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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
slide11
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

slide12
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
slide16
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

slide18
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
slide24
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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