Title: Using Perinatal Periods of Risk: Emerging Practice From the Field
1Using Perinatal Periods of Risk Emerging
Practice From the Field
7th Annual MCH Epidemiology Conference, December
2001 Clearwater Beach, Florida
2Using 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
3Perinatal 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
4Perinatal 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
5Perinatal Periods of Risk Mobilizing for Best
Results
6PPOR - 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.
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8Improving Maternal Infant Health
Readiness
Needs Assessment
Investment
Strategies
Evaluation
Plan
Monitoring
Implementation
9Perinatal Periods of RiskPractice Collaborative
Community Readiness Investment
10Community ReadinessFrom Concepts to Tools
- Leadership
- Partnership
- Commitment
- Change
RAISING THE ROOF FOR PPOR What Shape Is Your
Tent?
11Community 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
12RAISING 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?
13RAISING THE ROOF FOR PPOR What Shape
Is Your Tent?
14PPOR 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
15RAISING THE ROOF FOR PPOR New Haven
16PPOR Community Readiness What does it mean?
- Reasoning
- Results
- Roles
- Risks/Rewards
- Resources
17New Haven StoryCommunity Readiness Elements vs.
Skills
- Leadership
- Partnership
- Commitment
- Change
- Communicate Approach, Results
- Prioritize Actions
- Engage Over Time
- Mobilize for Action
18The Perinatal Periods of RiskPractice
Collaborative
Analytic Issues/Readiness
19What 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.
20PhiladelphiaInfant Mortality Rates
21Phase 1 Analysis
- Overall Summary of Infant Mortality in
Philadelphia - Identified disparities in Race Age of Mother
- Geographic analysis
22Phase 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
23Philadelphia, Phase I Results
24Philadelphia 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
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26Potential causes preconceptional health, health
behaviors perinatal care
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28Phase 2 Studies
Maternal Health/ Prematurity
Infant Health
SIDS
Birthweight Distribution
Injury
Birthweight- Specific Mortality
Infection
Anomalies
29Philadelphia Maternal Health/Prematurity Phase
IILower North Philadelphia Healthy Start Project
Area
30Philadelphia Maternal Health/Prematurity Phase
IILower North Philadelphia Healthy Start Project
Area
31Philadelphia Infant Health Phase IILower North
Philadelphia Healthy Start Project Area
32PPOR 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
33Frequently 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?
34Improving Maternal Infant Health
Readiness
Needs Assessment
Investment
Strategies
Evaluation
Plan
Monitoring
Implementation
35The Perinatal Periods of RiskPractice
Collaborative
Intervention Strategies
36Map 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
37Intervention Strategies
- Racial/Ethnic Disparity (Feto-Infant Mortality
Gap) - Maternal Health/Prematurity
- Maternal Care (Large Fetal Deaths)
- Infant Health (Large Postneonatal Deaths)
38Approach 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
395. 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).
40The Perinatal Periods of RiskPractice
Collaborative
Strategies for Integrating Analysis into Ongoing
Community Initiatives Duval County, Florida
41Impetus 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
42Infant Mortality Rates, Duval County, 1995-2000
43Our 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
44Black 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
46Fetal 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
47FIMR 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
48Linking 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
49Federal 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
50The 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
51The Magnolia Project
- Interventions
- Enhanced clinical care
- Case management risk reduction
- Outreach
- Community development
52The 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
53Integration 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)
54Integration 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
55In conclusion. . .
- PPOR links analysis to action
- Easily integrated into ongoing community
initiatives like FIMR, MCH planning - Can complement enhance existing MCH efforts
56The Perinatal Periods of RiskPractice
Collaborative
Next Steps
57What 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?
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59Perinatal 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
60For more Information, please go to the CityMatCH
website http//www.citymatch.org/PPOR/index.htm