Jamie S. Kim, MPH Co-Authors: Carol Gilbert, MS and Laurin Kasehagen, MA, PhD June 5, 2012

Our Vision – Healthy Kansans living in safe and sustainable environments.1

Our Vision – Healthy Kansans living in safe and sustainable environments.

Perinatal Periods of Risk (PPOR) approach to better understand

fetal-infant mortality: A State-level analysis in Kansas 2005-2009

Jamie S. Kim, MPH

Co-Authors: Carol Gilbert, MS and Laurin Kasehagen, MA, PhD

June 5, 2012

2


Acknowledgement CityMatCH: Carol Gilbert and Dr. Laurin Kasehagen

http://www.citymatch.org/ Kansas Department of Health and Environment:

http://www.kdheks.gov/ Bureau of Epidemiology and Public Health Informatics - Greg

Crawford, Carol Moyer, Dr. Farah Ahmed and Joy Crevoiserat Bureau of Family Health staff (especially Linda Williams, Dr. Debbie

Richardson, Joseph Kotsch, Jamey Kendall, Marc Shiff and Dave Thomason)

Center for Performance Management - Brenda Nickel Center for Health Equity - Aiko Allen

Kansas Blue Ribbon Panel on Infant Mortality and Connie Satzler (and her staff): http://kansasinfantmortality.org/

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http://www.citymatch.org/

http://www.kdheks.gov/

http://kansasinfantmortality.org/


Infant Mortality in Kansas

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The Problem

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

2

4

6

8

10

Infant Mortality Rate TrendsKansas and U.S., 2000-2009

Rate

per

1,0

00 li

ve b

irths

Source: Bureau of Epidemiology and Public Health Informatics, KDHE; National Center for Health Statistics

5


The Problem

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2

4

6

8

10

Infant Mortality Rate TrendsKansas and U.S., 2000-2010

Rate

per

1,0

00 li

ve b

irths

U.S. 2010 preliminary dataSource: Bureau of Epidemiology and Public Health Informatics, KDHE; National Center for Health Statistics

Desired Direction = Below Line

HP2020 = 6.0

HP2010 = 4.5

6


The Problem

*BNH= non-Hispanic black; **WNH=non-Hispanic whiteSource: Bureau of Epidemiology and Public Health Informatics, KDHE

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

5

10

15

20

25

Infant Mortality Rate Trends by Non-Hispanic Black and Non-Hispanic White

Kansas, 2000-2009

Rate

per

1,0

00 li

ve b

irths

7


The Problem

*BNH= non-Hispanic black; **WNH=non-Hispanic whiteSource: Bureau of Epidemiology and Public Health Informatics, KDHE

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

Infant Mortality Rate Trends by Non-Hispanic Black, Non-Hispanic White and Hispanic

Kansas, 2000-2010

Rate

per

1,0

00 li

ve b

irths

8


What We’re Doing

The Kansas Blue Ribbon Panel on Infant Mortality http://kansasinfantmortality.org/index.asp Releases updated recommendations (Apr 2011)

and actionable logic model (Oct 2011)

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http://kansasinfantmortality.org/index.asp


What We’re Doing KDHE Center for Health Equity (i.e., office of

minority health) and SIDS Network of Kansas coordinate multi-year statewide health promotion campaign on infant mortality. Healthy Baby Begins With You Tour KS/Tonya Lewis

Lee (April 2011): Wichita, Topeka, Kansas City 506 media events and estimated 6,112,313

audience reach (Sept, Oct, Nov - national campaign months for Infant Mortality, SIDS, Prematurity)

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What We’re Doing

SIDS Network of Kansas expands Safe Sleep Education outreach.

Sedgwick County FIMR releases first FIMA data report. (July 2011)

Preconception Peer Educator Training (PPE) Wichita, Topeka, Kansas City (Sept 2012)

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What We’re Doing Healthy Communities Wyandotte (HCW)

releases recommendations (Oct 2011) March of Dimes provides grants to Saline,

Sedgwick, Shawnee and Geary counties to establish community collaboratives that will address birth disparities through prenatal care and community health partnerships.

12


What We’re Doing State/County collaboration to facilitate use of

PPOR Kansas Leadership Center National FIMR Conference – Geary, Reno,

Saline, Sedgwick, Shawnee and Wyandotte FIMR in Kansas: Long-Term

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Purpose A recommendation from the Kansas Blue

Ribbon Panel on Infant Mortality

Describes the Perinatal Periods of Risk (PPOR) approach to analyze resident fetal and infant death data in Kansas for the period 2005-2009.

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Purpose Gain greater insight into the underlying factors

contributing to Kansas’ fetal and infant deaths. Data to Action: Results offer important

information that can be used to develop community-based prevention strategies related to racial/ethnic disparities in infant mortality rate (IMR).

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Methods Perinatal Periods of Risk (PPOR) approach

Phase 1: identifies populations and periods of risk with excess mortality

Phase 2: explains excess mortality and identifies important risk factors

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The Perinatal Periods of RiskAge at Death

Fetal Death>=24 weeks

Neonatal0-27 days

Post-neonatal

28-364 days

500-1499 grams Maternal Health/Prematurity

1500+ grams Maternal Care

Newborn Care

Infant Health

Birth weight

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PPOR Intervention Model

Maternal Health/Prematurity

Maternal Care

NewbornCare

Infant Health

Preconceptional HealthHealth Behaviors

Perinatal Care, etc.

Prenatal CareHigh Risk Referral

Obstetric Care, etc.

Perinatal ManagementNeonatal Care

Pediatric Surgery, etc.

Safe Sleep PositionBreast Feeding

Injury Prevention, etc.

18


Data Sources Bureau of Epidemiology and Public Health

Informatics, Kansas Department of Health and Environment Fetal death certificate data Live birth certificate data Linked birth-death cohort data

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Study Population Fetal deaths 2005-2009

24 weeks or greater gestational age 500 grams or larger

Live births 2005-2009 500 grams or larger

Linked birth and death data 2005-2009 500 grams or larger

Residents of Kansas at time of birth

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Reference Group External: USA 2000-2002 Reference Group

Defined by maternal characteristics 20 or more years of age 13 or more years of education Non-Hispanic white women Residents of the US at the time of baby’s birth

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Maternal Care

Newborn Care Infant Health

TotalFetal-Infant Mortality

2.2 1.5 1.1 0.9 5.7


Phase 1

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Overall PPOR Map of Fetal-Infant Deaths

Kansas, 2005-2009Age at Death

Fetal Death Neonatal Post-

neonatal Total

Birth weight

500-1499 grams 290 279 71 640

1500+ grams 424 302 467 1193714 581 538 1833

Fetal Deaths Live BirthsDenominator 714 + 205,338 = 206,052

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Fetal-Infant Mortality RateKansas, 2005-2009

Age at Death


neonatalOverall

Rate

Birth weight

500-1499 grams 3.1

1500+ grams 2.1 1.5 2.3

Period rates add up to overall rate 9.0

24


Calculating Excess RatesKansas, 2005-2009


Maternal Care

Newborn Care

Infant Health

Fetal-Infant Mortality

Kansas 3.1 2.1 1.5 2.3 9.0Minus

USA Reference Group* 2.2 1.5 1.1 0.9 5.7

Equals

Excess Mortality Rates 0.9 0.6 0.4 1.4 3.3

*USA 2000-2002 Reference Group

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Excess MortalityKansas, 2005-2009

Excess Fetal-Infant Mortality Rate=3.3

0.9

0.6 0.4 1.4 3.3

Excess Mortality 27.3%

18.2% 12.1% 42.4% 100.0%

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Kansas Excess MortalityKansas, 2005-2009

MH/P27.3%

MC18.2%

NC12.1%

IH42.4%

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Non-Hispanic White Kansas, 2005-2009

Age at DeathFetal

Death Neonatal Post-neonatal Total

Birth weight

500-1499 grams 190 176 35 401

1500+ grams 270 222 301 793460 398 336 1194

Fetal Deaths Live BirthsDenominator 460 + 147,560 = 148,020

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Fetal-Infant Mortality Rate Non-Hispanic White Kansas, 2005-2009

Age at Death


neonatalOverall

Rate

Birth weight

500-1499 grams 2.7

1500+ grams 1.8 1.5 2.0


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Calculating Excess Rates Non-Hispanic White (WNH)

Kansas, 2005-2009Maternal Health/

PrematurityMaternal

CareNewborn

CareInfant Health


WNH 2.7 1.8 1.5 2.0 8.0Minus


Equals



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Excess MortalityNon-Hispanic White Kansas, 2005-2009


0.5

0.3 0.4 1.1 2.3


13.0% 17.4% 47.8% 100.0%

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Non-Hispanic White Excess MortalityKansas, 2005-2009

MH/P21.7%

MC13.0%

NC17.4%

IH47.8%

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Non-Hispanic BlackKansas, 2005-2009

Age at DeathFetal


Birth weight

500-1499 grams 40 38 20 98

1500+ grams 54 24 55 13394 62 75 231

Fetal Deaths

Live Births

Denominator = 94 + 14,004 14,098

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Fetal-Infant Mortality RateNon-Hispanic BlackKansas, 2005-2009

Age at Death


neonatalOverall

Rate

Birth weight

500-1499 grams 7.0

1500+ grams 3.8 1.7 3.9


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Calculating Excess Rates Non-Hispanic Black (BNH)

Kansas, 2005-2009


Maternal Care

Newborn Care

Infant Health


BNH 7.0 3.8 1.7 3.9 16.4Minus


Equals



35


Excess MortalityNon-Hispanic Black Kansas, 2005-2009


4.8

2.3 0.6 3.0 10.7


21.5% 5.6% 28.0% 100.0%

36


Non-Hispanic Black Excess Mortality

Kansas, 2005-2009

MH/P44.9%

MC21.5%

NC5.6%

IH28.0%

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HispanicKansas, 2005-2009

Age at DeathFetal


Birth weight

500-1499 grams 42 49 13 104

1500+ grams 80 43 87 210122 92 100 314

Fetal Deaths

Live Births

Denominator = 122 + 32,832 32,954

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Fetal-Infant Mortality RateHispanic

Kansas, 2005-2009

Age at Death


neonatalOverall

Rate

Birth weight

500-1499 grams 3.2

1500+ grams 2.4 1.3 2.6


39


Calculating Excess RatesHispanic

Kansas, 2005-2009


Maternal Care

Newborn Care

Infant Health


Hispanic 3.2 2.4 1.3 2.6 9.5Minus


Equals



40


Excess MortalityHispanic

Kansas, 2005-2009


1.0

0.9 0.2 1.7 3.8


23.7% 5.3% 44.7% 100.0%

41


Hispanic Excess MortalityKansas, 2005-2009

MH/P26.3%

MC23.7%

NC5.3%

IH44.7%

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Phase I: Summary

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Period-Specific and Fetal Infant Mortality Rates by Race and Hispanic Origin of

Mother in Kansas, 2005-2009

Maternal Health/

PrematurityMaternal

CareNewborn

CareInfant Health


Kansas 3.1 2.1 1.5 2.3 9.0

White NH* 2.7 1.8 1.5 2.0 8.0Black NH* 7.0 3.8 1.7 3.9 16.4

Hispanic 3.2 2.4 1.3 2.6 9.5

*NH = non-Hispanic

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Excess Fetal-Infant Mortality RatesKansas, 2005-2009


Maternal Care

Newborn Care

Infant Health

Excess Fetal-Infant Mortality

Kansas 0.9 0.6 0.4 1.4 3.3

White NH* 0.5 0.3 0.4 1.1 2.3

Black NH* 4.8 2.3 0.6 3.0 10.7

Hispanic 1.0 0.9 0.2 1.7 3.8

*NH = non-Hispanic

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Calculating excess number of deaths from fetal-infant mortality rates

Kansas, 2005-2009Formula:Estimated number of excess deaths = Rate*Denominator/1000

Race/Ethnic Group

Overall Excess Mortality Rate

Live Births and

Fetal Deaths

MultiplyNumber of

Excess Deaths

Kansas 3.3 206,052 680White NH* 2.3 148,020 340Black NH* 10.7 14,098 151Hispanic 3.8 32,954 125*NH=Non-Hispanic

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Estimated Excess Number of DeathsKansas, 2005-2009

Maternal Health/

PrematurityMaternal

CareNewborn

CareInfant Health

Excess Fetal-Infant

Mortality

Kansas 185 124 82 288 680White NH* 74 44 59 163 340

Black NH* 68 32 8 42 151

Hispanic 33 30 7 56 125

*NH = non-Hispanic

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Adobe Acrobat Document


Phase 2

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Part A: Infant Health Risk Period

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Maternal Care

Newborn Care

Infant Health


Kansas 0.9 0.6 0.4 1.4 3.3

White NH* 0.5 0.3 0.4 1.1 2.3

Black NH* 4.8 2.3 0.6 3.0 10.7

Hispanic 1.0 0.9 0.2 1.7 3.8

*NH = non-Hispanic

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Part A: Infant Health Risk PeriodUnderlying cause of death

Birth defects (Q00-Q99) Infections (A00-B99, G009, J180 and J189) Injuries (V01-Y89) Perinatal conditions (P00-P96) Sudden Infant Death Syndrome (SIDS) (R95) Other ill-defined and unspecified causes of mortality

(R99), and other causes.

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Part A: Infant Health Risk Period

Mortality Rates and Excess Mortality Rates in the Infant Health Risk Period by Underlying Cause of Death by Race and

Hispanic Origin of Mother in Kansas, 2005-2009

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Adobe Acrobat Document


Part B: Maternal Health/ Prematurity Risk Period

Kitagawa Analysis

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Maternal Care

Newborn Care

Infant Health


Kansas 0.9 0.6 0.4 1.4 3.3

White NH* 0.5 0.3 0.4 1.1 2.3

Black NH* 4.8 2.3 0.6 3.0 10.7

Hispanic 1.0 0.9 0.2 1.7 3.8

*NH = non-Hispanic

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Components of the Excess Fetal Infant Mortality Rates (FIMR) in non-Hispanic Black

Kansas, 2005-2009

BirthweightDistribution

91%

Birthweight Specific Mortality

9%

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Conclusions

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PPOR Intervention Model


Maternal Care

NewbornCare

Infant Health

Preconceptional HealthHealth Behaviors

Perinatal Care, etc.

Prenatal CareHigh Risk Referral

Obstetric Care, etc.

Perinatal ManagementNeonatal Care

Pediatric Surgery, etc.

Safe Sleep PositionBreast Feeding

Injury Prevention, etc.

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Conclusions Opportunities for intervention to reduce

excess fetal-infant death vary according to the mother’s race/ethnicity.

Excess mortality in the Maternal Health/Prematurity risk period due primarily to high rates of VLBW births call for targeted interventions for improving preconception health of non-Hispanic black mothers in particular.

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Conclusions This could involve improving the overall health

of women in general. Or, a more targeted approach could focus on women of reproductive age with chronic diseases, previous poor outcomes, or poorly managed chronic diseases and ensuring better well-woman care and receipt of prenatal care (maternal health/prematurity issues).

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Conclusions Excess mortality in the Infant Health risk

period suggests the need for targeted interventions to better provide and monitor infant care, especially of non-Hispanic black and Hispanic infants, in the post-neonatal period. This may include promotion of breastfeeding and safe sleep practices, and prevention of life-threatening injuries.

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Conclusions The excess fetal infant deaths among non-

Hispanic blacks and Hispanics in the Maternal Care risk period highlights the importance of improving access to and utilization of prenatal care services and referrals for high-risk pregnancies.

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Conclusions To significantly impact Kansas overall IMR,

community-specific, tailored prevention efforts on prematurity, safe sleep, and injury prevention may be necessary.

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RecommendationsInfant Health Risk Period

Next step in PPOR Phase 2 analysis Examine the risk factors for SIDS

Smoking during and after pregnancy Infant sleep position Bedding

PRAMS Fetal Infant Mortality Review (FIMR) and Child

Death Review teams

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Recommendations

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Maternal Health/Prematurity Risk Period Next step in PPOR Phase 2 analysis

Study disparities in the prevalence of factors that are known to be associated with VLBW births

Maternal obesity Asthma Infections Hypertension

Vital records and Medicaid files PRAMS


Recommendations PRAMS

Understand maternal behaviors and experiences before, during, and shortly after pregnancy

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Public Health Implication Complex factors necessitate a multi-pronged

approach to reduce Kansas’ overall IMR and collaborative efforts of community members, public health, and the medical community.

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References Kansas Blue Ribbon Panel on Infant Mortality.

Infant Mortality in Kansas. April 2011 Bureau of Epidemiology and Public Health

Informatics, Kansas Department of Health and Environment. Infant Mortality Kansas, 2010, Provisional Findings

Handouts from Prematurity Briefing 2011. March of Dimes, 2011 Prematurity Conference. Sue Lyddon Hall, MD, Prediatrix Medical Group, Stormont-Vail HealthCare

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References Handouts from CityMatCH PPOR Workshop

“Perinatal Periods of Risk: Using Data and Community Involvement to Prevent Infant Mortality.” 2009 MCH Epidemiology Pre-Conference Data Skills Trainings.

Perinatal Periods of Risk (PPOR) materials from CityMatCH website. http://www.citymatch.org/ppor_index.php

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http://www.citymatch.org/ppor_index.php


References William M. Sappenfield, et al. Perinatal

Periods of Risk: Analytic Preparation and Phase 1 Analytic Methods for Investigating Feto-Infant Mortality. Matern Child Health J (2010) 14:838-850

William M. Sappenfield, et al. Perinatal Periods of Risk: Phase 2 Analytic Methods for Further Investigating Feto-Infant Mortality. Matern Child Health J (2010) 14:851-863

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References SUNNY FUTURES Healthy Start Consortium.

Data Subcommittee. Infant Mortality and Morbidity in Houston, Texas: 1999-2003. A report from the Neighborhood Centers Inc.

Jinwen Cai, Gerald L. Hoff, Rex Archer, Larry D. Jones, Paula S. Livingston, and V. James Guillory. Perinatal Periods of Risk Analysis of Infant Mortality in Jackson County, Missouri. J Public Health Management Practice, 2007, 13(3),270-277

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References W.H.O. Perinatal Periods of Risk Approach: The

U.S. Urban Experience. http://webmedia.unmc.edu/Community/CityMatch/PPOR/howto/PPORGeneralDescription.pdf

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http://webmedia.unmc.edu/Community/CityMatch/PPOR/howto/PPORGeneralDescription.pdf




Thank you!

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Jamie S. Kim, MPHMCH Epidemiologist

Bureau of Family Health/Bureau of Epidemiology and Public Health Informatics

Kansas Department of Health and [email protected]

785-296-6467

http://www.kdheks.gov/bfh/index.html

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http://www.kdheks.gov/bephi/index.html

http://www.kdheks.gov/bfh/index.html

http://www.kdheks.gov/bephi/index.html

Our Vision – Healthy Kansans living in safe and sustainable environments.74

Documents

Jamie S. Kim, MPH Co-Authors: Carol Gilbert, MS and Laurin Kasehagen, MA, PhD June 5, 2012