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Perinatal Periods of Risk Approach: The Michigan Experience

Perinatal Periods of Risk Approach: The Michigan Experience. Bao-Ping Zhu, MD, MS Lead Epidemiologist Division of Reproductive Health, CDC Chief MCH Epidemiologist, MDCH. Why a New Approach to Infant Mortality?. Simple approach – easy for communities nationwide to use

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Perinatal Periods of Risk Approach: The Michigan Experience

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  1. Perinatal Periods of Risk Approach:The Michigan Experience Bao-Ping Zhu, MD, MS Lead Epidemiologist Division of Reproductive Health, CDC Chief MCH Epidemiologist, MDCH

  2. Why a New Approach to Infant Mortality? • Simple approach – easy for communities nationwide to use • Identifies gaps in community • Targets resources for prevention • Mobilizes the community to action

  3. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners early to gain consensus and support 2) Map feto-infant mortality by birthweight & age at death 3) Focus on reducing overall feto-infant mortality 4) Examine potential opportunity gaps 5) Target further investigations and prevention efforts on gaps

  4. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

  5. Perinatal Periods of Risk Approach:5 Major Steps • Improving feto-infant mortality requires mobilization and change in many sectors and by many individuals in community • Consensus about and ownership of problem essential in developing community support • Monitoring the problem and the solutions and necessary strategy adjustments require effort by many partners

  6. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

  7. Map Feto-Infant Mortality Age at Death Fetal (24+ wks) Neonatal Postneonatal Birthweight 1 2 3 500-1499 g 4 5 6 1500+ g

  8. Map Feto-Infant Mortality Age at Death Post neonatal Neonatal Fetal Birthweight 500- 1499 g 1 2 3 1500+ g 4 5 6

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

  10. Maternal Health/ Prematurity Pregnancy Intention Smoking / Drinking / Drug Abuse Racial discrimination / Stress Prenatal Care Referral System High Risk OB Care Maternal Care Perinatal Management Perinatal System Pediatric Surgery Newborn Care Sleep Position Breast-Feeding Injury Prevention Infant Health Map Connections to Action

  11. Map Feto-Infant DeathsMichigan Overall, 2000 1582 fetal or infant deaths Maternal Health/ Prematurity 875 Total fetal deaths and live births: 137,496 Maternal Care 245 Newborn Care 200 Infant Health 262

  12. Map Feto-Infant DeathsBlacks, MI, 2000 531 fetal or infant deaths Maternal Health/ Prematurity 327 Total fetal deaths and live births: 24,304 Maternal Care 67 Newborn Care 43 Infant Health 94

  13. Map Feto-Infant MortalityWhat Is Missing in the 6 Cells? • Fetal deaths <24 wks • Live births <500 g • Spontaneous abortions • Induced abortions

  14. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

  15. 3. Focus on Reducing Overall Feto-Infant Mortality Rate • Include fetal deaths - often excluded • Calculate group specific mortality rates - add up to total feto-infant mortality rate • Calculate excess mortality rates and numbers - relate to total feto-infant rate

  16. Feto-Infant DeathsBlacks, MI, 2000 531 fetal or infant deaths Maternal Health/ Prematurity 327 Total fetal deaths and live births: 24,304 Maternal Care 67 Newborn Care 43 Infant Health 94

  17. Focus on Overall MortalityCell- or Group-Specific Mortality Rates 4 e.g., for Blacks: Maternal Health/ Prematurity: 327 Number of deaths in a cell or group Total number of live births & fetal deaths e.g, for Blacks: 24,304

  18. Focus on Overall Feto-Infant MortalityBlacks, MI, 2000 Maternal Health/ Prematurity 13.5 Total feto-infant mortality rate:21.8 =(531/24,304)x 1000 Maternal Care 2.8 Newborn Care 1.8 Infant Health 3.9

  19. Focus on Overall MortalityLearn by Comparisons • Compare within community feto-infant mortality rates by examining 4 group rates • Compare overall and group rates over time • Compare overall and group rates between different population groups

  20. Focus on Overall MortalityComparison of Socio-Demographic Groups • Maternal Race and Ethnicity • Race: white, black, other racial groups • Ethnicity: Hispanic, Arabic • Maternal Age and Education • <20 years of age • 20+ years and <13 years of education • 20+ years and 13+ years of education • Geography: SE vs. Non-SE; County; City • Health Care Payment Source

  21. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

  22. 4. Examine “Opportunity Gap” Between Population Groups • To identify potential for reduction in community • Involves: • Decide on reference groups • Calculate excess deaths and mortality rates by components

  23. Examine “Opportunity Gap”Reference Groups • Simple optimal group • At least 15% of population Reference group for MI state-wide analysis • Non-Hispanic white women in Michigan • Aged 20+ years • 13+ years of education

  24. Reference: MI non-Hispanic white women aged 20+, with 13+ yrs education, 1999 284 fetal or infant deaths Maternal Health/ Prematurity 99 (1.9) Total live births or fetal deaths: 52,206 Maternal Care 64 (1.2) Newborn Care 74 (1.4) Infant Health 47 (0.9) Total feto-infant mortality rate:5.4

  25. Examine the “Opportunity Gap” • Examine excess overall mortality, both rate and number • Examine excess mortality across four groups • Calculate contribution to overall excess mortality by socio-demographic groups

  26. Excess Feto-Infant MortalityBlacks, 2000 MI Blacks Reference Excess 13.5 1.9 11.6 - = 2.8 1.8 3.9 1.2 1.4 0.9 1.5 0.4 3.0 - = 21.8 5.4 16.5

  27. Excess Mortality 11.6 1.5 0.4 3.0 16.5 Excess Feto-Infant DeathsBlacks, 2000 Excess Deaths 281 Total fetal or infant deaths (24,304) × = 37 9 72 = 399 × 24,304 / 1000

  28. Perinatal Periods of Risk Approach:5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

  29. 5. Target Investigations & Prevention Efforts on the Gap • Focus more effort and attention to group(s) contributing most to the gap • Conduct further studies or mortality reviews on group(s) contributing to the gap (Phase 2 studies) • Examine current prevention efforts on group(s) contributing to the gap (Phase 2 policy/program reviews)

  30. MI Activities • Infant Mortality Summit – one of the main themes • Workshops at various conferences, county health departments • Spreadsheet program for calculation • Infant Mortality Workbook • MCH County Profiles

  31. Major Findings Maternal Health / Prematurity: Largest opportunity gap

  32. Programmatic Response • Pregnancy intention • Smoking • Drinking • Drug abuse • Stress • Racial discrimination • Nutrition • Pregnancy interval • Preconceptional care • Overall fitness Maternal Health/ Prematurity 281 Infant Health 72

  33. Major Findings Infant Health: Second largest opportunity gap

  34. Programmatic Response Maternal Health/ Prematurity 281 • Sleep position • Smoking • Breastfeeding • Medical home • Injury prevention Infant Health 72

  35. Michigan PPOR “Software” Demonstration

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