies in the reference group.”babies in the reference group.”

5050

Presenting kitagawa resultsPresenting kitagawa resultsKitagawa: Some cities have up to 40% Kitagawa: Some cities have up to 40% of excess deaths in the MH/P period of of excess deaths in the MH/P period of

risk due to birthweight specific risk due to birthweight specific mortality.mortality.

““Birthweight-specific mortality in our Birthweight-specific mortality in our target group is not as good as it is in the target group is not as good as it is in the reference group. Babies in that group reference group. Babies in that group that are born too small are not surviving that are born too small are not surviving as well as can be expected.”as well as can be expected.”

5151

SmokingSmoking Prenatal carePrenatal care RaceRace Maternal ageMaternal age ParityParity STD/Bacterial Vag.STD/Bacterial Vag. Multiple Preg.Multiple Preg. SES/EducationSES/Education Birth IntervalBirth Interval Maternal HTN/DiabetesMaternal HTN/Diabetes

Gestational ageGestational age Referral systemReferral system Perinatal carePerinatal care Mat. complicationsMat. complications Neonatal conditionsNeonatal conditions Pay sourcePay source

Birthweight Distribution (VLBW Births)



Estimate prevalence of risk and Estimate prevalence of risk and preventive factors by type of preventive factors by type of

mechanismmechanism

5252

Maternal Health/ Maternal Health/ PrematurityPrematurity

Birthweight Distribution


Percent VLBW

VLBW Births and Fetal Deaths

All Births And Fetal

Deaths

Mortality Rate

OUTCOME DENOMINATOR

Phase 2 Analyses-Mat. Phase 2 Analyses-Mat. Health/Prem. Health/Prem. Estimate prevalence of Estimate prevalence of risk and preventive factors by type of risk and preventive factors by type of

mechanismmechanism

5353

Prematurity—major contributor to Prematurity—major contributor to excess deathsexcess deaths

Examine risk factor disparity for Examine risk factor disparity for prematurityprematurity

Compare prevalence between study Compare prevalence between study population to reference populationpopulation to reference population

Denominator is all live birthsDenominator is all live births

Phase 2 Analyses-Mat. Phase 2 Analyses-Mat. Health/Prem.Health/Prem. Estimate prevalence of Estimate prevalence of

risk and preventive factors by type of risk and preventive factors by type of mechanismmechanism

5454

Phase 2 Analyses-Mat. Health/Prem.Phase 2 Analyses-Mat. Health/Prem.

Estimate prevalence of risk and preventive Estimate prevalence of risk and preventive factorsfactors

OTHER DATA SETSOTHER DATA SETS to consider: to consider: Hospital discharge systemHospital discharge system PRAMSPRAMS Birth defects surveillanceBirth defects surveillance Pregnancy/Pediatric Nutrition Surveillance Pregnancy/Pediatric Nutrition Surveillance Injury surveillanceInjury surveillance STD reportsSTD reports Child abuse reporting systemsChild abuse reporting systems Program files (Medicaid, WIC, etc)Program files (Medicaid, WIC, etc) Linked program filesLinked program files

5555

Should fetal deaths be Should fetal deaths be included in study of VLBW included in study of VLBW

Births?Births? Risk factor information on fetal deaths is Risk factor information on fetal deaths is

more frequently missing.more frequently missing.

Excluding fetal deaths will have little Excluding fetal deaths will have little impact because they make up less than impact because they make up less than 1% of all births in most communities. 1% of all births in most communities.

5656

Example CityExample CityPrevalence of Prematurity Risk FactorsPrevalence of Prematurity Risk Factors

Non-Hispanic White versus Ref. Non-Hispanic White versus Ref. PopulationPopulation

153022

75

020406080

100

Smoking DuringPregnancy

Satisfaction withPrenatal Care

Per

cen

t o

f A

ll L

ive

Bir

ths

Reference Population White, Non-Hispanic

5757

70

5

3010

0

20

40

60

80

100

Teenage Mothers Multiple Births

Per

cen

t o

f al

l li

ve b

irth

s

Black, Non-Hispanic Reference Population

Example CityExample CityPrevalence of Prematurity Risk FactorsPrevalence of Prematurity Risk Factors

Non-Hispanic Black versus Ref. Non-Hispanic Black versus Ref. PopulationPopulation

5858

PluralityPlurality

PPOR analyses are not restricted to PPOR analyses are not restricted to singleton live births. Multiple births singleton live births. Multiple births contribute to a community’s feto-infant contribute to a community’s feto-infant mortality rate and may contribute to mortality rate and may contribute to an increasing rate or population an increasing rate or population disparity. These births should be disparity. These births should be include in Phase 1 Analysis and further include in Phase 1 Analysis and further studied as part of the Phase 2 Analysis studied as part of the Phase 2 Analysis

5959

Plurality—bill’s slidePlurality—bill’s slide

Multiple births can contribute to a Multiple births can contribute to a community’s feto-infant mortality community’s feto-infant mortality rate, increasing trend or population rate, increasing trend or population disparity. disparity.

Phase 1 Analysis is not restricted to Phase 1 Analysis is not restricted to singleton live births. singleton live births.

Plurality studied separately as part of Plurality studied separately as part of Phase 2 Analyses.Phase 2 Analyses.

6060

PluralityPlurality

PPOR analyses are not restricted to PPOR analyses are not restricted to singleton live births. Multiple births singleton live births. Multiple births contribute to a community’s feto-infant contribute to a community’s feto-infant mortality rate and may contribute to mortality rate and may contribute to an increasing rate or population an increasing rate or population disparity. These births should be disparity. These births should be include in Phase 1 Analysis and further include in Phase 1 Analysis and further studied as part of the Phase 2 Analysis studied as part of the Phase 2 Analysis

6161

Map of Fetal-Infant Mortality Map of Fetal-Infant Mortality RatesRates by Pluralityby Plurality

Baltimore City 1997–99Baltimore City 1997–99

61.8 (52)61.8 (52)

0.00.0

(0)(0)

34.434.4

(29)(29)

28.528.5

(24)(24)

Total Rate = 124.7 per 1000

Multiple Gestation

Excess Deaths = 95

5.4 (151)5.4 (151)

3.33.3

(92)(92)

1.01.0

(29)(29)

2.22.2

(62)(62)

Total Rate = 11.9 per 1000

Singleton

6262

Map of Map of ExcessExcess Fetal-Infant Fetal-Infant DeathsDeaths

Baltimore City, 1997 – 1999Baltimore City, 1997 – 1999Multiple Gestation to Singleton Multiple Gestation to Singleton

PregnancyPregnancy

50%0%

-3%

23%Maternal Health/PrematurityMaternal Care

Newborn Care

Infant Health

6363

FIMR RecommendationsFIMR RecommendationsMultiple Gestation Multiple Gestation

PregnancyPregnancy Baltimore City, 1997 – 1999Baltimore City, 1997 – 1999

Increase awareness of the increased Increase awareness of the increased risk associated with multiple risk associated with multiple gestation pregnancy in the gestation pregnancy in the community.community.

Improve case management of Improve case management of multiple gestation pregnancy.multiple gestation pregnancy. Educate the provider communityEducate the provider community Modify the Prenatal Risk Assessment Modify the Prenatal Risk Assessment

protocol to include multiple gestation as protocol to include multiple gestation as a risk factor for referral to the Maternal a risk factor for referral to the Maternal and Infant nursing program.and Infant nursing program.

6464

•Relative risk•Population attributable risk•Logistic regression for adjusted odds ratios

Phase 2 Analyses-Mat. Phase 2 Analyses-Mat. Health/Prem.Health/Prem. Estimate the impact of Estimate the impact of

the risk and preventive factorsthe risk and preventive factors

6565

Impact of Risk Factors for Orange County 1999

Comparison Adjusted Odds-Ratio

95% Confidence Interval

White Hispanics vs. Non-Whites Hispanics

1.105 0.896-1.362

Black Non-Hispanic vs. White Non-Hispanics

1.667 1.364-2.038

Odds Ratio adjusting for: Age, Marital Status, Number of Pre-natal visits, weight gain, mother’s education, mother’s tobacco use and mother’s alcohol use.

Phase 2 Analyses-Mat. Phase 2 Analyses-Mat. Health/Prem.Health/Prem. Estimate the impact of Estimate the impact of

the risk and preventive factorsthe risk and preventive factors

6666

LNP Healthy Start – Pop. Attributable Risk for LNP Healthy Start – Pop. Attributable Risk for VLBWVLBW

FactorFactor PARPAR RR RR

(95% CI)(95% CI)

Previous Preterm DeliveryPrevious Preterm Delivery 16.0%16.0% 136.9136.9

(59.0-341.7)(59.0-341.7)

Pregnancy Related HypertensionPregnancy Related Hypertension 11.8%11.8% 4.84.8

(3.1-7.3)(3.1-7.3)

Inadequate PNC and Eclampsia or Inadequate PNC and Eclampsia or Hypertension (Chronic or Hypertension (Chronic or pregnancy induced) pregnancy induced)

8.3%8.3% 3.7 3.7

(1.6-7.6)(1.6-7.6)

Chronic HypertensionChronic Hypertension 6.7%6.7% 3.33.3

(1.5-6.5)(1.5-6.5)

Med Risk Factors and Inadequate Med Risk Factors and Inadequate PNCPNC

3.3%3.3% 2.5 2.5

(1.5-4.0)(1.5-4.0)

High ParityHigh Parity 1.7%1.7% 1.8 1.8

(1.3-2.5)(1.3-2.5)

SmokingSmoking 0.4%0.4% 1.2 1.2

(.79-1.7)(.79-1.7)

Inadequate PNCInadequate PNC 0%0% 1.01.0

(.7-1.4)(.7-1.4)

PAR results help focus discussions on specific interventions for reduction of VLBW in Lower North HS area

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PPOR Phase II AnalysisPPOR Phase II AnalysisUseful Epidemiological ToolsUseful Epidemiological Tools

•KitagawaKitagawa•Relative RiskRelative Risk•Odds RatioOdds Ratio•Population Attributable RiskPopulation Attributable Risk•Logistic RegressionLogistic Regression•Poisson RegressionPoisson Regression•Multi-level ModelingMulti-level Modeling

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MATERNAL MATERNAL CARE PERIODCARE PERIOD

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Phase 2 Analyses-Maternal Care Phase 2 Analyses-Maternal Care PeriodPeriod

The epidemiology of fetal deaths is The epidemiology of fetal deaths is less knownless known

Fetal Deaths have more missing Fetal Deaths have more missing informationinformation

Causal pathways such as Causal pathways such as chromosomal abnormalities, severe chromosomal abnormalities, severe congenital anomalies, and placental congenital anomalies, and placental vascular abnormalities not captured vascular abnormalities not captured on vital records on vital records

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Risk Factors that are more reliably Risk Factors that are more reliably collected on fetal death certificates includecollected on fetal death certificates include Birthweight and Gestational ageBirthweight and Gestational age Maternal age and raceMaternal age and race Parity and previous fetal lossParity and previous fetal loss SmokingSmoking Education/socioeconomicEducation/socioeconomic Inter-pregnancy intervalInter-pregnancy interval Multiple gestationMultiple gestation

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Risk Factors from other data sourcesRisk Factors from other data sources BMIBMI Weight gained during pregnancy adjusted for BMIWeight gained during pregnancy adjusted for BMI DiabetesDiabetes HypertensionHypertension RH diseaseRH disease

FIMR can be used to examine larger fetal FIMR can be used to examine larger fetal deathsdeaths

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USE OF FIMRUSE OF FIMR

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Integrating PPOR & FIMRIntegrating PPOR & FIMR

•PPOR and FIMR have complementary strengths.

•PPOR and FIMR use similar community-oriented processes.

•An existing FIMR Community Action Team might include the community stakeholders that the PPOR approach requires, and vice-versa.

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Integrating PPOR & FIMRIntegrating PPOR & FIMR

•FIMR data can help in Phase 2 of PPOR Analysis, as a way to better understand the reasons for excess deaths.

•PPOR can help an existing FIMR team by providing a context or framework for their case reviews and community action teams.

•PPOR can help a community focus their FIMR reviews on cases that will most benefit the community.

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Integrating FIMR & PPORIntegrating FIMR & PPORthe Magnolia Project in Jacksonville, FLthe Magnolia Project in Jacksonville, FL

Annual Annual update of contributing update of contributing factorsfactors using PPOR framework using PPOR framework

Case selectionCase selection to gain info on PPOR to gain info on PPOR areas of concernareas of concern

2000-YTD 2003 case reviews: 2000-YTD 2003 case reviews: maternal health, black outcomes, maternal health, black outcomes, target area (n=99)target area (n=99)

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Integrating PPOR & FIMRIntegrating PPOR & FIMRthe Magnolia Project in Jacksonville, FL, the Magnolia Project in Jacksonville, FL,

1995-19991995-1999

MATERNAL HEALTHMATERNAL HEALTH

(n=28)(n=28) 85%–Preterm labor or premature 85%–Preterm labor or premature

rupture of membranesrupture of membranes 46%–Sexually transmitted diseases46%–Sexually transmitted diseases 36%–Maternal age less than 21 years or 36%–Maternal age less than 21 years or

more than 35 yearsmore than 35 years 36%–No, late or inconsistent prenatal 36%–No, late or inconsistent prenatal

carecare 32%–Infant infection32%–Infant infection 29%–Pre-existing medical condition29%–Pre-existing medical condition 29%–Substance use (alcohol, tobacco or 29%–Substance use (alcohol, tobacco or

drugs)drugs) 25%–Maternal obesity25%–Maternal obesity 25%–History of previous adverse 25%–History of previous adverse

pregnancy outcomepregnancy outcome 21%–Family planning issues21%–Family planning issues

MATERNAL CAREMATERNAL CARE

(n= 15)(n= 15) 67%–Sexually transmitted 67%–Sexually transmitted

diseasesdiseases 47%–Lack of patient 47%–Lack of patient

educationeducation 33%–Maternal obesity 33%–Maternal obesity 33%–No, late or 33%–No, late or

inconsistent prenatal careinconsistent prenatal care 33%–Substance use 33%–Substance use

(alcohol, tobacco or drugs)(alcohol, tobacco or drugs)

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NEWBORN CARENEWBORN CARE

(n=29)(n=29) 55%–Pre-existing infant medical condition55%–Pre-existing infant medical condition 45%–No, late or inconsistent prenatal care45%–No, late or inconsistent prenatal care 34%–Maternal age less than 21 years or 34%–Maternal age less than 21 years or

more than 35 yearsmore than 35 years 31%–No Healthy Start screening 31%–No Healthy Start screening

completedcompleted 28%–History of previous adverse 28%–History of previous adverse

pregnancy outcomepregnancy outcome 21%–Family planning issues21%–Family planning issues 21%–Lack of support systems21%–Lack of support systems 21%–Preterm labor or premature rupture 21%–Preterm labor or premature rupture

of membranesof membranes 21%–Sexually transmitted diseases21%–Sexually transmitted diseases 21%–Substance use (alcohol, tobacco or 21%–Substance use (alcohol, tobacco or

drugs)drugs)

INFANT HEALTHINFANT HEALTH

(n=44)(n=44) 52%–Sexually transmitted 52%–Sexually transmitted

diseasesdiseases 48%–No, late or inconsistent 48%–No, late or inconsistent

prenatal careprenatal care 41%–Need for SIDS education41%–Need for SIDS education 36%–Maternal age less than 21 36%–Maternal age less than 21

years or more than 35 yearsyears or more than 35 years 25%–Pre-existing infant medical 25%–Pre-existing infant medical

conditioncondition 25%–Maternal obesity25%–Maternal obesity 23%–Lack of preventive and 23%–Lack of preventive and

medical follow upmedical follow up

Integrating PPOR & FIMRIntegrating PPOR & FIMRthe Magnolia Project in Jacksonville, FL, the Magnolia Project in Jacksonville, FL,

1995-19991995-1999

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Role of FIMRRole of FIMRthe Magnolia Project in Jacksonville, FLthe Magnolia Project in Jacksonville, FL

Aggregate info on contributing factors Aggregate info on contributing factors can help can help identify specific needs, risksidentify specific needs, risks

FIMR info can be used to formulate, FIMR info can be used to formulate, tailor tailor interventionsinterventions

FIMR findings can be used to FIMR findings can be used to monitor monitor impactimpact of new interventions of new interventions

PPOR questions can guide PPOR questions can guide case case selectionselection process process

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USE OF USE OF GISGIS

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PPOR rates by Neighborhood (red=higher than city rate Philadelphia, PAPhiladelphia, PA)

Maternal Maternal Health/ Health/ Prematurity Prematurity

Maternal Maternal CareCare

Newborn Newborn CareCare

Infant Infant HealthHealth

TotalTotal

All All PhiladelphiaPhiladelphia

5.1 5.1 3.0 3.0 1.5 1.5 2.7 2.7 12.3 12.3

SouthSouth 5.2 5.2 1.6 1.6 1.7 1.7 2.1 2.1 10.6 10.6

SouthwestSouthwest 4.6 4.6 3.7 3.7 1.6 1.6 3.6 3.6 13.513.5

WestWest 6.8 6.8 3.0 3.0 1.8 1.8 2.8 2.8 14.4 14.4

Lower NorthLower North 9.5 9.5 3.5 3.5 2.2 2.2 3.5 3.5 18.7 18.7

Upper NorthUpper North 6.6 6.6 4.0 4.0 1.8 1.8 4.1 4.1 16.5 16.5

Bridesburg/Bridesburg/Kensington/Kensington/RichmondRichmond

4.3 4.3 3.8 3.8 1.7 1.7 2.6 2.6 12.4 12.4

Olney/oak Olney/oak LaneLane

4.2 4.2 2.7 2.7 0.7 0.7 3.93.9 11.5 11.5

Lower NELower NE 3.5 3.5 2.4 2.4 1.3 1.3 1.3 1.3 8.5 8.5

Upper NEUpper NE 3.2 3.2 3.8 3.8 1.4 1.4 0.7 0.7 9.1 9.1

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Very Low Birth Weight Births Very Low Birth Weight Births 1998-2000 Density Analysis1998-2000 Density Analysis

Philadelphia, PAPhiladelphia, PA

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The Magnolia ProjectThe Magnolia Project Project area:Project area: Five zip codesFive zip codes in in NW NW

JacksonvilleJacksonville Account for Account for more more than than halfhalf of the Black infant mortality of the Black infant mortality in the cityin the city

About About 25,000 women25,000 women age 15-44 age 15-44 years oldyears old live in the project area live in the project area

85%85% African-AmericanAfrican-American

1 The Perinatal Periods of Risk CityMatCH

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