Disparities in Perinatal Outcomes

1
Disparities in Perinatal Outcomes using PPOR
Results for the Bay Area Data Collaborative
Ellen J. Stein, MD, MPH, FACOG
2
Additional Authors Al Abramowitz, MS
Janet Brown, MSc Anand Chabra, MD, MPH
And Special Thanks To Jerry A. Sierra
BADC Collaborative CA Department of Health
Services MCAH Branch Epi and Eval Section
3
From 1990 to 2001 the birth rate in San Francisco
County dropped significantly for all races and
ethnicities except Whites
4
San Francisco County

• uses the Perinatal Periods of Risk (PPOR) model
  for fetal-infant mortality rates
• birth rates are too low for PPOR analysis of
  racial/ethnic disparities
• African-American births have dropped to 699 per
  year

5
Trends in SF Resident Births by Ethnicity Age
15-44, 1990 to 2001
Total Births 1990 10,125
Total Births 2001 8,233
Source UCSF FHOP Perinatal Databook (Compiled, A
Abramowitz)
6
Changes in Birth RatesSF Residents Age 15-44,
1990 to 2001
Births per 1,000 Female Residents
Source UCSF FHOP Perinatal Databook (Compiled, A
Abramowitz)
7
Nine Bay Area Counties
8
The San Francisco Bay Area Region consists of 9
counties Alameda, Contra Costa, Marin, Napa, San
Francisco, San Mateo, Santa Clara, Solano and
Sonoma
The Bay Area Data Collaborative (BADC) represents
these counties
9
The Bay Area region had 287,044 births and 2,210
fetal-infant deaths from 1999 to 2001
10
Bay Area regional birth data have the statistical
power to analyze racial/ethnic disparities
Distribution of African-American Population in
the Bay Area
11
Fetal-infant mortality (FIM) rates for the Bay
Area Data Collaborative are close to the
regional mean
12
County and Bay Area Data Collaborative (BADC)
Fetal-Infant Mortality (FIM) Rates, 1999-2001
Rates per 1,000

Source CA Birth Cohort File, 1999-2001
13
BADC Region and County Fetal-Infant Mortality
Rates and 95 Confidence Intervals, 2001
14
Bay Area regional racial/ethnic health
disparities reflect the county disparities
15
Racial/Ethnic Disparities PPOR Rates Bay Area
Data Collaborative? (BADC) Region
18.0
16.2
Fetal-Infant Mortality Rates per 1,000 fetal
deaths births, 1999-2001
16.0
14.0
12.0
10.0
7.7
7.6
8.0
6.9
6.2
6.0
4.0
2.0
0.0
Black
White
Hispanic
Asian/PI
All Races
(n664)
(n355)
(n666)
(n464)
(n2210 )
? Alameda, Contra Costa, Marin, Napa, San
Francisco, San Mateo, Santa Clara, Solano, Sonoma
Source CA Birth Cohort File, 1999-2001
16
The Power of Collaboration
17
Using PPOR to Demonstrate Racial/Ethnic
Disparities for Evidence Based Health
Interventions
18
Different Than Conventional Analysis
Perinatal Periods of Risk

• Combines Fetal And Infant Deaths In A
  Fetal-Infant Mortality Rate
• Includes Fetal Deaths 24 Weeks
• Includes Fetal And Infant Deaths with birth
  weight 499 Grams

19
Parameters
Perinatal Periods of Risk

• AGE AT DEATH ?
• BIRTH WEIGHT ?

Fetal-Infant Mortality
20
Perinatal Periods of Risk
4 Periods of Risk represent potential gaps in
maternal and child health systems that lead to
fetal-infant mortality
21
Maternal Health/PrematurityRisk Factors Include

• Infection
• Stress and Work
• General state of health prior to pregnancy
• Injuries and abuse
• Family planning
• Nutrition
• Tobacco/alcohol/drug use
• Previous pregnancy outcomes

22
Maternal CareRisk Factors Include

• Late/inadequate prenatal care
• Infection
• Tobacco/alcohol/drug use
• Inadequate problem recognition
• Early labor
• Nutrition
• Poor weight gain
• Obesity

23
Newborn CareRisk Factors Include

• Access to obstetric expertise
• Access to neonatal intensive care
• Emergency situations
• Infection
• Access to pediatric expertise
• Access to newborn care

24
Infant HealthRisk Factors Include

• Birth defects and developmental anomalies
• Lack of recognition of signs symptoms of
  illness
• Infection
• Injuries
• Inadequate well-child care or follow-up
• SIDS

25
PreconceptionalRisk Factors Also Include

• Infection
• Stress and Work
• General state of health prior to pregnancy
• Injuries and abuse
• Family planning
• Nutrition
• Tobacco/alcohol/drug use
• Previous pregnancy outcomes

26
Perinatal Periods of Risk
Analytic Model
Age at Death



Maternal Health/Prematurity Deaths (Rate)

500-1499 grams
Total Deaths Births Fetal Deaths
Newborn Care Deaths (Rate)
Maternal Care Deaths (Rate)
Infant Health Deaths (Rate)
Total Fetal Infant Mortality (FIM) Rate per 1,000
1500 grams
Birth Weight
27
BADC Distribution and (Rates)FIM, 1999-2001



Prematurity/Maternal Health946 (3.3)

500-1499 grams
2,210 total deaths 288,170 births
fetal deaths
Newborn Care 306 (1.1)
Maternal Care 608 (2.1)
Infant Health 350 (1.2)
Total FIM Rate7.7 per 1,000
1500 grams
Source CA Birth Cohort File, 1999-2001
28
BADC Black Distribution and Rates FIM, 1999-2001
Prematurity/Maternal Health 178 (8.1)

500-1499 grams
355 total deaths 28,160 births
fetal deaths
Newborn Care 25 (1.1)
Maternal Care 90 (4.1)
Infant Health 62 (2.8)
1500 grams
Total FIM Rate16.2
Source CA Birth Cohort File, 1999-2001
29
BADC, All Other, Distribution and Rates FIM,
1999-2001



Prematurity/Maternal Health768 (2.9)

500-1499 grams
1,855 total deaths 266,310 births
fetal deaths
Newborn Care 281 (1.1)
Maternal Care 518 (1.9)
Infant Health 288 (1.1)
Total FIM Rate7.0 per 1,000
1500 grams
Source CA Birth Cohort File, 1999-2001
30
BADC Black, All Other FIM Disparities, 1999-2001


Prematurity/Maternal Health Black 8.1 All
Other 2.9 OR 2.84 (95 CI 2.41- 3.34)
Newborn Care Black 1.1All Other 1.1 OR
1.08 (95 CI .72 - 1.63)
Maternal Care Black 4.1 All Other 1.9 OR
2.12 (95CI 1.69 2.65)
Infant Health Black 2.8All Other 1.1 OR
2.63(95 CI 1.99-3.40)
Black 16.2, All Other 7.0 Total OR 2.35
(95 CI 2.10 2.64)
31
How to Calculate Excess Deaths
TAKE A COMPARISON GROUP
32
Perinatal Periods of Risk
Opportunity gaps
Uses a comparison group model to calculate
excess deaths in the four risk periods against a
standard reference group. Shows the specific
period of risk with the best opportunity to
improve mortality rates.
33
US Standard Reference Group

• White women
• Married
• Over 20 years of age
• 13 years of education

34
U.S. Whites, 13 yrs. Education, 12 U.S.
Cities Fetal Infant Mortality Rates 1998-2000



Maternal Health/Prematurity 2.2
500-1499 grams
Total Deaths Births Fetal Deaths
Newborn Care 1.0
Maternal Care 1.5
Infant Health 1.2
Total FIM Rate 5.9 per 1,000
1500 grams
Source NCHS Perinatal Mortality Data Files,
1998-2000
35
All Races Excess Deaths BADC Region, 1999-2001
Against U.S. White Comparison Group, 1998-2000



Prematurity/Maternal Health 367 (56)

500-1499 grams
Total Excess Deaths 658 (100)
Newborn Care 43 (7)
Maternal Care 213 (32)
Infant Health 34 (5)
1500 grams
Source CA Birth Cohort File, 1999-2001
36
Black Excess Deaths BADC Region, 1999-2001
Against U.S. White Comparison Group, 1998-2000



Prematurity/Maternal Health 130 (58)

Newborn Care 3 (1)
Maternal Care 57 (25)
Infant Health 36 (16)
Total Excess Deaths226
37
African American births are 7.5 of the total
births for the Bay Area Data Collaborative
Excess African American fetal-infant deaths are
1/3 of the excess mortality for the Bay Area Data
Collaborative
38
Preconceptional Risk Factors Continue the Black
Fetal-Infant Mortality Trend1999-2002
PPOR Rate per 1,000
Source CA Birth Cohort File, 1999-2002
39
Preconceptional care is our opportunity to
reduce African American fetal and infant deaths