The Perinatal Periods of Risk Approach

1. The Perinatal Periods of Risk Approach Phase 1 Analytic Methods CityMatCH Training August 25, 2007 Denver, Colorado

2. Workshop Objectives During this session, participants will have the opportunity to: • Recognize and understand the PPOR approach and its six stages • Learn how to assess “community readiness” • Learn how to assess “analytic readiness” • Understand what it takes to conduct the first phase of analysis

3. Six Stages:Perinatal Periods of Risk Approach Stage 1: Assure Analytic and Community Readiness Stage 2: Conduct Analytic Phases of PPOR Stage 3: Develop Strategic Actions for Targeted Prevention Stage 4: Strengthen Existing and/or Launch New Prevention Initiatives Stage 5: Monitor and Evaluate Approach Stage 6: Sustain Stakeholder Investment and Political Will

4. DEFINITIONS Traditional Infant Mortality Rate “IMR” is deaths before first birthday, per thousand live births =deaths x 1,000 ÷ births This can be done for any subpopulation, for example, the White IMR would be white deaths before first birthday, per thousand white live births

5. Definitions Ideally, we use a BIRTH COHORT, count births in one year, and watch those babies until they reach their first birthday (must wait until the end of the following year ) to count deaths. Often, we use a DEATH COHORT count births in one year, count deaths IN THE SAME YEAR. This is an easy way to approximate the true mortality rate.

6. Infant Mortality Rate,Urban County, 1990-2001 Source: DHHS

7. What do PPOR analytic methods bring “to the table”

8. The Importance of Fetal DeathsOne difference between PPOR and traditional analysis is that PPOR includes fetal deaths, an important part of the picture.

9. PPOR Uses a Reference Group • A subpopulation with optimal outcomes or an external population • Comparison of target population with reference group helps target deaths that could be prevented.

10. PPOR Examines Deaths in TWO dimensions simultaneously: • Age at death • Weight at birth

11. 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

12. 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

13. PPOR ANALYTIC METHODS Steps of Analytic Preparation Acquire access to three required vital records computer files Prepare vital records files and required data elements Assess data quality Assess study sample size

14. PPOR Analytic Preparation • Fetal death certificate files (24+ wks, 500+ grams) • Infant death certificate files (500+ grams) • Live birth files (500 + grams) • Linked birth—infant death certificate files are needed to find birth information for the infants who died • Spontaneous and induced abortions are NOT included (they are not given certificates)

15. Analytic Preparation—Number of Deaths • At least sixty deaths overall and at least ten deaths in each period of risk, for each population being studied • May combine UP TO 5 years to reach adequate number of deaths (no more, due to changes in medical practice) • Phase 2 analyses require even more deaths.

16. Analytic Preparation – Data Quality • Serious bias is introduced if more than 5-10% of births, deaths, and fetal deaths are missing key data items such as birthweight, age at death, and maternal characteristics. • Imputation (educated guessing) can help when key data are missing: e.g. if gestational age >=31 weeks we impute birthweight >=1500 grams

17. Relationship Between Gestational Age and Median Birthweight

18. Imputation I: Fetal Deaths GA Unknown BW Unknown GA>=32 Y BW>=1500 Y BW>=500 N GA >=24 GA>=24 Y 500<=BW<1500 N <500 <24

19. Imputation II: Infant Deaths GA Unknown BW Unknown GA>=31 Y BW>=1500 N / A N GA>=22 Y 500<=BW<1500 N <500

20. What is PPOR Analysis?

21. 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.

22. PPOR Maps Fetal & Infant Deaths Age at Death Fetal (24+ wks) Neonatal Postneonatal Birthweight 1 2 3 500-1499 g 4 5 6 1500+ g

23. Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health PPOR Maps Fetal & Infant Deaths Age at Death Fetal Death Post- neonatal Neonatal Birthweight 500-1499 g 1500+ g

24. 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)

25. 35 Fetal Deaths Maternal Health/ Prematurity 48 Maternal Care (fetal deaths) PPOR Map of Feto-Infant Deaths Urban County, All Races2000-2002 83 Fetal Deaths are sorted into two periods of risk

26. 62 Infant Deaths Maternal Health/ Prematurity (live births) 44 Newborn Care (live births) 47 Infant Health(live births) PPOR Map of Feto-Infant Deaths Urban County, All Races2000-2002 Of the 23,199 Infants born alive, 153 died. These are sorted into three periods of risk

27. 97 Maternal Health/ Prematurity (35 fetal deaths, 62 live births) 48 Maternal Care (fetal deaths) 44 Newborn Care (live births) 47 Infant Health(live births) PPOR Map of Feto-Infant Deaths Urban County, All Races2000-2002 236 Feto-Infant Deaths

28. PPOR ANALYTIC METHODS Steps of Phase 1 Define study population Restrict study population by birthweight and gestational age Calculate numbers and rates for the feto-infant mortality map Compare different time periods, subpopulations and geographic areas

29. Steps of Phase 1 Defining the Study Population • Include mothers who are RESIDENTS of the target area at the time of the baby’s birth. • Define the baby’s race/ethnicity according to the mother’s. • Include multiple gestations. • Include congenital anomalies.

30. 97 Maternal Health/ Prematurity (35 fetal deaths, 62 live births) 48 Maternal Care (fetal deaths) 44 Newborn Care (live births) 47 Infant Health(live births) PPOR Map of Feto-Infant Deaths Urban County, All Races2000-2002 23,199 live births 153 died as infants 83 fetal deaths Denominator is 23,199 + 83 = 23,282

31. 2.1 Maternal Care 1.9 Newborn Care 2.0 Infant Health Calculating Feto-Infant Mortality Rate Urban County, All Races2000-2002 4.2 + 2.1 + 1.9 + 2.0 = 10.1 Period rates add up to overall rate (except for round-off error) Maternal Health/ Prematurity Rate=deaths x 1,000 ÷ births =97 deaths x1,000 ÷ 23,282 = 4.2

32. White Fetal-Infant Rate =8.6 (N=16,045) Black Fetal-Infant Rate =17.6 (N=3,291) 3.1 8.8 2.0 1.9 1.6 2.4 2.4 4.0 White non-Hispanic Black non-Hispanic PPOR Map of Feto- Infant Mortality Urban County, By Race, 2000-2002(N=number of live births and fetal deaths)

33. STOP HERE ANALYTIC EXERCISE CALCULATE RATES

34. PPOR ANALYTIC METHODS More Phase 1 Steps: “THE GAPS” • Select reference population • Calculate excess mortality rates and numbers of deaths • Identify excess mortality gaps

35. PPORRedefines Disparities, Estimates “Opportunity” Gap • ASK: Which women/infants have the "best" outcomes? • ASSUME: allinfants can have similar “best” outcomes • CHOOSE: a comparisongroup(s) (‘reference group’) who already has achieved “best” outcomes • COMPARE: fetal-infant mortality rates in your targetgroup with those of the comparison group(s) • CALCULATE:excessdeaths (= target – comparison groups). This is your community’s “Opportunity Gap.”

36. Reference Groups • Choose an easily defined optimal group • At least 15% of the population • At least 60 deaths • Acceptable to the community • U.S. National Reference Group: • 20 or more years of age • 13 or more years of education • Non-Hispanic white women

37. 2.2 1.1 1.0 1.5 USA Reference Group 1998-2000 • Defined by maternalcharacteristics • 20 or more years of age • 13 or more years of education • Non-Hispanic white women • residents of the US at the time of baby’s birth Total Fetal-Infant Mortality Rate=5.9

38. Calculating ExcessRatesOverall populationUrban County, 2000-2002 (external reference group) ____________________________________________________________

39. Feto-Infant Mortality RatesRacial/Ethnic subgroups ofUrban County, 2000-2002(external reference group)

40. ExcessFeto-Infant Mortality RatesBased on USA 1998-2000 reference group

41. CALCULATING EXCESS NUMBER OF DEATHSFROM Fetal-Infant Mortality Ratesusing External Comparison GroupUrban County, 2000-2002

42. Urban County by Race2000-2002 estimated Excess Number of Deathsbased on external comparison group

43. ANALYTIC EXERCISECALCULATE EXCESS MORTALITY AND ESTIMATE EXCESS NUMBER OF DEATHS

44. 2.4 2.2 1.8 1.0 Feto-Infant Mortality Rates in theInternal Comparison Group(Best Outcomes in Urban County)Urban County, 2000-2002 • Defined by maternal characteristics • 20 or more years of age • 13 or more years of education • Non-Hispanic White women • Residents of Urban County at time of baby’s birth Total Fetal-Infant Mortality Rate = 7.4

45. Excess (Internal)Fetal-Infant Mortality RatesOverall populationUrban County, 2000-2002 ____________________________________________________________

46. Fetal-Infant Mortality RatesUrban County, by Race, Internal Comparison Group 2000-2002

47. Urban County by Race2000-2002 Excess Fetal-Infant Mortality Ratesbased on internal comparison group

48. Urban County by Race2000-2002 Estimated Excess Number of Deathsbased on internal comparison group

49. PPOR is about impact and results: • Builds data and epi capacity • Promotes effective data use • Strengthens essential partnerships • Fosters integration with other key efforts • Encourages evidence-basedinterventions • Helps leverage resources • Enables systems change for perinatal health

50. Please remember to turn in your evaluations !