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  2. How to Use the PerinatalPeriodsOfRisk ApproachMagda Peck, ScD Jennifer Skala, MEdThursday, November 13, 2003

  3. About CityMatCH • National public health organization • Since 1990, based at the University of Nebraska Medical Center in Omaha, NE • Functions: sustain communication and collaboration, build capacity, promote best practices/policies www.citymatch.org UNMC / CHP 10-15-02

  4. Our Mission Improving the health and well-being of urban women, children and families by strengthening public health organizations and leaders in their communities.

  5. Webcast Overview • Getting started on How to Use the PPOR approach • Top 5 things to Remember about using the PPOR approach • Next steps for PPOR Technical Assistance (Levels 1 and 2) UNMC / CHP 10-15-02

  6. Infant Mortality Rates,Douglas County, NE, 1990-2002 Source: Nebraska Department of Health and Human Service (DHHS) UNMC / CHP 10-15-02

  7. UNMC / CHP 10-15-02

  8. Building the PPOR“Map” • Uselinked infant birth – death file • Include fetal deaths • Examine how much baby weighed and when baby died at the same time • Look at very low birth weight births (less than 1500 grams or 3.3 pounds) UNMC / CHP 10-15-02

  9. “PPOR” is about: • Adding and combining tools to help solve very old problems • Translating data intoaction • Changingthe way we do business UNMC / CHP 10-15-02

  10. 6 Basic Steps:PerinatalPeriodsofRiskApproach • Bring community partners together to build consensus, support, and partnership. UNMC / CHP 10-15-02

  11. Partnership Leadership Commitment Change Community Readiness:From Concepts to Tools RAISING THE ROOF FOR PPOR: What Shape Is Your Tent? UNMC / CHP 10-15-02

  12. Community Readiness:From Concepts to Tools RAISING THE ROOF FOR PPOR: What Shape Is Your Tent? Tool for engaging partners Tool for reaching consensus Tool for identifying joint assets Tool for revealing critical gaps Tool for developing strategy UNMC / CHP 10-15-02

  13. RAISING THE ROOF FOR PPOR: What Shape Is Your Tent? UNMC / CHP 10-15-02

  14. Louisville June 2001 December 2002 UNMC / CHP 10-15-02

  15. 6 Basic Steps: Perinatal Periods of Risk Approach • Bring community partners together to build consensus, support, and partnership. 2) “Map” fetal & infant deaths by birth weight & age at death. UNMC / CHP 10-15-02

  16. Building the PPOR “Map” of Feto-Infant Mortality Age at Death Neonatal Postneonatal Fetal (24 wks) Birthweight 1 2 3 500-1499 g 4 6 5 1500+ g UNMC / CHP 10-15-02

  17. Map of Feto-Infant Mortality:What events are missing in the 6 Cells? • Fetal deaths are restricted to >24 wks • Live births are restricted to >500 g • Spontaneous abortions are not included • Induced abortions are not included UNMC / CHP 10-15-02

  18. PPOR Map of Feto-Infant Mortality Fetal Death Post- neonatal Neonatal Maternal Health/ Prematurity 500-1499 g Maternal Care Newborn Care Infant Health 1500+ g UNMC / CHP 10-15-02

  19. Maternal Health/ Prematurity From Data to Potential Action Preconceptional Health Health Behaviors Perinatal Care Prenatal Care High Risk Referral Obstetric Care Maternal Care Perinatal Management Neonatal Care Pediatric Surgery Newborn Care Sleep Position Breast Feeding Injury Prevention Infant Health UNMC / CHP 10-15-02

  20. PPOR Map of Fetal-Infant DeathsDouglas County, NE, All Races1999-2002 301 Total Fetal-Infant Deaths Maternal Health/ Prematurity 124 Maternal Care 69 Newborn Care 50 Infant Health 58 30,409 Total Fetal Deaths & Live Births UNMC / CHP 10-15-02

  21. How Do We Calculate the Fetal-Infant Mortality Rate?Douglas County, NE, All Races, 1999-2002 Numerator Denominator 110Fetal Deaths 24+ wks. 191Infant Deaths 301Fetal-Infant Deaths 110Fetal Deaths 24+ wks. 30,299Live Births 30,409Live Births & Fetal Deaths + + / = 9.9Fetal-Infant Deaths Per 1,000 Live Births & Fetal Deaths UNMC / CHP 10-15-02

  22. Map of Feto-Infant Mortality Rates Douglas County, NE, All Races1999-2002 Overall Fetal-Infant Mortality Rate = 9.9 4.1 2.3 1.6 1.9 UNMC / CHP 10-15-02

  23. 6 Basic Steps: Perinatal Periods of Risk Approach • Bring community partners together to build consensus, support, and partnership. • “Map” fetal & infant deaths by birth weight & age at death. • Focus onunderstanding the overallfetal-infant death rate. UNMC / CHP 10-15-02

  24. PPOR Map of Feto-Infant Mortality Douglas County, Nebraska All Races, 1991-2002 Fetal-Infant Rate=11.7 Fetal-Infant Rate=10.2 4.1 Fetal-Infant Rate= 9.9 4.1 2.4 1.6 3.7 2.5 1.7 1.9 1991-1994 4.1 1995-1998 2.3 1.6 1.9 1999-2002 UNMC / CHP 10-15-02

  25. Douglas County Feto-Infant Mortality Rates by PPOR Component, 1990-2002 UNMC / CHP 10-15-02

  26. PPOR Map of Fetal-Infant Mortality Douglas County, NE, byRace, 1999-2002 WhiteFetal-Infant Rate = 8.4 BlackFetal-Infant Rate =17.9 3.2 8.8 2.2 1.6 1.4 2.6 2.3 4.2 White non-Hispanic Black non-Hispanic UNMC / CHP 10-15-02

  27. PPOR Map of Feto-Infant Mortality Douglas County, Nebraska All Races, 1991-2002 Fetal-Infant Rate=11.7 Fetal-Infant Rate=10.2 4.1 Fetal-Infant Rate= 9.9 4.1 2.4 1.6 3.7 2.5 1.7 1.9 1991-1994 4.1 1995-1998 2.3 1.6 1.9 1999-2002 UNMC / CHP 10-15-02

  28. Trends in White Feto-Infant Mortality Rates, by PPOR Component, Douglas County (4 year rolling averages) 1990-2002 UNMC / CHP 10-15-02

  29. Trends in Black Feto-Infant Mortality Rates, by PPOR Component, Douglas County (4 year rolling averages) 1990-2002 UNMC / CHP 10-15-02

  30. Maternal Health/ Prematurity From Data to Potential Action Preconception Health Health Behaviors Perinatal Care Prenatal Care High Risk Referral Obstetric Care Maternal Care Perinatal Management Neonatal Care Pediatric Surgery Newborn Care Sleep Position Breast Feeding Injury Prevention Infant Health UNMC / CHP 10-15-02

  31. Questions? Comments?Observations? UNMC / CHP 10-15-02

  32. 6 Basic Steps: Perinatal Periods of Risk Approach • Bring community partners together to build consensus, support, and partnership. • “Map” fetal & infant deaths by birth weight & age at death. • Focus on understandingthe overall fetal-infant death rate. • Find gaps: estimate “excess deaths” bycomparing with groups who already do better UNMC / CHP 10-15-02

  33. Comparison Group: • ASK: Which women/infants have the "best" outcomes? • ASSUME: all infants can have similar “best” outcomes • CHOOSE: a comparisongroup(s) (‘reference group’) who already has achieved “best” outcomes • COMPARE: fetal-infant mortality rates in your target group with those of the comparison group(s) • CALCULATE:excess deaths (= target – comparison groups). This is your community’s “Opportunity Gap.” UNMC / CHP 10-15-02

  34. Remember PPOR Rates in Douglas County, NE, All Races1999-2002 Overall Fetal-Infant Mortality Rate = 9.9 4.1 2.3 1.6 1.9 UNMC / CHP 10-15-02

  35. Ask! Strategic Joint Decision… • Internal vs External Reference Group? • Which External Reference Group? • Which Internal Reference Group? UNMC / CHP 10-15-02

  36. National PPOR Initiative “External” Reference Group • Defined by maternal characteristics • 20 or more years of age • 13 or more years of education • Non-Hispanic white women • Includesall U.S. resident mothers with these characteristics UNMC / CHP 10-15-02

  37. National External Comparison Group’sFetal-Infant Mortality Rates 2.2 Total Fetal-Infant Mortality Rate= 5.9 1.5 1.1 1.0 Source: NCHS Data, 1998-2000 Calculations by CityMatCH UNMC / CHP 10-15-02

  38. National PPOR External Reference Rates, 1995-1997 versus 1998-2000 (Table 6) UNMC / CHP 10-15-02

  39. What if we used an Internal “Reference Group” from within our community to make comparisons?Douglas County infants with the “best” outcomes have mothers who are: -- 20 or more years of age--have 13 or more years of education--non-Hispanic white women UNMC / CHP 10-15-02

  40. Feto-Infant Mortality Rates for the InternalComparison GroupDouglas County, NE, 1999-2002 Total Fetal-Infant Rate= 7.0 2.3 2.3 1.5 0.9 UNMC / CHP 10-15-02

  41. Now, compare Feto-Infant Mortality Rates Douglas County, NE, All Races, 1999-2002 4.1 Total Feto-Infant Mortality Rate = 9.9 2.3 1.6 1.9 UNMC / CHP 10-15-02

  42. Excess Feto-Infant Mortality Rates, Internal vs. External Comparison GroupsDouglas County, NE, 1999-2002 UNMC / CHP 10-15-02

  43. Excess Fetal-Infant Deaths,Internal vs. External Comparison GroupsDouglas County, NE, 1999-2002 UNMC / CHP 10-15-02

  44. Estimated ExcessFetal-Infant Deaths Douglas County, NE, All Races, 1999-2002 compared to the NATIONAL (external)reference group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Total 122excessdeaths Blacks Whites 53excessWhite deaths 49excessBlack deaths UNMC / CHP 10-15-02 (301 Total Fetal-Infant Deaths)

  45. Estimated ExcessFetal-Infant Deaths Douglas County, NE, All Races, 1999-2002 compared to the LOCAL (internal) reference group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Total 88 (-1) excess deaths Whites Blacks 30 (-2) excessWhite deaths 47excess Black deaths (301 Total Fetal-Infant Deaths) UNMC / CHP 10-15-02

  46. Maternal Health/ Prematurity From Data to Potential Action Preconceptional Health Health Behaviors Perinatal Care Prenatal Care High Risk Referral Obstetric Care Maternal Care Perinatal Management Neonatal Care Pediatric Surgery Newborn Care Sleep Position Breast Feeding Injury Prevention Infant Health UNMC / CHP 10-15-02

  47. Questions? Comments?Observations? UNMC / CHP 10-15-02

  48. 6 Basic Steps: Perinatal Periods of Risk Approach • Bring community partners together to build consensus, support, and partnership. • “Map” fetal & infant deaths by birth weight & age at death. • Focus on understandingthe overall fetal-infant death rate. • Estimate “excess deaths” – how many fewer deaths if the best outcomes for some were achieved by all • Target further investigations and actions on the gaps. UNMC / CHP 10-15-02

  49. NEXT: Target Investigations & Prevention Efforts on the Gaps • 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 contribute(s) to the gap. • Examine current prevention efforts on the group(s) that contribute(s) to the gap - policy/program reviews. UNMC / CHP 10-15-02

  50. Preliminary Analyses • Causes of Death: Newborn Care and Infant Health • Multiple Gestation: How big is its effect on fetal-infant mortality? • Birthweight Distribution vs. Birthweight-specific Mortality: How much mortality is from the number of very small babies vs. how many babies die at a given birth weight? (“Kitagawa Analysis”) UNMC / CHP 10-15-02