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Revealing Disparities in Revealing Disparities in Pregnancy Outcomes Using Pregnancy Outcomes Using PPOR and FIMMRR PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA MD, MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA Center for Maternal and Child Health Center for Maternal and Child Health State University of New York Upstate Medical University State University of New York Upstate Medical University Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Supported by a grant from the Community Health Foundation of Western and Supported by a grant from the Community Health Foundation of Western and Central New York. Central New York. The Community Health Foundation is a non-profit private foundation with a The Community Health Foundation is a non-profit private foundation with a mission to mission to improve the health and health care of the people of Western and Central New improve the health and health care of the people of Western and Central New York. York. February 2010 February 2010

Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

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Page 1: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Revealing Disparities in Revealing Disparities in Pregnancy Outcomes Using Pregnancy Outcomes Using

PPOR and FIMMRR PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD,

MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BAMPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA

Center for Maternal and Child Health Center for Maternal and Child Health State University of New York Upstate Medical University State University of New York Upstate Medical University

Department of Obstetrics and GynecologyDepartment of Obstetrics and Gynecology

Supported by a grant from the Community Health Foundation of Western and Central New York. Supported by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private foundation with a mission to The Community Health Foundation is a non-profit private foundation with a mission to

improve the health and health care of the people of Western and Central New York.improve the health and health care of the people of Western and Central New York.

February 2010February 2010

Page 2: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Objective

To examine the relationship of To examine the relationship of poor socioeconomic condition, as poor socioeconomic condition, as reflected by Medicaid status, to reflected by Medicaid status, to poor outcomes of pregnancy.poor outcomes of pregnancy.

Page 3: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

The Central New York Region consists of a 13 county area spanning The Central New York Region consists of a 13 county area spanning from St. Lawrence County in the North to Broome and Tioga from St. Lawrence County in the North to Broome and Tioga

counties in the South and includes 21 birth hospitals.counties in the South and includes 21 birth hospitals.

Page 4: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Statewide Perinatal Data System (SPDS)Statewide Perinatal Data System (SPDS)

Population-based birth registry that captures Population-based birth registry that captures information on all live births in New York State. It information on all live births in New York State. It consists of the New York State Electronic Birth consists of the New York State Electronic Birth Certificate (EBC) and additional voluntary questions, Certificate (EBC) and additional voluntary questions, e.g., such as the content of prenatal care, intentions of e.g., such as the content of prenatal care, intentions of pregnancy, and perinatal depression, that are expected pregnancy, and perinatal depression, that are expected to be used for quality improvement purposes. The to be used for quality improvement purposes. The SPDS contains data on: maternal demographics; SPDS contains data on: maternal demographics; obstetrical history; prenatal care; labor and delivery obstetrical history; prenatal care; labor and delivery information; and birth outcomes. information; and birth outcomes.

Page 5: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

SPDS: Pay Source CodingSPDS: Pay Source Coding

Medicaid – select this choice if the mother’s care was paid for by Medicaid, PCAP, MOMS, Child Health Plus A, Medicaid Managed Care, or Family Health Plus (39.8%) Private Insurance – select this item if the mother’s care was paid for by private insurance including indemnity insurance and/or managed care insurance (51.2%) Self-pay – select this item if the mother had no health insurance (1.1%) Indian Health Service (0.1%) CHAMPUS/TRICARE (Military and dependents) (5.0%) Other government (e.g. Child Health Plus B, Veteran’s Administration) (1.0%) Other (1.8%) Unknown (0.1%)

Medicaid group also applies to Medicaid as secondary payor. (5.5%)

Page 6: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Fetal-Infant Mortality/Morbidity Fetal-Infant Mortality/Morbidity Review/Registry (FIMMRR)Review/Registry (FIMMRR)

Clinically oriented, community based registry to capture Clinically oriented, community based registry to capture detailed data on mortalities/ morbidities for the 21 birth detailed data on mortalities/ morbidities for the 21 birth hospitals in the Central New York Region. hospitals in the Central New York Region.

By evaluating data from chart reviews of all fetal and By evaluating data from chart reviews of all fetal and infant mortalities (infant mortalities (≥ 300 grams) as well as major≥ 300 grams) as well as major morbidities, patterns have been identified which have morbidities, patterns have been identified which have informed recommendations for improvements (both informed recommendations for improvements (both social and medical).social and medical).

Page 7: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

FIMMRR: Maternal Risk FactorsFIMMRR: Maternal Risk Factors____ Major pre-pregnancy medical problems: ____________________ Poor OB History: ____ Adolescent pregnancy (≤ 16 y.o.)

____ History of infertility ____ Advanced maternal age (≥ 35 y.o.)____ 2 Prior losses before 20 weeks ____ Housing problems____ Prior loss after 20 weeks ____ Mental illness (past or present) ____ History of preterm delivery (<37 Wks) ____ Maternal stress: ____ History of previous SGA/IUGR birth ____ Emotional stress (at work or home)

____ Poor nutrition, BMI______ ____ Physical stress (at work or home)(circle) Obese, underweight ____ Loss of partner (circle)

____ Poor Care Seeker (circle) Divorce, Separation, Death, Military Deployment, OtherSecond Trimester, Third Trimester, No Prenatal Care ____ Death of family member

____ Poor compliance with prenatal visits (missed >2) ____ Pt or partner incarcerated/Legal problems ____ Substance abuse (circle) ____ Other

Tobacco, alcohol, marijuana, prescription drugs, other ____ Family violence____ Poor social setting (in present pregnancy): ____ Cultural problems:____ < 12th Grade education completed and no GED ____ Recent immigrant (Non-Western origin)____ Partner uninvolved ____ Language barrier (written or verbal)____ History of parenting problems ____ Cultural/Religious belief system limits or

____ Other prohibits medical interventions ____ Transportation problems ____ Other ____ Occupational problems ____ Less than 6 months since last birth____ Family planning problems ____ Current pregnancy result of Assisted ____ Economic issues: Reproductive Technology

____ Unemployed/ partner unemployed ____ Other____ Medicaid Insurance

____ Needs public assistance (housing, healthcare, etc.) ____ WIC referral ____ Other

Page 8: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

FIMMRR: Causes of Fetal Death / FIMMRR: Causes of Fetal Death / Prenatal/Intrapartal Factors Prenatal/Intrapartal Factors

Contributing to Infant Death Contributing to Infant Death

_____ Abruptio Placenta/Placental Infarct _____ Perinatal TORCH Infection __________ _____ Antiphospholipid/SLE Syndrome _____ Intrapartal asphyxia_____ Blood Factor Sensitization _____ Intrauterine Growth Restriction_____ Chorioamnionitis (bacterial) _____ Maternal Trauma – Type _________________ Chronic hypertension/Pre-eclampsia _____ Non-Immune Hydrops _____ Cocaine Abuse _____ Termination of Pregnancy, _____ Diabetes: Class ___, Type ___ Indication_______________________ Fetal Anomaly/Chromosomal Abnormality _____ Twin-Twin Transfusion Syndrome_____ Feto-Maternal Hemorrhage _____ Other ________________

Page 9: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

FIMMRR: Causes of Infant DeathFIMMRR: Causes of Infant Death

Circle single dominant cause, check all others noted:

_____Congenital Anomaly/Chromosomal Abnormality If SIDS, check-off appropriate items:_____Metabolic Disorder _____Co-sleeping_____Sepsis – Bacterial _____ Smoking Household_____Perinatal Viral Infection _____ Substance Abuse in Household_____Perinatal asphyxia _____ Use of Any Impairing Substance_____Hyaline Membrane Disease _____ Unsafe Sleep Environment_____Blood Factor Sensitization _____ Exclusive Breastfeeding_____CNS hemorrhage _____ Any Breastfeeding_____SIDS _____Unsafe Sleep Environment_____Trauma – accident _____Smoking Household_____Termination of Pregnancy, Indication _____Substance Abuse in Household_____Overwhelming Immaturity _____Prone Sleeping_____Unexplained _____Other ____________________Physical Abuse/Neglect_____Other _____________________

Page 10: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

FIMMRR: Causes of Death-ICD10FIMMRR: Causes of Death-ICD10

_____Congenital malformations, deformations and chromosomal abnormalities

_____Disorders related to short gestation, low birth weight, not elsewhere classified

_____Sudden infant death syndrome_____Newborn affected by maternal complications of pregnancy_____Newborn affected by complications of placenta, cord and membranes_____Accidents (unintentional injuries)_____Respiratory distress of newborn_____Bacterial sepsis of newborn_____Neonatal hemorrhage_____Intrauterine hypoxia and birth asphyxia_____All other causes

Page 11: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Data NotesData Notes

Statewide Perinatal Data System (SPDS) primary source for population characteristics secondary source for identification of neonatal

and post neonatal deaths

Fetal Infant Morbidity/Mortality Review/Registry (FIMMRR) only source for detailed data on fetal deaths primary source for detailed data on neonatal and post neonatal deaths

Page 12: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Population CharacteristicsPopulation CharacteristicsCentral New York Region 2006-2007Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-Non-

MedicaidMedicaidInsuredInsured

MedicaidMedicaidInsuredInsured

p valuep value

Live Births + Fetal DeathsLive Births + Fetal Deaths 3896238962 2127721277 1768517685

Live BirthsLive Births 3873938739 2116621166 1757317573

Maternal Age Maternal Age (<17 y)(<17 y) 1.2%1.2% 0.3%0.3% 2.2%2.2% < .001< .001

Maternal Race Maternal Race (non-white)(non-white) 14.7%14.7% 9.4%9.4% 21.0%21.0% < .001< .001

Maternal Education Maternal Education (< 12 y)(< 12 y) 16.0%16.0% 4.3%4.3% 30.2%30.2% < .001< .001

Marital Status Marital Status (not married)(not married) 42.5%42.5% 17.8%17.8% 72.2%72.2% <.001<.001

Page 13: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Population CharacteristicsPopulation CharacteristicsCentral New York Region 2006-2007Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-Non-

MedicaidMedicaidInsuredInsured

MedicaidMedicaidInsuredInsured

p valuep value

Live Births + Fetal Live Births + Fetal DeathsDeaths

3896238962 2127721277 1768517685

Live BirthsLive Births 3873938739 2116621166 1757317573

Early Prenatal CareEarly Prenatal Care 75.3%75.3% 84.4%84.4% 64.3%64.3% < .001< .001

Adequate Prenatal CareAdequate Prenatal Care 82.5%82.5% 88.4%88.4% 75.4%75.4% < .001< .001

Smoking During Smoking During PregnancyPregnancy

21.8%21.8% 10.3%10.3% 35.6%35.6% < .001< .001

Illegal Drug UseIllegal Drug Use 2.1%2.1% 0.5%0.5% 4.1%4.1% < .001< .001

Obese Obese (prepregnancy BMI>30)(prepregnancy BMI>30) 27.1%27.1% 25.8%25.8% 28.7%28.7% < .001< .001

BreastfeedingBreastfeeding 67.6%67.6% 76.8%76.8% 56.6%56.6% < .001< .001

Page 14: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Despite increased risk factors for the Despite increased risk factors for the Medicaid insured women, most birth Medicaid insured women, most birth outcomes in the Central New York outcomes in the Central New York Region are not significantly different Region are not significantly different between Medicaid and Non-Medicaid between Medicaid and Non-Medicaid insured women.insured women.

Birth OutcomesBirth Outcomes

Page 15: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Gestational Age Gestational Age

Central New York Region 2006-2007Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-MedicaidNon-Medicaid

InsuredInsuredMedicaidMedicaidInsuredInsured

p valuep value

Live Births + Fetal DeathsLive Births + Fetal Deaths 3896238962 2127721277 1768517685

Live BirthsLive Births 3873938739 2116621166 1757317573

PretermPreterm 9.7%9.7% 9.8%9.8% 9.5%9.5% NSNS

<24 weeks<24 weeks 0.2%0.2% 0.2%0.2% 0.2%0.2% NSNS

24-27 weeks24-27 weeks 0.5%0.5% 0.4%0.4% 0.5%0.5% NSNS

28-31 weeks28-31 weeks 1.0%1.0% 1.0%1.0% 0.9%0.9% NSNS

32-36 weeks32-36 weeks 8.0%8.0% 8.1%8.1% 7.9%7.9% NSNS

37+ weeks37+ weeks 90.3%90.3% 90.2%90.2% 90.4%90.4% NSNS

Page 16: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Birthweight/Intrauterine GrowthBirthweight/Intrauterine GrowthCentral New York Region 2006-2007Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-MedicaidNon-Medicaid

InsuredInsuredMedicaidMedicaidInsuredInsured

p valuep value

Live Births + Fetal Deaths Live Births + Fetal Deaths

3896238962 2127721277 1768517685

Live BirthsLive Births 3873938739 2116621166 1757317573

LBW (<2500 grams)LBW (<2500 grams) 7.7%7.7% 7.3%7.3% 8.2%8.2% < .001< .001

VLBW (<1500 grams)VLBW (<1500 grams) 1.4%1.4% 1.5%1.5% 1.4%1.4% NSNS

ELBW (< 1000 grams)ELBW (< 1000 grams) 0.6%0.6% 0.7%0.7% 0.7%0.7% NSNS

Small for Gestational AgeSmall for Gestational Age 10.6%10.6% 7.0%7.0% 13.4%13.4% < .001< .001

Large for Gestational AgeLarge for Gestational Age 9.1%9.1% 10.8%10.8% 8.2%8.2% < .001< .001

Page 17: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Rates of LBW and especially Small for Rates of LBW and especially Small for Gestational Age are significantly higher Gestational Age are significantly higher in Medicaid Insured births.in Medicaid Insured births.

MorbidityMorbidity

Page 18: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Using the Fetal-Infant Morbidity/Mortality Using the Fetal-Infant Morbidity/Mortality Review/Registry (FIMMRR), we also explored Review/Registry (FIMMRR), we also explored the Fetal/Infant death rates among Medicaid and the Fetal/Infant death rates among Medicaid and Non-Medicaid insured women.Non-Medicaid insured women.

MortalityMortality

Page 19: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

OverallOverallnumber of total deaths/total live births + fetal deathsnumber of total deaths/total live births + fetal deaths

FetalFetalnumber of intrauterine deaths/total live births + fetal deathsnumber of intrauterine deaths/total live births + fetal deaths

NeonatalNeonatalnumber of deaths number of deaths ≤ 28 days of life/total live births≤ 28 days of life/total live births

Post-NeonatalPost-Neonatalnumber of deaths 29 -365 days of life/total live birthsnumber of deaths 29 -365 days of life/total live births

InfantInfantNeonatal + Post-NeonatalNeonatal + Post-Neonatal

Standard Calculation of Death RatesStandard Calculation of Death Rates(all ≥ 300 grams)(all ≥ 300 grams)

Page 20: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

0

2

4

6

8

10

12

14

Overall Fetal Neonatal Post-Neonatal

Infant

TotalNon-Medicaid InsuredMedicaid Insured

Central New York Region 2006-2007 Central New York Region 2006-2007 Total Live Births + Fetal Deaths = 38962Total Live Births + Fetal Deaths = 38962

rate

/100

0

*

*

*

* p< .001 Non-Medicaid Insured vs Medicaid Insured

Page 21: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

≥ ≥ 300 grams300 grams Overall Fetal NeonatalPost

NeonatalInfant

Total 11.4 5.7 4.3 1.4 5.7

Non-Medicaid 9.4 5.2 3.7 0.5 4.2

Medicaid 13.7 6.3 5.0 2.5 7.5

Central New York Region 2006-2007 Central New York Region 2006-2007 Total Live Births + Fetal Deaths = 38962Total Live Births + Fetal Deaths = 38962

Page 22: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

The significant difference in mortality is concentrated The significant difference in mortality is concentrated within the Infant Deaths, most strikingly the Post-within the Infant Deaths, most strikingly the Post-Neonatal Deaths.Neonatal Deaths.

The lack of a significant difference in mortality for both The lack of a significant difference in mortality for both Fetal and Neonatal Deaths, suggests a potential Fetal and Neonatal Deaths, suggests a potential protective effect by Medicaid.protective effect by Medicaid.

Further analysis, using the Perinatal Periods of Risk Further analysis, using the Perinatal Periods of Risk approach, provided a different prospective.approach, provided a different prospective.

FindingsFindings

Page 23: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

300-1499 g

1500+ g

Fetal Death Neonatal Post- neonatal

Maternal Health/ Prematurity 6.9

Maternal Care

1.9

Newborn Care

1.4

Infant Health

1.1

Age at Death

Birth

weigh

t

Central New York Region 2006-2007Central New York Region 2006-2007Live Births + Fetal Deaths = 38962

Overall Fetal-Infant Mortality Rate 11.3 per 1, 000 Live Births & Fetal Deaths

TotalTotal

Page 24: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

300-1499 g

1500+ g

Maternal Health/ Prematurity 6.1

Maternal Care

2.0

Newborn Care

0.9

Infant Health

0.4

Age at Death

Birth

weigh

t

Central New York Region 2006-2007Central New York Region 2006-2007Live Births + Fetal Deaths = 21277

Overall Fetal-Infant Mortality Rate 9.4 per 1, 000 Live Births & Fetal Deaths

Fetal Death Neonatal Post- neonatal

Non-Medicaid InsuredNon-Medicaid Insured

Page 25: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

300-1499 g

1500+ g

Maternal Health/ Prematurity 8.0

Maternal Care

1.8

Newborn Care

1.9

Infant Health

2.0

Age at Death

Birth

weigh

t

Central New York Region 2006-2007Central New York Region 2006-2007Live Births + Fetal Deaths = 17685

Overall Fetal-Infant Mortality Rate 13.7 per 1, 000 Live Births & Fetal Deaths

Fetal Death Neonatal Post- neonatal

Medicaid InsuredMedicaid Insured

Page 26: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)

≥ ≥ 300 grams300 grams TotalTotalNon-MedicaidNon-Medicaid

InsuredInsuredMedicaidMedicaidInsuredInsured

sigsig

Live Births + Fetal DeathsLive Births + Fetal Deaths 3896238962 2127721277 1768517685

Live BirthsLive Births 3873938739 2116621166 1757317573

Overall Fetal-Infant Mortality RateOverall Fetal-Infant Mortality Rate 11.311.3 9.49.4 13.713.7 SS

Maternal Health/PrematurityMaternal Health/Prematurity 6.96.9 6.16.1 8.08.0 SS

Maternal CareMaternal Care 1.91.9 2.02.0 1.81.8 NSNS

Newborn CareNewborn Care 1.41.4 0.90.9 1.91.9 NSNS

Infant HealthInfant Health 1.11.1 0.40.4 2.02.0 SS

Central New York Region 2006-2007Central New York Region 2006-2007

Page 27: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)

≥ ≥ 300 grams300 grams TotalTotalReference Reference

GroupGroup

Non-Non-ReferenceReferenceGroupGroup

sigsig

Live Births + Fetal DeathsLive Births + Fetal Deaths 3896238962 2680626806 1215612156

Live BirthsLive Births 3873938739 2666726667 1207212072

Overall Fetal-Infant Mortality RateOverall Fetal-Infant Mortality Rate 11.311.3 9.69.6 15.215.2 SS

Maternal Health/PrematurityMaternal Health/Prematurity 6.96.9 5.95.9 9.39.3 SS

Maternal CareMaternal Care 1.91.9 1.81.8 2.12.1 NSNS

Newborn CareNewborn Care 1.41.4 1.21.2 1.71.7 NSNS

Infant HealthInfant Health 1.11.1 0.70.7 2.22.2 SS

Central New York Region 2006-2007

Page 28: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-Non-

MedicaidMedicaidInsuredInsured

MedicaidMedicaidInsuredInsured

ReferenceReferenceGroupGroup

Live Births + Fetal DeathsLive Births + Fetal Deaths 3896238962 2127721277 1768517685 2680626806

Live BirthsLive Births 3873938739 2116621166 1757317573 2666726667

Overall Fetal-Infant Mortality Overall Fetal-Infant Mortality RateRate

11.311.3 9.49.4 13.713.7 9.69.6

Maternal Health/PrematurityMaternal Health/Prematurity 6.96.9 6.16.1 8.08.0 5.95.9

Maternal CareMaternal Care 1.91.9 2.02.0 1.81.8 1.81.8

Newborn CareNewborn Care 1.41.4 0.90.9 1.91.9 1.21.2

Infant HealthInfant Health 1.11.1 0.40.4 2.02.0 0.70.7

Page 29: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)Central New York Region 2006-2007

≥ ≥ 300 grams300 grams TotalTotalNon-MedicaidNon-Medicaid

InsuredInsuredMedicaidMedicaidInsuredInsured

Overall Fetal-Infant Mortality RateOverall Fetal-Infant Mortality Rate 1.701.70 -0.20-0.20 4.14.1

Maternal Health/PrematurityMaternal Health/Prematurity 1.001.00 0.200.20 2.102.10

Maternal CareMaternal Care 0.100.10 0.200.20 0.000.00

Newborn CareNewborn Care 0.200.20 -0.30-0.30 0.700.70

Infant HealthInfant Health 0.400.40 -0.30-0.30 1.301.30

Excess Mortality Rates in comparison with Reference Group

Page 30: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)Central New York Region 2006-2007

Excess Mortality Numbers in comparison with Reference Group

≥ ≥ 300 grams300 grams TotalTotalNon-MedicaidNon-Medicaid

InsuredInsuredMedicaidMedicaidInsuredInsured

Overall Fetal-Infant Mortality RateOverall Fetal-Infant Mortality Rate 6666 -4-4 7373

Maternal Health/PrematurityMaternal Health/Prematurity 3939 44 3737

Maternal CareMaternal Care 44 44 00

Newborn CareNewborn Care 88 -6-6 1212

Infant HealthInfant Health 1616 -6-6 2323

Page 31: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Comparison to Reference Group supports our previous Findings.

It is also useful to examine the distribution of various causes of death in each PPOR category.

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)Central New York Region 2006-2007

Page 32: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Fetal-Infant Morbidity/Mortality Review & RegistryFetal-Infant Morbidity/Mortality Review & Registry

Central New York Region 2006-2007Central New York Region 2006-2007Dominant Cause of Death: Dominant Cause of Death: rate/1000 live births + fetal deaths

≥ ≥ 300 grams300 grams Maternal Health/Prematurity Maternal Care

Non-Medicaid6.1

Medicaid8.0

Non-Medicaid2.0

Medicaid1.8

Abruptio/Placental Infarct 0.66 1.41 0.23 0.45

Other Placental Problems 0.47 0.56 0.33 0.39

Cord Accident/Prolapse 0.29 0.45 0.38 0.11

Congenital Anomaly/ Chromosomal Abnormality

1.34 1.02 0.33 0.06

Prematurity 0.52 0.96 0 0.17

Overwhelming Immaturity 2.05 2.25 0 0

Other 0.15 0.34 0.14 0.11

Sepsis 0.19 0.34 0 0.06

SIDS/SUID 0 0.11 0 0

Trauma 0 0.06 0 0

Unexplained 0.43 0.50 0.57 0.45

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Fetal-Infant Morbidity/Mortality Review & RegistryFetal-Infant Morbidity/Mortality Review & Registry

Central New York Region 2006-2007Central New York Region 2006-2007Dominant Cause of Death: Dominant Cause of Death: rate/1000 live births + fetal deaths

≥ ≥ 300 grams300 grams Newborn Care Infant Health

Non-Medicaid0.9

Medicaid1.9

Non-Medicaid0.4

Medicaid2.0

Abruptio/Placental Infarct 0 0 0 0

Other Placental Problems 0.22 0.06 0 0

Cord Accident/Prolapse 0 0.06 0 0

Congenital Anomaly/ Chromosomal Abnormality

0.54 1.34 0.13 0.46

Prematurity 0 0 0 0

Overwhelming Immaturity 0 0 0 0

Other 0.09 0.06 0 0.29

Sepsis 0.05 0.17 0.04 0.11

SIDS/SUID 0 0.11 0.18 0.74

Trauma 0 0.11 0.04 0.4

Unexplained 0 0 0 0

Page 34: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Cause of Death ConclusionsCause of Death Conclusions

These findings support our earlier Findings that These findings support our earlier Findings that pre-pregnancy and early pregnancy factors, along pre-pregnancy and early pregnancy factors, along with post neonatal factors play the largest role in with post neonatal factors play the largest role in the disparity between death rates among Medicaid the disparity between death rates among Medicaid and Non-Medicaid insured women.and Non-Medicaid insured women.

A protective effect of Medicaid Status is A protective effect of Medicaid Status is suggested regarding Fetal and Neonatal deaths.suggested regarding Fetal and Neonatal deaths.

Page 35: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Sharing the ResultsSharing the ResultsCNY Regional Perinatal ForumCNY Regional Perinatal Forum

CNY Regional Perinatal Program/Affiliate HospitalsCNY Regional Perinatal Program/Affiliate Hospitals

Onondaga County Health Department/Syracuse Healthy StartOnondaga County Health Department/Syracuse Healthy Start

SUNY Upstate Medical UniversitySUNY Upstate Medical University

Departmental Grand Rounds (OB-GYN/Pediatrics)Departmental Grand Rounds (OB-GYN/Pediatrics)

Masters in Public Health coursesMasters in Public Health courses

Page 36: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Resultant Targeted InterventionsResultant Targeted Interventions

ImproveImprove preconceptional/interconceptional carepreconceptional/interconceptional care Facilitate access to early/quality prenatal careFacilitate access to early/quality prenatal care Implement stronger smoking cessation programsImplement stronger smoking cessation programs Improve maternal post partum supports and Improve maternal post partum supports and

counseling about importance of Safe Sleep counseling about importance of Safe Sleep EnvironmentEnvironment

Page 37: Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

Contact Information:Contact Information:Center for Maternal & Child HealthCenter for Maternal & Child Health

www.upstate.edu/cmatch//315-464-5706315-464-5706

Richard H. Aubry, MD, MPH Richard H. Aubry, MD, MPH [email protected]@upstate.edu Pamela Parker, BAPamela Parker, BA [email protected]@upstate.edu Kristen Luke-Houseman, RN, BAKristen Luke-Houseman, RN, BA [email protected]@upstate.edu

Preliminary Data. Not for release without permission.Preliminary Data. Not for release without permission.