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The Perinatal Periods of Risk Approach. Sanil Thomas MS Biostatistics candidate April 27, 2010. Introduction. Infant mortality rate (IMR) is a critical indicator of nation’s health IMR remains higher in United States than in other industrialized countries

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slide1

The Perinatal Periods of Risk Approach

Sanil Thomas

MS Biostatistics candidate

April 27, 2010

introduction
Introduction
  • Infant mortality rate (IMR) is a critical indicator of nation’s health
  • IMR remains higher in United States than in other industrialized countries
  • But IMR does not provide sufficient information to understand the factors that contribute to infant mortality
introduction1
Introduction
  • Traditional methods don’t include the fetal death counts for the analysis of mortality rates
  • Fetal-infant mortality is a multi dimensional issue and a detailed analytical approach to fetal- infant mortality is needed to focus community initiatives for improving maternal and infant health.
objectives
Objectives
  • To look at Feto-Infant mortality in a new way
  • Apply PPOR framework for New York State
  • To see the distribution of common risk factors by county level
perinatal periods of risk ppor approach
Perinatal Periods of Risk (PPOR) Approach
  • The Perinatal Periods of Risk Approach was developed by Dr. Brian McCarthy from the W.H.O. Perinatal Collaborative Center at CDC and other W.H.O. colleagues.
  • Simple method that is based on a strong conceptual prevention
  • The PPOR Data allow you to look at feto-infant mortality in new ways
ppor 6 basic steps
PPOR : 6 Basic Steps

Step 1: Assure Analytic and Community Readiness 

Step 2: Conduct Analytic Phases of PPOR

Step 3: Develop Strategic Actions for Targeted Prevention

Step 4: Strengthen Existing and/or Launch New Prevention Initiatives

Step 5: Monitor and Evaluate Approach

Step 6: Sustain Stakeholder Investment and Political Will

analytic phases of ppor
Analytic Phases of PPOR

Phase 1: Identifies populations and periods of risk with the largest excess mortality.

Phase 2: Explains why the excess deaths occurred.

slide9

The First Dimension Of PPOR Analysis:

Age at Death

1 Year

Conception

Birth

Fetal

4 wks

Infancy

20 wks

28 wks

Spontaneous Abortion

Early Fetal

Late Fetal

Neonatal

Postneonatal

Infant

Feto-Infant

second dimension birthweight
Very Low Birthweight (PPOR limit)

= less than 1500 grams (3.3 pounds)

Low Birthweight

= less than 2500 grams (5.5 pounds)

Normal Birthweight

e.g., a 7.5-pound baby weighs 3,400 grams

Second Dimension: Birthweight

Birthweight

ppor map fetal infant deaths
PPOR “Map” fetal & infant deaths

Age at Death

Fetal (24+ wks)

Neonatal

Postneonatal

Birthweight

1

2

3

500-1499 g

4

5

6

1500+ g

ppor map fetal infant deaths1

Maternal Health/ Prematurity

Maternal Care

Newborn Care

Infant Health

PPOR “Map” fetal & infant deaths

Age at Death

Fetal Death

Post- neonatal

Neonatal

Birthweight

500-1499 g

1500+ g

ppor is about action each period of risk is associated with a set of possible areas for action

Maternal Health/ Prematurity

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

PPOR is about ACTION(each period of risk is associated with a set of possible areas for action)
ppor phase 2
PPOR: Phase 2
  • Poisson log linear modeling
  • Covariates/Fixed effects
      • Mother’s race
      • Mother’s education
      • Mother’s age
      • Payor
      • Random effect - County
ppor phase 21
PPOR: Phase 2
  • Fetal death was not used
  • 2004-2007
  • Predicted death counts were used to obtain smoothed death rates
  • Modeling done for each county
      • Relative risk calculated from the beta estimates
slide16
Data
  • New York State Dept. of Health.
    • Electronic records of births
    • Linked birth-death cohort
    • selected fetal deaths
    • Phase 1 : 2003-2007
    • Phase 2 : 2004-2007
software used
Software used
  • SAS
  • Excel
  • ArcGIS
phase 1 results1

2.58

Maternal Health/ Prematurity

1.63 Maternal Care

1.12 Newborn Care

1.21

Infant Health

Phase 1 Results

New York State

Death Rates per 1000 live births and fetal deaths

conclusions
Conclusions
  • Infant mortality
      • Higher risk ratio for black mothers relative to white mothers
      • Higher risk ratio for mothers having education less than high school when compared to mothers having education more than bachelors
      • Higher risk ratio for mothers of age less than 20 when compared to mothers of age between 20 and 34
  • Smoothed rates are higher in St.Lawrence, Erie, Schenectady, Oneida, Broome, Cortland etc
  • Risk ratio for black mothers relative to white mothers are higher in the counties Orleans, Oswego, Chenango and Cortland
limitation
Limitation
  • Missing data
    • 12428 records out of 497787 records
    • 246 deaths
    • Inconsistent fetal data
future study
Future study
  • Detailed Phase 2 analysis including fetal deaths
  • MHP and IH categories – Protocol for Phase 2 studies
  • Cluster Analysis
  • Spatial smoothing analysis
reference
Reference
  • http://www.citymatch.org/ppor_index.php
  • Cai, J, Hoff GL, Dew PC et al. Perinatal periods of risk: analysis of fetalinfant mortality rates in Kansas City, Missouri. Matern Child Health J.2005;9:199-205
  • Cai J, Hoff GL, Archer R et al. Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri. J Public Health Manage Pract. 2007;13:270-277.
acknowledgments
Acknowledgments
  • Dr. Glen D. Johnson, PhD, MS, MA
  • Dr. Marilyn A. Kacica, M.D.,M.P.H