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Perinatal Periods of Risk Approach: The Michigan Experience. Bao-Ping Zhu, MD, MS Lead Epidemiologist Division of Reproductive Health, CDC Chief MCH Epidemiologist, MDCH. Why a New Approach to Infant Mortality?. Simple approach – easy for communities nationwide to use

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Perinatal periods of risk approach the michigan experience

Perinatal Periods of Risk Approach:The Michigan Experience

Bao-Ping Zhu, MD, MS

Lead Epidemiologist

Division of Reproductive Health, CDC

Chief MCH Epidemiologist, MDCH


Why a new approach to infant mortality
Why a New Approach to Infant Mortality?

  • Simple approach – easy for communities nationwide to use

  • Identifies gaps in community

  • Targets resources for prevention

  • Mobilizes the community to action


Perinatal periods of risk approach 5 major steps
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners early to gain consensus and support

2) Map feto-infant mortality by birthweight &

age at death

3) Focus on reducing overall feto-infant mortality

4) Examine potential opportunity gaps

5) Target further investigations and prevention efforts on gaps


Perinatal periods of risk approach 5 major steps1
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners

2) Map feto-infant mortality

3) Focus on reducing overall feto-infant mortality

4) Examine opportunity gaps

5) Further investigations and prevention efforts


Perinatal periods of risk approach 5 major steps2
Perinatal Periods of Risk Approach:5 Major Steps

  • Improving feto-infant mortality requires mobilization and change in many sectors and by many individuals in community

  • Consensus about and ownership of problem essential in developing community support

  • Monitoring the problem and the solutions and necessary strategy adjustments require effort by many partners


Perinatal periods of risk approach 5 major steps3
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners

2) Map feto-infant mortality

3) Focus on reducing overall feto-infant mortality

4) Examine opportunity gaps

5) Further investigations and prevention efforts


Map feto infant mortality
Map Feto-Infant Mortality

Age at Death

Fetal (24+ wks)

Neonatal

Postneonatal

Birthweight

1

2

3

500-1499 g

4

5

6

1500+ g


Map feto infant mortality1
Map Feto-Infant Mortality

Age at Death

Post neonatal

Neonatal

Fetal

Birthweight

500- 1499 g

1

2

3

1500+ g

4

5

6


Map feto infant mortality2
Map Feto-Infant Mortality

Post neonatal

Neonatal

Fetal

Maternal Health/ Prematurity

500-1499 g

Maternal Care

Newborn Care

Infant Health

1500+ g


Map connections to action

Maternal Health/ Prematurity

Pregnancy Intention

Smoking / Drinking / Drug Abuse

Racial discrimination / Stress

Prenatal Care Referral System High Risk OB Care

Maternal Care

Perinatal Management Perinatal System Pediatric Surgery

Newborn Care

Sleep Position Breast-Feeding Injury Prevention

Infant Health

Map Connections to Action


Map Feto-Infant DeathsMichigan Overall, 2000

1582 fetal or infant deaths

Maternal Health/ Prematurity 875

Total fetal deaths and live births: 137,496

Maternal Care 245

Newborn Care 200

Infant Health 262


Map Feto-Infant DeathsBlacks, MI, 2000

531 fetal or infant deaths

Maternal Health/ Prematurity 327

Total fetal deaths and live births: 24,304

Maternal Care 67

Newborn Care 43

Infant Health 94


Map feto infant mortality what is missing in the 6 cells
Map Feto-Infant MortalityWhat Is Missing in the 6 Cells?

  • Fetal deaths <24 wks

  • Live births <500 g

  • Spontaneous abortions

  • Induced abortions


Perinatal periods of risk approach 5 major steps4
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners

2) Map feto-infant mortality

3) Focus on reducing overall feto-infant mortality

4) Examine opportunity gaps

5) Further investigations and prevention efforts


3 focus on reducing overall feto infant mortality rate
3. Focus on Reducing Overall Feto-Infant Mortality Rate

  • Include fetal deaths - often excluded

  • Calculate group specific mortality rates - add up to total feto-infant mortality rate

  • Calculate excess mortality rates and numbers - relate to total feto-infant rate


Feto-Infant DeathsBlacks, MI, 2000

531 fetal or infant deaths

Maternal Health/ Prematurity 327

Total fetal deaths and live births: 24,304

Maternal Care 67

Newborn Care 43

Infant Health 94


Focus on overall mortality cell or group specific mortality rates
Focus on Overall MortalityCell- or Group-Specific Mortality Rates

4

e.g., for Blacks: Maternal Health/ Prematurity: 327

Number of deaths in a cell or group

Total number of live births & fetal deaths

e.g, for Blacks: 24,304


Focus on Overall Feto-Infant MortalityBlacks, MI, 2000

Maternal Health/ Prematurity 13.5

Total feto-infant mortality rate:21.8 =(531/24,304)x 1000

Maternal Care 2.8

Newborn Care 1.8

Infant Health 3.9


Focus on overall mortality learn by comparisons
Focus on Overall MortalityLearn by Comparisons

  • Compare within community feto-infant mortality rates by examining 4 group rates

  • Compare overall and group rates over time

  • Compare overall and group rates between different population groups


Focus on overall mortality comparison of socio demographic groups
Focus on Overall MortalityComparison of Socio-Demographic Groups

  • Maternal Race and Ethnicity

    • Race: white, black, other racial groups

    • Ethnicity: Hispanic, Arabic

  • Maternal Age and Education

    • <20 years of age

    • 20+ years and <13 years of education

    • 20+ years and 13+ years of education

  • Geography: SE vs. Non-SE; County; City

  • Health Care Payment Source


Perinatal periods of risk approach 5 major steps5
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners

2) Map feto-infant mortality

3) Focus on reducing overall feto-infant mortality

4) Examine opportunity gaps

5) Further investigations and prevention efforts


4 examine opportunity gap between population groups
4. Examine “Opportunity Gap” Between Population Groups

  • To identify potential for reduction in community

  • Involves:

    • Decide on reference groups

    • Calculate excess deaths and mortality rates by components


Examine opportunity gap reference groups
Examine “Opportunity Gap”Reference Groups

  • Simple optimal group

  • At least 15% of population

Reference group for MI state-wide analysis

  • Non-Hispanic white women in Michigan

  • Aged 20+ years

  • 13+ years of education


Reference: MI non-Hispanic white women aged 20+, with 13+ yrs education, 1999

284 fetal or infant deaths

Maternal Health/ Prematurity 99 (1.9)

Total live births or fetal deaths: 52,206

Maternal Care 64 (1.2)

Newborn Care 74 (1.4)

Infant Health 47 (0.9)

Total feto-infant mortality rate:5.4


Examine the opportunity gap
Examine the “Opportunity Gap”

  • Examine excess overall mortality, both rate and number

  • Examine excess mortality across four groups

  • Calculate contribution to overall excess mortality by socio-demographic groups


Excess feto infant mortality blacks 2000
Excess Feto-Infant MortalityBlacks, 2000

MI Blacks

Reference

Excess

13.5

1.9

11.6

-

=

2.8

1.8

3.9

1.2

1.4

0.9

1.5

0.4

3.0

-

=

21.8

5.4

16.5


Excess feto infant deaths blacks 2000

Excess Mortality

11.6

1.5

0.4

3.0

16.5

Excess Feto-Infant DeathsBlacks, 2000

Excess Deaths

281

Total fetal or infant deaths (24,304)

×

=

37

9

72

=

399

× 24,304 / 1000


Perinatal periods of risk approach 5 major steps6
Perinatal Periods of Risk Approach:5 Major Steps

1) Engage community partners

2) Map feto-infant mortality

3) Focus on reducing overall feto-infant mortality

4) Examine opportunity gaps

5) Further investigations and prevention efforts


5 target investigations prevention efforts on the gap
5. Target Investigations & Prevention Efforts on the Gap

  • Focus more effort and attention to group(s) contributing most to the gap

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

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


Mi activities
MI Activities

  • Infant Mortality Summit – one of the main themes

  • Workshops at various conferences, county health departments

  • Spreadsheet program for calculation

  • Infant Mortality Workbook

  • MCH County Profiles


Major findings
Major Findings

Maternal Health / Prematurity:

Largest opportunity gap


Programmatic response
Programmatic Response

  • Pregnancy intention

  • Smoking

  • Drinking

  • Drug abuse

  • Stress

  • Racial discrimination

  • Nutrition

  • Pregnancy interval

  • Preconceptional care

  • Overall fitness

Maternal Health/ Prematurity 281

Infant Health 72


Major findings1
Major Findings

Infant Health: Second largest opportunity gap


Programmatic response1
Programmatic Response

Maternal Health/ Prematurity 281

  • Sleep position

  • Smoking

  • Breastfeeding

  • Medical home

  • Injury prevention

Infant Health 72



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