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