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PPOR Literature

Perinatal Periods of Risk Office of Epidemiology & Community Health Monitoring Kansas City, Mo, Health Department. PPOR Literature. Few published articles reporting PPOR findings Emphasis generally on blacks and whites

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PPOR Literature

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  1. Perinatal Periods of RiskOffice of Epidemiology & Community Health MonitoringKansas City, Mo, Health Department

  2. PPOR Literature • Few published articles reporting PPOR findings • Emphasis generally on blacks and whites • PPOR may not be mentioned by name, but fetal-infant deaths are distributed using the PPOR matrix • Kitagawa analysis generally lacking • Other phase 2 analyses may be lacking • Kansas City, Mo, Health Department has published four (4) papers in recent years

  3. Cai J et al. Perinatal Periods of Risk: analysis of fetal-infant mortality rates in Kansas City, Missouri. Matern Child Health J 2005;9(2):199-205 • Report on PPOR for Kansas City, Mo • Kitagawa analysis • Other phase 2 analyses • Restricted to non-Hispanic blacks and whites • No discussion of community efforts other than mention of a limited FIMR project and a Child Fatality Review Program for one of the counties in which KCMo is situated • KCMo is part of 4 different counties

  4. Cai J et al. Perinatal Periods of Risk analysis of infant mortality in Jackson County, Missouri. J Public Health Manage Pract 2007;13(3):270-277 • Restricted to non-Hispanic blacks and whites • Kitagawa analysis (methodology shown in Appendix) • Other phase 2 analyses • Jackson County is 2nd most populous county in Mo • Approximately 50% of population lives in Kansas City • Demography quite different between city residents and non-city residents • Demonstrated geographic and racial differences in fetal-infant mortality • Geographic differences suggested that different intervention strategies may have to be used

  5. Guillory VJ et al. Secular trends in excess fetal and infant mortality using Perinatal Periods of Risk Analysis. J Natl Med Ass 2008;100(12):1450-1456 • Restricted to non-Hispanic blacks and whites in KCMo • Kitagawa analysis • Other phase 2 analyses • Compared PPOR findings for 1996-2000 to those for 2001-2005 • Demonstrated 30% reduction in excess fetal-infant mortality overall (17.0% for blacks, 66.7% for whites) • Nearly doubled the disparity ratio between the two groups

  6. Hoff GL et al. Excess Hispanic fetal-infant mortality in a Midwestern community. Public Health Rep 2009;124(5):711-717 • Used 5 county area of Missouri and Kansas • Kitagawa analysis • Goal was to look at Hispanic fetal-infant mortality • 92.4% of Hispanic population in the Kansas City-Overland Park-Kansas City, MO-KS, CSA resided in the 5 counties • 7.8% of population in the 5 counties; 77.0% of Mexican heritage • Hispanic and non-Hispanic white fetal-infant mortality rates similar; half that of non-Hispanic blacks • Excess Hispanic mortality (91%) concentrated in the MHP category • Interventions would have different focus

  7. PPOR Analytic Purpose • Perinatal Periods of Risk (PPOR): A Useful Tool for Analyzing Fetal and Infant Mortality • PPOR analysis is an approach to investigating and monitoring causes of fetal and infant deaths. • The purpose of PPOR analyses is to change in community direction and priorities for reducing fetal and infant deaths. • Kitagawa analysis is to identify excess deaths due to birthweight distribution or due to birthweight-specific mortality. Mainly, it is used to partition the excess in Maternal Health/Prematurity

  8. PPOR Analytic Methods

  9. Analytic Preparation • Access and process fetal and infant death, live birth, and linked birth-infant death data files • Quality of data: assess to miss % of gestational week, birthweight (grams), education, and race/ethnicity

  10. Phases • Phase I Analysis: • Identifies subpopulations and periods of risk with the largest excess fetal and infant deaths • Phase II Analysis: • Explains why the excess deaths occurred and directs prevention efforts

  11. Selected basic variables for PPOR phase I and II analysis

  12. Published in Public Health Reports Table 3* using percentages of very low birthweight contribution instead of percentages of total excess MHP Percent attributable Percent attributable to Very low birthweight to birthweight birthweight- specific (500-1,499 grams) distribution mortality White 93.7% (41.5/44.3) 6.3% (2.8/44.3) Black 100% 0% Hispanic 90.8% (85.0/93.6) 9.2% (8.6/93.6) For example, among Hispanic, 91% is attributable to birthweight frequency, therefore, the target improvements should focus on reducing birthweight frequency. *Table 3 is from page 715, Public Health Reports/ Sept-Oct. 2009/Volume 124

  13. Kitagawa Table for birthweight—Target population Kitagawa Table for birthweight—Reference population

  14. Birthweight-specific components for the absolute differencein overall feto‑infant mortality rates between populations due to birthweight distribution and feto‑infant mortality rates Birthweight-specific components for the percentage difference in overall feto‑infant mortality rates between populations due to birthweight distribution and feto‑infant mortality rates

  15. Conclusion • Of the overall excess of 8.5, the majority (62.2%) is attributable to birthweight frequency in the target population. The high rate of live births and fetal deaths of 500-749 grams birthweight alone contributes 24.7% to the overall excess. The overall contribution of VLBW is 4.0, of which 4.2 (100%) is attributable to difference in birthweight frequency and -0.2 – to negative difference in the birthweight-specific mortality. Clearly, in addressing Maternal Health/ Prematurity excess, special attention should be directed to reducing the percentage of very low birthweight.

  16. Perinatal Periods of Risk (PPOR) Analysis of Feto-Infant Mortality Rates in Kansas City, Missouri, 1996-2000 vs. 2001-2005

  17. Map Feto-Infant Mortality Post neonatal Neonatal Fetal Maternal Health/ Prematurity 500-1499 g Maternal Care Newborn Care Infant Health 1500+ g

  18. Map Feto-Infant DeathsBlacks, KCMO, 1996-2000 vs. 2001-2005 1996-2000 Maternal Health/ Prematurity 84 210 fetal and infant deaths. Total fetal deaths and live births: 12,795 Maternal Care 37 Newborn Care 23 Infant Health 66 2001-2005 Maternal Health/ Prematurity 81 190 fetal and infant deaths. Total fetal deaths and live births: 13,154 Maternal Care 40 Newborn Care 24 Infant Health 45

  19. Focus on Overall Feto-Infant MortalityBlacks, KCMO, 1996-2000 vs. 2001-2005 1996-2000 Maternal Health/ Prematurity 6.5 Total feto-infant mortality rate:16.4 =(210/12,795)x 1000 Maternal Care 2.9 Newborn Care 1.8 Infant Health 5.2 2001-2005 Maternal Health/ Prematurity 6.2 Total feto-infant mortality rate:14.4 =(190/13,154)x 1000 Maternal Care 3.0 Newborn Care 1.8 Infant Health 3.4

  20. KCMO Blacks KCMO Blacks U.S. Reference U.S. Reference Excess Excess 6.2 6.5 2.2 2.2 4.3 4.0 - - = = 3.0 2.9 1.8 1.8 5.2 3.4 1.5 1.5 1.1 1.1 1.0 1.0 1.4 1.5 0.7 0.7 4.2 2.4 - - = = 16.4 14.4 5.8 5.8 10.6 8.6 Excess Feto-Infant MortalityBlacks, 1996-2000 vs. 2001-2005 1996-2000 2001-2005

  21. Percentage of Excess Black Feto-Infant Mortality, KCMO. 1996-2000 vs. 2001-2005 1996-2000 2001-2005 Total Excess Deaths =136 Total Excess Deaths =113

  22. Feto-Infant Mortality: Contribution of the Birthweight Distribution and Birthweight-Specific Mortality-Blacks KCMO. 1996-2000 vs. 2001-2005 1996-2000 2001-2005 A. Overall Excess Rates B. Maternal Health/Prematurity Excess Rates

  23. Phase 2 Analysis: Maternal Health /Prematurity Risk and Preventive Factors Birthweight Distribution (VLBW Births: 500-1499 grams) in Kansas City, MO 2001-2008

  24. Kansas City FIMR Results (2005-2009) • Maternal Health and Prematurity (N=44) • 43% Preterm labor • 46% Smoking • 32% Substance abuse • 11% Alcohol use • 34% 1st trimester care • 14% Teen mothers • 73% multiple pregnancies • 36% Maternal STDs • 30% Maternal bacterial infection • 18% Maternal HTN/diabetes • 17% History of fetal/infant loss

  25. From Dr. William M Sappenfield, CDC

  26. Black Infant Health KCMO 1996-2000 vs. 2001-2005

  27. Black Infant Mortality Rates, Infant Health Category, Kansas City, MO. 1996-2000 vs. 2001-2005 During 2006-2008, the rate remained 3.4 deaths per 1,000 live births at the same category.

  28. Contact Information • Jinwen Cai, MD • Biostatistician, Office of Epidemiology & Community Health Monitoring • Jinwen_cai@kcmo.org • 816.513.6044 • Gerald L Hoff, PhD, FACE • Epidemiologist & Manager, Office of Epidemiology & Community Health Monitoring • Gerald_hoff@kcmo.org • 816.513.6149

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