Perinatal Periods of Risk-A Tool for Improving the Health of Mothers and Infants Carolyn Slack, MS, RN Columbus (OH) Health Department

Perinatal Periods of Risk-A Tool for Improving the Health

of Mothers and Infants

Carolyn Slack, MS, RN

Columbus (OH) Health Department

Map of Feto-Infant Mortality

500-1499 g

1500+ g

Fetal Deaths Neonatal

Post neonatal

1 2 3

4 5 6


500-1499 g

1500+ g


Post neonatal

Maternal Health/ Maternal Health/ PrematurityPrematurity

Maternal Maternal CareCare

Newborn Newborn CareCare

Infant Infant HealthHealth

Feto-Infant MortalityFranklin County, Ohio, All Races

1997-1998

Maternal Health/ Maternal Health/ Prematurity Prematurity

123123

Maternal Maternal Care Care

7171

Newborn Newborn Care Care

4343

Infant Infant Health Health

8282

319 Feto-Infant Deaths

32,673 Fetal Deaths & Live Births

Background

WHO and Dr. Brian McCarthy

CityMatCH PPOR Work Group

Why a new approach to infant mortality?

National Practice Collaborative

Description of the PPOR Practice Collaborative

Application Process Practice Collaborative Curriculum Participating Cities

– Baltimore, MD, Columbus, OH, Durham, NC, Jacksonville, FL, Kansas City, MO, Louisville, KY, Nashville, TN, New Haven, CT, Orlando, FL, Philadelphia, PA, Phoenix, AZ, Portland, OR, Raleigh, NC, and St. Petersburg, FL.

Perinatal Periods of Risk Approach:5 Major Principles

1) Engage community partners early to gain consensus and support

2) Map feto-infant mortality by birthweight &

age at death

3) Focus on reducing the overall feto-infant mortality rate

4) Examine potential opportunity gaps between population groups

5) Target further investigations and prevention efforts on the gaps

Community Readiness: From Concepts to Tools

Tool for engaging partners Tool for reaching consensus Tool for identifying joint assets Tool for revealing critical gaps Tool for developing strategy

What shape is your tent?

Raising the roof for PPOR:

5 4 3 2 1 2 3 4 5

5

4

3

2 2

3

4

5

23

4

5

Reasoning

RolesResources

Risk/Rewards

Results

What shape is your tent?

PPOR Community Readiness“5 Tent Poles”

1. Reasoning: partners can communicate clear, compelling case for PPOR based on its value-add

2. Results: partners can articulate what measurable results are expected from doing PPOR, and by when

3. Roles: partners are willing and able to champion PPOR over a time in their various roles in the community

4. Risks/Rewards: sufficient strategic balance exist between benefits and consequences for essential stakeholders to support PPOR implementation

5. Resources: sufficient systems and resources to support full implementation

PPOR Partnerships in ColumbusLead Partners

&Columbus Health Department

Caring for 2 (Healthy Start)

Other Partners

Child Death Review Team

WIC/CFHS (Title V) Advisory Council

Council onHealthy Mothers andBabies

Ohio Dept. of Health

2. Map of Feto-Infant Mortality

Age at Death

Birth

weig

ht

Linked Birth & Death Certificates

Infant Deaths

Live BirthCertificate

Birth Characteristics

Infant DeathCertificate

Death Characteristics

FetalDeaths

Fetal Death Certificate

Birth Versus Death Cohort

Birth Cohort

Births

Deaths

1999 2000

Death Cohort

Births

Deaths

1999 2000

Data Recommendations

Need at least 60 deaths in every population you want to study

No more than 5 years of data due to changes in medical practice

Assess data quality – Missing birth weight and gestational age– Missing education and race


Age at Death

Birth

weig

ht

500-1499 g

1500+ g

Fetal

(24

wks

)

Neonat

al

Postneo

natal

1 2 3

54 6

Map of Feto -Infant MortalityWhat Is Missing in the 6 Cells?

Fetal deaths restricted to

>500 gLive births restricted to

Spontaneous abortions

Induced abortions

24 wks and 500 g


500-1499 g

1500+ g


Post neonatal

Maternal Health/ Maternal Health/ PrematurityPrematurity




3. Focus on Reducing the Overall Feto-Infant Mortality Rate

The overall rate includes fetal deaths which are often excluded

Cell or group specific mortality rates are calculated such that they add up to the total feto-infant mortality rate

Excess mortality rates and numbers are also calculated such that they relate to the total feto-infant rate

Focus on Overall MortalityMap of Feto-Infant Mortality

Compare within feto-infant mortality rates by examining the 4 group rates

Compare overall and group rates over time

Compare overall and group rates between different population groups

4. Examine the “Opportunity Gap” Between Population Groups

Identify the potential for reduction in the community

Decide on internal reference groups for comparison

Consider external reference groups for comparison

Calculate excess mortality rates by components

Examine the “Opportunity Gap”Reference Groups

20 or more years of age

13 or more years of education

Non-hispanic white women

Attempt to choose a simple optimal group; at least 15% of the population

US studies:

Examine the “Opportunity Gap”

Examine excess overall mortality, both rate and number

Examine excess mortality across the 4 groups

Calculate the percentage of excess mortality by racial and socio-economic

5. Target Investigations & Prevention Efforts on the Gap

Shift effort and attention to the group(s) that contributes most to the gap

Conduct further studies or mortality reviews on the group(s) that contributes to the gap (Phase 2 studies)

Examine current prevention efforts on the group(s) that contributes to the gap (Phase 2 policy/program reviews)

Map of Feto-Infant MortalityMaternal Maternal Health/ Health/

PrematurityPrematurity




Preconceptional Health Health Behaviors Perinatal Care

Prenatal Care High Risk Referral Obstetric Care

Perinatal Management Neonatal Care Pediatric Surgery

Sleep Position Breast Feeding Injury Prevention

Feto-Infant MortalityFranklin County, Ohio, All Races

1997-1998


123123


7171


4343


8282

319 Feto-Infant Deaths

32,673 Fetal Deaths & Live Births

Feto-Infant Mortality RatesFranklin County, Ohio, All Races

1997-1998


3.83.8


2.22.2


1.31.3


2.52.5

Feto-Infant Mortality Rate =

319 x 1,000 32,673

= 9.8 deaths per 1,000 births

& fetal deaths

Excess Feto-Infant Mortality Franklin County, Ohio, 1997-1998

- =

Franklin Co. All Races

U.S. Reference Excess

3.83.8

2.22.2 1.31.3 2.52.5

9.8

2.22.2

1.51.5 1.01.0 1.21.2

5.8

1.61.6

0.7 0.30.3 1.31.3

4.0

Feto-Infant Mortality RatesFranklin County, Ohio, Black

1997-1998


5.85.8


3.83.8


1.61.6


5.55.5

Feto-Infant Mortality Rate =

106 x 1,000 6,349

= 16.7 deaths per 1,000 births

& fetal deaths

Excess Black Feto-Infant Mortality

Franklin County, Ohio, 1997-1998

- =

Franklin Co. Black

U.S. Reference Excess

5.85.8

3.83.8 1.61.6 5.55.5

16.7

2.22.2

1.51.5 1.01.0 1.21.2

5.8

3.63.6

2.3 0.60.6 4.34.3

10.9

Excess Feto-Infant MortalityOverall and Black

Franklin County, Ohio, 1997-1998

Franklin County Overall Excess

Black Excess

1.61.6

0.70.7 0.30.3 1.31.3

3.63.6

2.3 0.60.6 4.34.3

Infant Health – Phase IIFranklin County, 1997-98

Postneonatal deaths of birth weight of 1500 grams or above

Race of Mother

# of deaths

% of black

deaths# of

deaths

% of white

deaths# of

deaths

% of all B & W deaths

Causes of Deathcongenital anomalies 12 33% 11 25% 23 29%prematurity (<26 wks) 0 0% 0 0% 0 0%SIDS 12 33% 24 55% 36 45%illness 10 28% 3 7% 13 16%injury 2 6% 2 5% 4 5%infection 0 0% 0 0% 0 0%undetermined 0 0% 1 2% 1 1%unknown 0 0% 3 7% 3 4%

1997-1998 subtotals 36 44 80

BLACK WHITE B & W total

Prevalence of Selected Risk FactorsFranklin County, 1997-98

*Postneonatal deaths of birth weight of 1500 grams or above

Infant Health deaths*

SIDS deaths*

Live births

(>=500 g)

Characteristics & (n=80) (n=36) (n=32,342)Risk Factors % % %

education <13 years 72.1% 80.0% 45.6%unmarried 53.5% 50.0% 35.3%

late prenatal care (after 1st trimester) 14.3% 20.0% 16.9%

smoking 26.3% 36.1% 16.4%age <20 years 21.3% 13.9% 12.3%

alcohol use 2.5% 2.8% 0.1%male child 55.0% 55.6% 50.1%

Issues and PlansVital Statistics - Statewide

Availability of matched certificatesStreet address vs. census tractsCompleteness of dataSource of congenital anomalies

dataNCHS perinatal mortality data filesEBC plans and access

Issues and PlansVital Statistics - Local

Completeness of data– Follow-up and training of VS staff,

hospital and other medical personnelCause of death problemsMissing certificates

Issues and PlansOur Response

Create our own electronic database– Using Child Death Review data

Improve process to get out of county certificates

Continue to work with fetal death data

Issues and PlansOther Stuff

Focus on singletonsUse of other data sets for next level

of analysis– e.g., programs: STD, CFHS, NHCs

– e.g., surveillance: PRAMS, BRFSS

Issues and PlansOther Stuff

Talk in terms of excess deaths, rather than rates

Power of selecting an internal reference group (must be at least 15% of population)

Examine PTB and C-section rates Multiracial moms

Issues and PlansOne Parting Thought…

An Ohio MCH/PPOR Collaborative– Based on national (City MatCH) model– Possible funding through MOD

Acknowledgements

Kelly Welch Williams, MS, Caring for 2 Project Director

Kathleen Cowen, MS, Senior Epidemiologist – Columbus Health Department

For Further Information, visit the CityMatCH website:www.citymatch.org

Documents

Perinatal Periods of Risk-A Tool for Improving the Health of Mothers and Infants Carolyn Slack, MS, RN Columbus (OH) Health Department