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Using Perinatal Periods of Risk: Emerging Practice From the Field

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Title: Using Perinatal Periods of Risk: Emerging Practice From the Field


1
Using Perinatal Periods of Risk Emerging
Practice From the Field
7th Annual MCH Epidemiology Conference, December
2001 Clearwater Beach, Florida
2
Using Perinatal Periods of Risk Emerging
Practice From the Field
Magda Peck, CityMatCH Maria Damiani, New Haven
CT Amos Smith, New Haven CT Ken Gross,
Philadelphia PA Carol Brady, Jacksonville
FL Jennifer Skala, CityMatCH Bill Sappenfield,
CDC/Atlanta
3
Perinatal Periods of RiskTranslating Science to
Practice
  • Review and validate the science
  • Test the feasibility and applicability
  • Refine the methods
  • Develop best practices
  • Disseminate the approach

4
Perinatal Periods of Risk
Age at Death
  • Engage community partners
  • Map feto-infant mortality
  • Focus on overall rate
  • Examine potential opportunity gaps
  • Target further efforts

Post neonatal
Fetal
Neonatal
Birthweight

500- 1499g
Maternal Health/ Prematurity
Newborn Care
Maternal Care
Infant Health
1500g
6
5
Perinatal Periods of Risk Mobilizing for Best
Results
6
PPOR - Practice Collaborative
  • Our purpose is to determine and describe,
    together, the best practices in using the
    Perinatal Periods of Risk approach as a tool to
    improve maternal and infant health in
    communities and, when necessary, to further
    develop, modify and strengthen the approach for
    its best use.

7
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8
Improving Maternal Infant Health
Readiness
Needs Assessment
Investment
Strategies
Evaluation
Plan
Monitoring
Implementation
9
Perinatal Periods of RiskPractice Collaborative
Community Readiness Investment
10
Community ReadinessFrom Concepts to Tools
  • Leadership
  • Partnership
  • Commitment
  • Change

RAISING THE ROOF FOR PPOR What Shape Is Your
Tent?
11
Community ReadinessFrom 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

12
RAISING THE ROOF FOR PPOR
  • Review the 5 essential elements questions
  • Assess the current status of each
  • Reach consensus on a score for each readiness
    element
  • Plot each score on the tent by marking the
    number on each corresponding axis.
  • Connect the 5 points between the axises to form
    the roof, then shade the tent.
  • Identify the tent pattern most like yours what
    does this mean for PPOR readiness?

13
RAISING THE ROOF FOR PPOR What Shape
Is Your Tent?
14
PPOR Community Readiness5 Tent Poles
  • Reasoning partners can communicate clear,
    compelling case for PPOR based on its value-add
  • Results partners can articulate what measurable
    results are expected from doing PPOR, and by when
  • Roles partners are willing and able to champion
    PPOR over time in their various roles in
    community
  • Risks/Rewards sufficient strategic balance
    exists between benefits and consequences for
    essential stakeholders to support PPOR
    implementation
  • Resources sufficient systems and resources to
    support full implementation

15
RAISING THE ROOF FOR PPOR New Haven
16
PPOR Community Readiness What does it mean?
  • Reasoning
  • Results
  • Roles
  • Risks/Rewards
  • Resources

17
New Haven StoryCommunity Readiness Elements vs.
Skills
  • Leadership
  • Partnership
  • Commitment
  • Change
  • Communicate Approach, Results
  • Prioritize Actions
  • Engage Over Time
  • Mobilize for Action

18
The Perinatal Periods of RiskPractice
Collaborative
Analytic Issues/Readiness
19
What do we mean by PPOR Analytic Phases?
  • Phase 1 Identifies the populations with excess
    mortality. It examines the 4 mortality
    componentsMaternal Health/ Prematurity, Maternal
    Care, Newborn Care Infant Healthfor various
    populations and uses a reference group to
    estimate excess mortality.
  • Phase 2 Explains the excess mortality. It
    examines reasons for the excess mortality through
    further epidemiologic studies, mortality reviews
    and community assessments.

20
PhiladelphiaInfant Mortality Rates
21
Phase 1 Analysis
  • Overall Summary of Infant Mortality in
    Philadelphia
  • Identified disparities in Race Age of Mother
  • Geographic analysis

22
Phase 1 PPOR Analysis Philadelphia
of Excess Mortality
Number of Deaths
Age at Death
Post neonatal
Fetal
Neonatal

Birthweight
341
6
102
201
177
Total Excess 519 Deaths
Total Number of Deaths 821
23
Philadelphia, Phase I Results
24
Philadelphia Phase I results
  • Comparing Black PPOR results to White,
    non-Hispanic PPOR results
  • Maternal Health/ Prematurity rates are 2.0 times
    greater
  • Maternal Care rates are 1.5 times greater
  • Newborn Care rates are 2.0 times greater
  • Infant Health rates are 2.6 times greater

25
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26
Potential causes preconceptional health, health
behaviors perinatal care
27
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28
Phase 2 Studies
Maternal Health/ Prematurity
Infant Health
SIDS
Birthweight Distribution
Injury
Birthweight- Specific Mortality
Infection
Anomalies
29
Philadelphia Maternal Health/Prematurity Phase
IILower North Philadelphia Healthy Start Project
Area
30
Philadelphia Maternal Health/Prematurity Phase
IILower North Philadelphia Healthy Start Project
Area
31
Philadelphia Infant Health Phase IILower North
Philadelphia Healthy Start Project Area
32
PPOR Analytic Readiness What does it mean?
  • Data access/quality
  • Minimum number of events
  • Adequately trained analytic staff
  • Adequately trained communication staff
  • Analysis team including program staff
  • Sufficient staff hours
  • Strong leadership agreement support

33
Frequently Asked Data Analytic Questions
  • What do you mean by two PPOR Analytic Phases?
  • What are linked birth and infant death files?
  • What is the quality of our fetal death
    certificates?
  • What is the difference between residence and
    occurrence?
  • How many years should we combine?
  • Do we really have to eliminate lt500 gram babies?
  • Who should we include in our PPOR analysis?
  • Which reference group should we use?

34
Improving Maternal Infant Health
Readiness
Needs Assessment
Investment
Strategies
Evaluation
Plan
Monitoring
Implementation
35
The Perinatal Periods of RiskPractice
Collaborative
Intervention Strategies
36
Map Connections to Action
Maternal Health/ Prematurity
Preconceptional Health Health Behaviors
Perinatal Care
Prenatal Care Referral System High Risk OB Care
Maternal Care
Sleep Position Breast-Feeding Injury
Prevention
Infant Health
37
Intervention Strategies
  • Racial/Ethnic Disparity (Feto-Infant Mortality
    Gap)
  • Maternal Health/Prematurity
  • Maternal Care (Large Fetal Deaths)
  • Infant Health (Large Postneonatal Deaths)

38
Approach to Interventions Strategies
  • Identify critical information and evidence-based
    approaches in all four areas
  • Share access to the information to participating
    communities
  • Assess current intervention strategies and
    compare to evidence-based strategies
  • Develop new plan based on community assessment,
    intervention strategy assessment or other
    information

39
5. Target Investigations Prevention Efforts on
the Gap
  • 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 contributes to the gap (Phase 2
    studies).
  • Examine current prevention efforts on the
    group(s) that contributes to the gap (Phase 2
    policy/program reviews).

40
The Perinatal Periods of RiskPractice
Collaborative
Strategies for Integrating Analysis into Ongoing
Community Initiatives Duval County, Florida
41
Impetus for Using PPOR
  • Duval was one of three counties in 1995-97 that
    had an infant mortality rate significantly higher
    than the state
  • Two factors contribute to higher infant mortality
    rates in Duval
  • Proportion of nonwhites in the population
  • Poor outcomes among nonwhites

42
Infant Mortality Rates, Duval County, 1995-2000
43
Our Approaches in Duval County
  • PPOR analysis
  • Linking of FIMR findings
  • Development of specific interventions for federal
    Healthy Start grant application
  • Integration into ongoing community planning
    process

44
Black White Fetal-Infant Death Rates By Period
of Risk, Duval County 1995-97
Fetal (24 Wks Gestation)
Neonatal
Postneonatal
Maternal Health/Prematurity Black 6.9 White
2.3 R 3.01 (2.14, 4.25 95 C.I.)
500- 1499g 1500g
Maternal Care Black 3.4 White 2.0 R1.70 (1.12,
2.58 95 C.I.)
Newborn Care Black 1.5 White 1.2 R 1.22 (0.67,
2.20 95 C.I.)
Infant Care Black 2.8 White 1.9 R 1.44 (.092,
2.24 95 C.I.)
Total Feto-Infant Deaths/1000 (Live Births
Fetal Deaths) Black 14.6 White
7.4 R1.96 (1.59, 2.41 95 C.I.)
45
  • PPOR Findings
  • Greatest racial disparities occurred in
    Maternal Health and Maternity Care
  • Disparities disappeared in the other categories
  • Indicate the need for intervention with women
    before they become pregnant as well as improved
    access to prenatal care

46
Fetal Infant Mortality Review (FIMR)
  • Information abstracted from birth, death,
    medical, hospital and autopsy records
  • Family interviews
  • ACOG process
  • Case review team determines medical, social,
    financial and other issues that may have impacted
    on poor outcome

47
FIMR Process
  • 142 fetal and infant cases reviewed by CRT since
    1995
  • 83 white
  • 53 black
  • 6 other
  • Systematic, not random, sample based on specific
    criteria

48
Linking FIMR to PPOR
  • Most Frequent FIMR Factors
  • Infections and STDs
  • No Healthy Start screening
  • Late/inadequate prenatal care
  • Previous poor outcome
  • Family planning problems
  • General state of mothers health
  • Poor nutrition

49
Federal Healthy Start Application
  • RFP in 1999 for projects to address racial
    disparities in birth outcomes
  • Opportunity to use PPOR FIMR Findings to design
    interventions
  • Proposed a Pre- and Interconceptional Model

50
The Magnolia Project
  • Project area
  • Five zip codes in NW Jacksonville (32202, 32204,
    32206, 32208 and 32209)
  • Area accounts for more than half of the Black
    infant mortality in the city
  • About 25,000 women age 15-44 years old live in
    the project area
  • 85 African-American

51
The Magnolia Project
  • Interventions
  • Enhanced clinical care
  • Case management risk reduction
  • Outreach
  • Community development

52
The Magnolia Project
  • Clinic services
  • Age 15-44
  • Resident of target area
  • Pregnant or able to get pregnant
  • Case management
  • 15-44 and living in target area
  • Not pregnant, but sexually active
  • 3 or more risk factors previous loss, repeated
    STDs, no family planning, substance abuse,
    pregnancy lt15 yrs, mental health
    problems, protective services, no source of care

53
Integration of PPOR into Community Planning
Process
  • Community coalitions organized in 1991 as part of
    Florida Healthy Start program
  • Responsible for developing implementing 3 year
    Service Delivery Plan
  • Plan linked to funding (State GR, Healthy Start
    Medicaid waiver)

54
Integration of PPOR into Community Planning
Process
  • Update of initial PPOR analysis (1997-99)
  • Maternal Health Infant Care now areas of
    concern
  • Racial disparities focus
  • Phase 2 analysis
  • Birthweight specific analysis
  • Cause of death (Infant Care)
  • Focus on preterm delivery SIDS

55
In conclusion. . .
  • PPOR links analysis to action
  • Easily integrated into ongoing community
    initiatives like FIMR, MCH planning
  • Can complement enhance existing MCH efforts

56
The Perinatal Periods of RiskPractice
Collaborative
Next Steps
57
What Do We Need to Do Differently?
  • Are we doing the right things?
  • Do community-based initiatives work?
  • Does PPOR work?
  • Have effective strategies been chosen?
  • Are we doing things right?
  • Are essential stakeholders on board?
  • Has the community process been successfully
    implemented?
  • Have barriers and opportunities been addressed?

58
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59
Perinatal Periods of Risk Next Steps
Through these initiatives, PPOR Partners are
working to maximize the impact of PPOR as a
valid, community-based tool to improve the
health and well-being of women and children
60
For more Information, please go to the CityMatCH
website http//www.citymatch.org/PPOR/index.htm
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