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Perinatal Periods of Risk (PPOR). Indianapolis Healthy Start Amanda Raftery, MPH Julie Sautter, MSW. Indianapolis Healthy Start. Goal: To reduce infant mortality rates and improve perinatal outcomes by eliminating disparities in perinatal health systems.

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Perinatal Periods of Risk (PPOR)

Indianapolis Healthy Start

Amanda Raftery, MPH

Julie Sautter, MSW

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Indianapolis Healthy Start

  • Goal: To reduce infant mortality rates and improve perinatal outcomes by eliminating disparities in perinatal health systems.

  • Target Population:Underserved and disadvantaged pregnant women in Marion County including minorities (African American, Hispanic and Appalachian), or those at risk by demographic factors (teenagers), or those at the highest risk of poor birth outcomes.

  • Core Services : Outreach, Health Education, Case Management (Prenatal Care, Interconceptional Care, Depression Screening & Referral)

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PPOR Team Members

  • Originally started with only three members; currently 13 members:

    • Marion County Health Department – 7 members

      • Population Health Bureau Director, Maternal & Child Health Director, Healthy Start, FIMR, and Epidemiology

    • Indiana State Department of Health – 2 members

      • MCH Nurse Consultant, Epidemiology

    • Indiana Perinatal Network – 2 members

      • Indiana Access, SIDS Alliance

    • Wishard Health Services – 1 member

      • Indiana University Child Protection Team

      • Child Fatality Review Team

    • Healthy Families – 1 member

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PPOR Team Activities

  • Attended three PPOR “How to Do” Workshops

    • Phoenix, AZ – December 2003

    • Washington, DC – March 2004

    • Portland, OR – September 2004

  • Participate in monthly PPOR seminar calls

  • Presented to Indianapolis Healthy Babies Consortium – July 2004

    • Presented preliminary PPOR data

    • Recruited team members

    • Collected community surveys and community readiness tents

  • Held three team meetings

    • Meet bi-monthly – November, February and April

    • Review data until July 2005

    • Develop logic model and interventions by December 2005

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Indianapolis PPOR Map

PPOR Excess Deaths *

Compared to Internal and External Reference Groups**

1999-2003 Birth Cohort Data***

Marion County, IN

*Excluded are infants who weighed <500 grams at birth and fetal deaths that occurred before the 24th week or were <500 grams.

**Internal Reference Group: White, non-Hispanic women, age >=20 yrs., married, non-smoking, who have an education >=13 years, received prenatal care in the 1st trimester and reside in Marion County, IN.

External Reference Group: White non-Hispanic women, age >=20 yrs., who have an education >=13 years.

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

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Kitagawa, Risk Factor, and Cause of Death Analyses Results


  • Kitagawa Analysis

    Black women and women 20-34 years have 40% of their excess mortality rate occurring from excess birth weight specific mortality.

  • Risk Factors for VLBW and Survivability of VLBW infants

    Risk Factors: One of the most notable findings was that Black women and women 20-34 were more likely than the reference group to have had prenatal care in the Kotelchuck Index category of “Intermediate”.

  • Cause of Death Analysis for Infant Health Category

    The injury category had highest percentage of deaths. A large percentage were due to suffocation and strangulation.

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Additional Data Analyses

  • Generated profiles of women most likely to experience a VLBW birth

    • Black women, being single, <12 years education, <24 years of age and smoking during pregnancy

    • The impact of being single was relatively small among blacks and women with few prior births

  • Examined preterm status with regards to VLBW and SGA infants

    • Black women and women <20 years of age were most likely to have preterm births that were VLBW or SGA

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Future Data Analysis

  • Investigate factors surrounding deaths due to suffocation and strangulation.

  • Summary of SIDS by age at death (in months)

  • Summary of causes of death for higher weight fetal deaths and where death occurred (i.e. hospital or after discharge)

  • Summary of VLBW broken down by weight distribution

  • Investigate factors surrounding C-sections for high risk groups

  • Map VLBW births vs. VLBW births resulting in death.

  • Identify zip codes at high risk for VLBW births

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Community Partner

Indiana Access

Larry Humbert

Program Director

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Indiana Access


  • Modeled after the Disney Institute of Customer Service

  • Community based – action research

  • Asset based

  • Consumer focused customer service

  • Changing the culture in which maternal and child health services are delivered

    Data Collection Efforts

  • Hypothesis – “How people are treated may play a role in whether they access and remain in care”

  • Four pilot community health centers

  • 525 Interviews with postpartum women

  • 550 Interviews with parents of children 6 mos. – 5 yrs.

  • 95 surveys of prenatal and pediatric providers and support staff

  • Focus groups of current and recently pregnant women

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  • Intent of Pregnancy

    • 18% wanted to be pregnant now

    • 45% wanted to be pregnant later

    • 26% never wanted to be pregnant

  • Not Using Family Planning

    • 68% of unintended pregnancies were not using a family planning method

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Reasons for Not Using Family Planning

  • 27% Wanted to be pregnant

  • 14% Did not think I could get pregnant

  • 12% Did not want to use birth control

  • 11% Don’t know / not sure

  • 10% I had side effects

  • 4% Didn’t think I was going to have sex

  • 3% Husband / partner did not want

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Early Prenatal Care

24% Did Not Receive Early Prenatal Care


  • 31% Did not know I was pregnant

  • 20% Could not get an earlier appointment

  • 12% Did not have enough $ / insurance

  • 12% I had too many other things going on

  • 3% No one to care for other children

  • 5% Did not want to know I was pregnant

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Fetal and Infant Mortality Review (FIMR)

Teri Conard

FIMR Coordinator

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FIMR Mission andPurpose

Mission Statement:

To tell the stories of the mothers whose infants represent the fetal infant mortality rates in Marion County, by “painting the the faces behind the numbers” through studying fetal infant death information, listening to the mothers and protecting their privacy, with the goal of improving maternal child services and infant mortality through community partnerships.


To enhance the health and well-being of women, infants, and families by improving the community resources and service delivery systems available to them

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IHB-FIMR Activities

  • Case Review Activities

    • 39 Cases Abstracted

    • 6 FIMR Maternal Interviews

    • 6 Case Review Team Meetings

  • Community Action Team (CAT)

    • Indianapolis Healthy Babies Consortium

    • PPOR Team

    • Marion County Healthcare System Representation

    • Development still a Work in Progress

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PPOR Next Steps

  • Continue analyzing data

  • Development of community action teams/projects

  • Begin and develop logic model and interventions

  • Tentative joint technical assistance visit with CityMatCH, Friendly Access, and HRSA

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Contact Information

  • Indianapolis Healthy Start/PPOR

    • Julie Sautter


    • Amanda Raftery


  • Fetal Infant Mortality Review

    • Teri Conard


  • Indiana Access

    • Larry Humbert