Fetal and InfantMortality Review

(FIMR)

Marion County Health Department

Perinatal Periods of Risk:The PPOR Map

• Developed over a decade ago to:– Monitor and investigate fetal-infant mortality.– Identify community gaps/challenges in perinatal health.

– Develop interventions to address these challenges.

• Operates in a cycle to:– Assess the problems.– Identify strategies.– Create and implement an action plan.– Monitor and evaluate progress.– Apply lessons learned and continue commitment in a

sustained fashion.

Why does the PPOR Map Work?• It is strategic.

– It’s a plan.

• It is consistent.– It sets a standard for terminology and formulas.– Can now compare statistics no matter where you are.

• It is data driven.– It uses real-time statistics.– We are no longer guessing.

• It is formal and provides:– Who– Where– Why– Now know who to target for future efforts

Understanding the PPOR Mapof Fetal-Infant Mortality

Connecting Results to Actions

PPOR Focus AreaPotential Action Areas for Community Interventions to Decrease Deaths in this

Category

Maternal Health/Prematurity

Preconceptual HealthHealth BehaviorsPerinatal Care

Maternal CarePrenatal CareReferral SystemHigh Risk OB Care

Newborn CarePerinatal ManagementPerinatal SystemPediatric Surgery

Infant HealthSleep PositionBreast-FeedingInjury Prevention

PPOR Map Examples: Example 1:•Age at death = Neonatal

•Birthweight = 1,600 grams

•This means = Newborn Care

PPOR Focus Area Potential Action Area

Newborn CarePerinatal ManagementPerinatal SystemPediatric Surgery

PPOR Map Examples: Example 2:•Age at death = Post-Neonatal

•Birthweight = 1,700 grams

•This means = Infant Health

PPOR Focus Area Potential Action Area

Infant HealthSleep PositionBreast-FeedingInjury Prevention

The Tale of Three Cities: The PPOR in Action.

• From 1995 to 1997 three cities had an IMR of:

• City 1- 12.5• City 2- 12.0• City 3- 12.8

Looking at these rates: • Do we know at what age in the perinatal period

that babies are dying the most?• Do we know where it is happening or who it is

happening to? • Do we know why it is happening?• Do we know what interventions can be done to

improve each cities infant mortality rate?

Plugging in the Numbers…

12.5 12.0 12.8

City 2 City 3

First we calculate the IMR for each of the four primary PPOR categories and plug it into the PPOR:•Maternal Health/Prematurity•Maternal Care•Newborn Care•Infant Health

City 1

4.7

3.4 1.7 2.7City 1

5.2

3.0 1.9 2.0City 1

5.0

2.2 2.2 3.5

City 1

The total score =

Fetal-Infant MortalityNational Reference Group Rates* for 1998-2000

Compared to Marion County Reference groupRates per 1,000 pregnancies and (total deaths)

500-1499 g

1500+ g

Fetal Death Neonatal

Post- neonatal

2.2(8,671)

1.5(6,002)

1.1(4,437)

1.0(3,944)

*Total number of pregnancies=3,907,458, overall rate=5.9** PPOR reference group data at www.citymatch.org/ppor. National data uses cities with >250,000 population by state.

1.93(27)

United States rates Marion County rates

1.00(14)

1.15(16)

.93(13)

Marion County, Indiana Fetal-Infant Mortality1999-2003 Birth Cohort Data

Rates per 1,000 pregnancies and (total number of deaths)

500-1499 g

1500+ g

Fetal Death

NeonatalPost-

neonatal

3.88 (273)

2.09 (147)

1.42 (100)

2.31 (163)

Total number of pregnancies=70,431 Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, IN

9.70

Excess (Preventable) Infant Mortality Rates for Marion County, Indiana

9.70 5.01 4.69

All Races* Reference Excess/Preventable

Total number of pregnancies + 13.955 overall rate = 5.02

*Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, In

City 1

3.88

2.09 1.42 2.31

City 1

1.93

1 1.15 .93

City 1

1.95

1.09 .27 1.38

What to do with PPOR Map data:

• We can see that the highest IM rate falls into the Maternal Health/Prematurity Category.

• We can evaluate the demographics of the category to find out more about the mothers and their stories.

• We can target these women in the community and educate or assist them.

• We can focus our efforts on the areas listed in the corresponding potential action area to decrease future infant mortality.

City 1

3.88

2.09 1.42 2.31

Marion CountyPotential

Action Area

Preconceptual Health

Health Behaviors

Perinatal Care

PPOR Map Results for Excess Deaths in Marion County, Indiana

Maternal Health/Prematurity Category

This category had the largest number of excess deaths in Marion County

(Fetal, Neonatal, Post neonatal deaths of infants 500-1,499 g)

Category Demographics Part 1:

• Mothers with the highest rate of excess deaths in category:

African American women and women age 20 to 34 years old.

• Top zip code areas with the highest rates for VLBW in category:

46202, 46205, 46208, 46214, 46218, 46226, 46228

• Mothers with >40% chance of mortality due to birth-weight:

Black women and women age 20 to 34 years old.

PPOR Map Results for Excess Deaths in Marion County, Indiana

Maternal Health/Prematurity Category

This category had the largest number of excess deaths in Marion County

(Fetal, Neonatal, Post neonatal deaths of infants 500-1,499 g)

Category Demographics Continued:

• Mothers with the highest probability of having a VLBW infant:

Single women with an education of 12 years or less, women who smoked during pregnancy, Black women and women age 24 or younger.

• Risk Factors for this category of having a VLBW birth:

Black women were 1.9 times more likely to have an intermediate-level/amount of prenatal care than the reference group. Women age 20 to 34 years were 1.7 times more likely than the reference group.

Potential Action Area

Preconceptual HealthHealth BehaviorsPerinatal Care

•Category Demographics:

•Suffocation Related Deaths and Racial Differences:

• Blacks were mentioned as having been found on an adult bed 2.5 times more than Whites. Whites were mentioned as sleeping with multiple family members (bed sharing) 3 times more than Blacks.

•Causes of Infant Deaths For Category:• Highest category is injury (39%), with most being suffocation deaths.

Largest number of deaths occurred while co-sleeping on an adult bed or sofa.

PPOR Map Results for Excess Deaths in Marion County, Indiana

Infant Health Category(Post neonatal deaths of infants weighing 1,500 g or more at birth)

This category had the second largest number of excess deaths in Marion County

Potential Action Area

Sleep PositionBreast FeedingInjury Prevention

Category Demographics:

Causes of Fetal Death:• Perinatal Conditions contributed largely (74%) with the top

contributor “fetal death of unspecified cause” (35%).

Potential Action Area

Prenatal CareHigh Risk ReferralObstetric Care

PPOR Map Results for Excess Deaths in Marion County, Indiana

Maternal Care Category(Fetal deaths of infants weighing 1,500 g or more at birth)

This category had the third largest number of excess deaths in Marion County

To date, the data for this category has not been examined.

PPOR Map Results for Excess Deaths in Marion County, Indiana

Newborn Care Category(Neonatal deaths of infants weighing 1,500 g or more at birth)

This category had the least number of excess deaths in Marion County

Potential Action Area

Perinatal ManagementNeonatal CarePediatric Surgery

PPOR Will Allow FIMR to:

• Focus FIMR activities on the group contributing to the gap.

• Describe in greater depth the risk factors, events or services that may contribute to the gap.

• Validate the quality of vital records and other information.

• Paint the faces behind the numbers.