Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR

1. Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA Center for Maternal and Child Health State University of New York Upstate Medical University Department of Obstetrics and Gynecology Supported by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private foundation with a mission to improve the health and health care of the people of Western and Central New York. February 2010

2. Objective To examine the relationship of poor socioeconomic condition, as reflected by Medicaid status, to poor outcomes of pregnancy.

3. The Central New York Region consists of a 13 county area spanning from St. Lawrence County in the North to Broome and Tioga counties in the South and includes 21 birth hospitals.

4. Statewide Perinatal Data System (SPDS) Population-based birth registry that captures information on all live births in New York State. It consists of the New York State Electronic Birth Certificate (EBC) and additional voluntary questions, e.g., such as the content of prenatal care, intentions of pregnancy, and perinatal depression, that are expected to be used for quality improvement purposes. The SPDS contains data on: maternal demographics; obstetrical history; prenatal care; labor and delivery information; and birth outcomes.

5. SPDS: Pay Source Coding  Medicaid – select this choice if the mother’s care was paid for by Medicaid, PCAP, MOMS, Child Health Plus A, Medicaid Managed Care, or Family Health Plus (39.8%)  Private Insurance – select this item if the mother’s care was paid for by private insurance including indemnity insurance and/or managed care insurance (51.2%)  Self-pay – select this item if the mother had no health insurance (1.1%)  Indian Health Service (0.1%)  CHAMPUS/TRICARE (Military and dependents) (5.0%)  Other government (e.g. Child Health Plus B, Veteran’s Administration) (1.0%)  Other (1.8%)  Unknown (0.1%) Medicaid group also applies to Medicaid as secondary payor. (5.5%)

6. Fetal-Infant Mortality/Morbidity Review/Registry (FIMMRR) Clinically oriented, community based registry to capture detailed data on mortalities/ morbidities for the 21 birth hospitals in the Central New York Region. By evaluating data from chart reviews of all fetal and infant mortalities (≥ 300 grams) as well as major morbidities, patterns have been identified which have informed recommendations for improvements (both social and medical).

7. FIMMRR: Maternal Risk Factors ____ Major pre-pregnancy medical problems: ________________ ____ Poor OB History: ____ Adolescent pregnancy (≤ 16 y.o.) ____ History of infertility ____ Advanced maternal age (≥ 35 y.o.) ____ 2 Prior losses before 20 weeks ____ Housing problems ____ Prior loss after 20 weeks ____ Mental illness (past or present) ____ History of preterm delivery (<37 Wks) ____ Maternal stress: ____ History of previous SGA/IUGR birth ____ Emotional stress (at work or home) ____ Poor nutrition, BMI______ ____ Physical stress (at work or home) (circle)Obese, underweight ____ Loss of partner (circle) ____ Poor Care Seeker (circle) Divorce, Separation, Death, Military Deployment, Other Second Trimester, Third Trimester, No Prenatal Care ____ Death of family member ____ Poor compliance with prenatal visits (missed >2) ____ Pt or partner incarcerated/Legal problems ____ Substance abuse (circle) ____ Other Tobacco, alcohol, marijuana, prescription drugs, other ____ Family violence ____ Poor social setting (in present pregnancy): ____ Cultural problems: ____ < 12th Grade education completed and no GED ____ Recent immigrant (Non-Western origin) ____ Partner uninvolved ____ Language barrier (written or verbal) ____ History of parenting problems ____ Cultural/Religious belief system limits or ____ Other prohibits medical interventions ____ Transportation problems ____ Other ____ Occupational problems ____ Less than 6 months since last birth ____ Family planning problems ____ Current pregnancy result of Assisted ____ Economic issues: Reproductive Technology ____ Unemployed/ partner unemployed ____ Other ____ Medicaid Insurance ____ Needs public assistance (housing, healthcare, etc.) ____ WIC referral ____ Other

8. FIMMRR: Causes of Fetal Death / Prenatal/Intrapartal Factors Contributing to Infant Death _____ Abruptio Placenta/Placental Infarct _____ Perinatal TORCH Infection __________ _____ Antiphospholipid/SLE Syndrome _____ Intrapartal asphyxia _____ Blood Factor Sensitization _____ Intrauterine Growth Restriction _____ Chorioamnionitis (bacterial) _____ Maternal Trauma – Type ____________ _____ Chronic hypertension/Pre-eclampsia _____ Non-Immune Hydrops _____ Cocaine Abuse _____ Termination of Pregnancy, _____ Diabetes: Class ___, Type ___ Indication__________________ _____ Fetal Anomaly/Chromosomal Abnormality _____ Twin-Twin Transfusion Syndrome _____ Feto-Maternal Hemorrhage _____ Other ________________

9. FIMMRR: Causes of Infant Death Circle single dominant cause, check all others noted: _____Congenital Anomaly/Chromosomal Abnormality If SIDS, check-off appropriate items: _____Metabolic Disorder _____Co-sleeping _____Sepsis – Bacterial _____ Smoking Household _____Perinatal Viral Infection _____ Substance Abuse in Household _____Perinatal asphyxia _____ Use of Any Impairing Substance _____Hyaline Membrane Disease _____ Unsafe Sleep Environment _____Blood Factor Sensitization _____ Exclusive Breastfeeding _____CNS hemorrhage _____ Any Breastfeeding _____SIDS _____Unsafe Sleep Environment _____Trauma – accident _____Smoking Household _____Termination of Pregnancy, Indication _____Substance Abuse in Household _____Overwhelming Immaturity _____Prone Sleeping _____Unexplained _____Other _______________ _____Physical Abuse/Neglect _____Other _____________________

10. FIMMRR: Causes of Death-ICD10 _____Congenital malformations, deformations and chromosomal abnormalities _____Disorders related to short gestation, low birth weight, not elsewhere classified _____Sudden infant death syndrome _____Newborn affected by maternal complications of pregnancy _____Newborn affected by complications of placenta, cord and membranes _____Accidents (unintentional injuries) _____Respiratory distress of newborn _____Bacterial sepsis of newborn _____Neonatal hemorrhage _____Intrauterine hypoxia and birth asphyxia _____All other causes

11. Data Notes Statewide Perinatal Data System (SPDS) • primary source for population characteristics • secondary source for identification of neonatal • and post neonatal deaths Fetal Infant Morbidity/Mortality Review/Registry (FIMMRR) • only source for detailed data on fetal deaths • primary source for detailed data on neonatal and post neonatal deaths

12. Population CharacteristicsCentral New York Region 2006-2007

13. Population CharacteristicsCentral New York Region 2006-2007

14. Birth Outcomes Despite increased risk factors for the Medicaid insured women, most birth outcomes in the Central New York Region are not significantly different between Medicaid and Non-Medicaid insured women.

15. Gestational Age Central New York Region 2006-2007

16. Birthweight/Intrauterine GrowthCentral New York Region 2006-2007

17. Morbidity Rates of LBW and especially Small for Gestational Age are significantly higher in Medicaid Insured births.

18. Mortality Using the Fetal-Infant Morbidity/Mortality Review/Registry (FIMMRR), we also explored the Fetal/Infant death rates among Medicaid and Non-Medicaid insured women.

19. Standard Calculation of Death Rates(all ≥ 300 grams) Overall number of total deaths/total live births + fetal deaths Fetal number of intrauterine deaths/total live births + fetal deaths Neonatal number of deaths ≤ 28 days of life/total live births Post-Neonatal number of deaths 29 -365 days of life/total live births Infant Neonatal + Post-Neonatal

20. Central New York Region 2006-2007 Total Live Births + Fetal Deaths = 38962 * rate/1000 * * * p< .001 Non-Medicaid Insured vs Medicaid Insured

21. Central New York Region 2006-2007 Total Live Births + Fetal Deaths = 38962

22. Findings The significant difference in mortality is concentrated within the Infant Deaths, most strikingly the Post-Neonatal Deaths.The lack of a significant difference in mortality for both Fetal and Neonatal Deaths, suggests a potential protective effect by Medicaid.Further analysis, using the Perinatal Periods of Risk approach, provided a different prospective.

23. Fetal Death Neonatal Post- neonatal Maternal Health/ Prematurity 6.9 Maternal Care 1.9 Newborn Care 1.4 Infant Health 1.1 Total Central New York Region 2006-2007 Live Births + Fetal Deaths = 38962 Overall Fetal-Infant Mortality Rate 11.3 per 1, 000 Live Births & Fetal Deaths Age at Death Birthweight 300-1499 g 1500+ g

24. Non-Medicaid Insured Maternal Health/ Prematurity 6.1 Maternal Care 2.0 Newborn Care 0.9 Infant Health 0.4 Central New York Region 2006-2007 Live Births + Fetal Deaths = 21277 Overall Fetal-Infant Mortality Rate 9.4 per 1, 000 Live Births & Fetal Deaths Age at Death Fetal Death Neonatal Post- neonatal Birthweight 300-1499 g 1500+ g

25. Maternal Health/ Prematurity 8.0 Maternal Care 1.8 Newborn Care 1.9 Infant Health 2.0 Medicaid Insured Central New York Region 2006-2007 Live Births + Fetal Deaths = 17685 Overall Fetal-Infant Mortality Rate 13.7 per 1, 000 Live Births & Fetal Deaths Age at Death Fetal Death Neonatal Post- neonatal Birthweight 300-1499 g 1500+ g

26. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007

27. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007

28. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007

29. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007 Excess Mortality Rates in comparison with Reference Group

30. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007 Excess Mortality Numbers in comparison with Reference Group

31. Perinatal Periods of Risk (PPOR) Central New York Region 2006-2007 Comparison to Reference Group supports our previous Findings. It is also useful to examine the distribution of various causes of death in each PPOR category.

32. Fetal-Infant Morbidity/Mortality Review & RegistryCentral New York Region 2006-2007Dominant Cause of Death: rate/1000 live births + fetal deaths

33. Fetal-Infant Morbidity/Mortality Review & RegistryCentral New York Region 2006-2007Dominant Cause of Death: rate/1000 live births + fetal deaths

34. Cause of Death Conclusions These findings support our earlier Findings that pre-pregnancy and early pregnancy factors, along with post neonatal factors play the largest role in the disparity between death rates among Medicaid and Non-Medicaid insured women. A protective effect of Medicaid Status is suggested regarding Fetal and Neonatal deaths.

35. Sharing the Results CNY Regional Perinatal Forum CNY Regional Perinatal Program/Affiliate Hospitals Onondaga County Health Department/Syracuse Healthy Start SUNY Upstate Medical University Departmental Grand Rounds (OB-GYN/Pediatrics) Masters in Public Health courses

36. Resultant Targeted Interventions • Improvepreconceptional/interconceptional care • Facilitate access to early/quality prenatal care • Implement stronger smoking cessation programs • Improve maternal post partum supports and counseling about importance of Safe Sleep Environment

37. Contact Information:Center for Maternal & Child Healthwww.upstate.edu/cmatch/315-464-5706 • Richard H. Aubry, MD, MPH aubryr@upstate.edu • Pamela Parker, BA parkerp@upstate.edu • Kristen Luke-Houseman, RN, BA lukehouk@upstate.edu Preliminary Data. Not for release without permission.