World Health Organization

1. World Health Organization Collaborating Center in Reproductive Health Promoting Healthy Birth Outcomes October 27-28, 2009 Emory University Woodruff Health Sciences Center The National Centers for Disease Control and Prevention (CDC) Georgia Department of Human Resources Division of Public Health Alfred W. Brann, Jr., MD, Director Woodruff Health Sciences Center Emory University Brian McCarthy, MD, Principal Investigator The National Centers for Disease Control and Prevention

2. AFRO Kenya Madagascar Tanzania Uganda EMRO Afghanistan Egypt Jordan Sudan ERO Armenia Kazakstan Moldova Republic of Georgia Russia Bosnia Czech Republic Poland Romania Yugoslavia Cypress Greece Turkey PAHO Guatemala Honduras Mexico Cuba Grenada Argentina Columbia Ecuador United States - Georgia - Mississippi SEARO India Indonesia South Korea WPRO China Philippines UNRWA For Palestinian Refugees Gaza West Bank WHO Collaborating CenterCountries Receiving HSR Support

3. Health Services Research The systematic study of whether current medical and other relevant knowledge has been brought to bear to improve the health of a community under a set of existing conditions. Expertise required- *Clinical Practice *P.H. Program Management *Epidemiology *Cultural and Social *Behavioral Science Aspects of Health *Public Policy *Country or state-specific Knowledge

4. Infant Mortality and Per Capita GNP

5. Objectives • Objective 1 – List the largest contributor to infant mortality. • Objective 2 – Describe a new indicator for the status of health of a community. • Objective 3 – Describe an approach to a quantified recurrent public health risk. • Objective 4 – Describe four critical questions that are critical for reproductive-aged women.

6. Georgia Perinatal Surveillance • Total cohort accountability begins with the reporting of all products of conception.

7. Georgia Perinatal Surveillance • Feto-infant mortality (FIMR) is used as the measure of mortality rather than infant mortality.

8. Georgia Perinatal Surveillance • Five hundred grams (500gm) or twenty week gestation is used as the starting point for counting feto-infant deaths.

9. Georgia Perinatal Surveillance • Birth weight and age of death are used to classify each death two-dimensionally in order to identify pockets of excess feto-infant deaths, along with the most effective strategies for reducing these excess deaths.

10. Georgia Perinatal Surveillance • Sociodemographic (SD) groups are used to identify disparities as follows: Group 1: ≥ 20 years of age, ≥13 years of education Group 2: ≥ 20 years of age, <13 years of education Group 3: < 20 years of age, <13 years of education

11. Georgia Perinatal Surveillance • The opportunity gap is based on a comparison between the “standard” feto-infant mortality in Georgia (the lowest rate achieved by one SD group in a defined geographical area) with the rates experienced by the remaining SD groups.

12. Georgia’s Six Perinatal Regions Hospital Perinatal Center

13. Number of Feto-Infant Deaths Data Rich, Information Poor Total Deaths 3936

14. Number of Feto-Infant Deaths Data Rich, Information Poor Age at Death Total Deaths 3936 Birth Weight

15. Birthweight and Age at Death Late Fetal Death (28+ wks) Early Neontal Death (<7 days) Late Neonatal Death (7-27days) Post Neonatal Death (28+ days) 1 2 3 4 VVLBW (500 - 999gms) 5 6 7 8 VLBW (999-1499 gms) 9 10 11 12 IBW (1499-2499 gms) 13 14 15 16 NBW (2500+ gms)

16. Interventions for Reducing Mortality Women’s and Maternal Health Maternal and Fetal Care Neonatal Care Infant Care

17. Birthweight and Age at Death Late Fetal Death (28+ wks) Early Neontal Death (<7 days) Late Neonatal Death (7-27days) Post Neonatal Death (28+ days) W & M Health 1 W & M Health 2 W & M Health 3 W & M Health 4 VVLBW (0-999gms) W & M Health 5 W & M Health 6 W & M Health 7 W & M Health 8 VLBW (999-1499 gms) M & F Care 9 Newborn Care 10 Newborn Care 11 Infant Care 12 IBW (1499-2499 gms) M & F Care 13 Newborn Care 14 Infant Care 15 Infant Care 16 NBW (2500+ gms)

18. Summary of Perinatal Health Care Interventions • Reproductive Awareness • Preconception Care • Child Spacing • Nutrition • Micronutrients • STDs • Substance Abuse • Domestic Violence Women’s & Maternal Health Interventions: Infant Care Interventions: • Pregnancy Identification • Prenatal Surveillance & Care • Anticipatory Guidance • Intrapartum Monitoring • “ART” for complications • Surgical Services • High Risk Maternal • Followup Maternal & Fetal Care Interventions: Newborn Care Interventions: • Parenting Skill Education • Child Health Supervision • Breastfeeding/nutrition • Immunization • Growth/Development Monitoring • Anticipatory Guidance • A.R.I. • D.D. • Injury Control • “ART” for the At-Risk-Infant • Community Services • Clean Delivery • Resuscitation • Thermal Control • Breast Feeding • “ART” for the At-Risk-Infant • “Baby Friendly” Concept • Parenting Skill Education

19. Georgia’s Six Perinatal Regions Hospital Perinatal Center

20. Excessive Mortality Rate by Region Georgia, 1991-1993 3.2 7.4 4.2 Total=5.6 Total=8.2 Total=11.4 0.3 1.2 1.0 0.7 1.0 0.5 1.4 1.8 2.5 Atlanta Augusta Macon 4.3 4.1 4.6 Total=7.3 Total=8.3 Total=8.6 0.9 0.8 1.1 0.6 0.3 1.0 1.5 2.6 2.4 Columbus Savannah Albany

21. What do Current Data Show? • Excess fetal and infant death rates occur in all six perinatal regions, with the highest death rate in the Macon region followed by Albany, Savannah, Augusta, Columbus and Atlanta. • The “standard woman” has excess fetal and infant mortality when compared to the same woman who lives in Connecticut.

22. The “Opportunity Gap”- The potential for reduction in excessive mortality based on a comparison between rates already achieved by one sub-population in a defined geographical area with those experienced by the remaining population.

23. Analysis of Sociodemographic Risks Deaths per 1,000 live births Death Rate Excess Rate Education Sub-group Age White Group 1 >20 >13 years 5.7 .7 White Group 2 >20 <13 years 9.0 4.1 White Group 3 ≤19 <13 years 13.3 8.3 Black Group 1 >20 >13 years 14.0 9.0 Black Group 2 >20 <13 years 19.0 14.0 Black Group 3 ≤19 <13 years 19.6 14.6

24. W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health M & F Care Newborn Care Newborn Care Infant Care M & F Care Newborn Care Infant Care Infant Care Calculating “The Opportunity Gap” = Excess Mortality Excess Mortality = BWPR - BWPR TARGET POPULATION STANDARD Birthweight Proportionate Rate (BWPR) Number of deaths in a given weight group Total Number of births in all weight groups BWPR = x 1000 OR Maternal Health # of Deaths (# in cells) x 1000 (# in entire table)

25. Analysis of Sociodemographic Risks Deaths per 1,000 live births Death Rate Excess Rate Education Sub-group Age White Group 1 >20 >13 years 5.7 .7 White Group 2 >20 <13 years 9.0 4.1 White Group 3 ≤19 <13 years 13.3 8.3 Black Group 1 >20 >13 years 14.0 9.0 Black Group 2 >20 <13 years 19.0 14.0 Black Group 3 ≤19 <13 years 19.6 14.6

26. Total Feto-Infant Deaths 3936 Excessive Feto-Infant Deaths 2314

27. W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health M & F Care Newborn Care Newborn Care Infant Care M & F Care Newborn Care Infant Care Infant Care Calculating “The Opportunity Gap” = Excess Mortality Excess Mortality = BWPR - BWPR TARGET POPULATION STANDARD Birthweight Proportionate Rate (BWPR) Number of deaths in a given weight group Total Number of births in all weight groups BWPR = x 1000 OR Maternal Health # of Deaths (# in cells) x 1000 (# in entire table)

28. Feto-Infant Mortality Rate White Group I, Atlanta Region 2.1 0.8 0.9 1.2 Total = 5.0

29. Excessive Mortality Rate by Sociodemographic Group Georgia, 1991-1993 0.3 3.6 1.6 Total=0.7 Total=4.0 Total=8.3 0.1 0.5 0.9 0.1 0.4 0.4 0.2 1.5 3.4 White Group 1 White Group 2 White Group 3 7.2 8.7 8.3 Total=9.0 Total=14.0 Total=14.5 0.5 1.2 1.1 0.5 1.7 1.4 0.8 2.8 3.3 Black Group 1 Black Group 2 Black Group 3

30. Interventions for Reducing Mortality Women’s and Maternal Health Maternal and Fetal Care Neonatal Care Infant Care

31. Georgia’s Six Perinatal Regions Hospital Perinatal Center

32. Areas of Concentration to Reduce Infant Mortality Area Potential for Improvement LOW HIGH WOMEN’S & MATERNAL HEALTH 60% Maternal Fetal Care 10% Neonatal Intensive Care 9% POSTNATAL CARE 21%

37. Summary of Perinatal Health Care Interventions • Reproductive Awareness • Preconception Care • Child Spacing • Nutrition • Micronutrients • STDs • Substance Abuse • Domestic Violence Women’s & Maternal Health Interventions: Infant Care Interventions: • Pregnancy Identification • Prenatal Surveillance & Care • Anticipatory Guidance • Intrapartum Monitoring • “ART” for complications • Surgical Services • High Risk Maternal • Followup Maternal & Fetal Care Interventions: Newborn Care Interventions: • Parenting Skill Education • Child Health Supervision • Breastfeeding/nutrition • Immunization • Growth/Development Monitoring • Anticipatory Guidance • A.R.I. • D.D. • Injury Control • “ART” for the At-Risk-Infant • Community Services • Clean Delivery • Resuscitation • Thermal Control • Breast Feeding • “ART” for the At-Risk-Infant • “Baby Friendly” Concept • Parenting Skill Education

38. Background • Georgia’s infant mortality declined by 50% from 1975 to 1996, primarily due to improved survival of low birth weight (LBW; < 2500 gm) infants; • The largest contributor to Georgia’s infant mortality rate is the birth of LBW and VLBW (< 1500 gm) infants: % of Births% of Infant Deaths < 2500 g 11% 70% < 1500 g 2% (~2500 births) 50%

39. Background • African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality (1). • Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.

40. Background • No obstetrical or prenatal assessment or intervention has been successful in predicting or preventing a woman’s first preterm/LBW delivery (4); • The single best predictor of a preterm/VLBW delivery is a history of a previous preterm/VLBW delivery (5). • White women – 8% • African-American women – 13%

41. Background • Experience and a growing body of evidence link the delivery of a VLBW infant to aspects of a woman's health status, including (1): • Unrecognized and poorly-controlled medical problems; • Reproductive tract infections (including BV and STI’s); • Substance abuse disorders; • Periodontal disease; • Psychosocial factors including psychological stress and domestic violence.

42. Background • Short interpregnancy intervals increase the risk of preterm/LBW delivery (2, 3), • the critical interval varies by race (4): • 9 months for African-American women; • 3 months for white women.

43. Background • Pregnancy is too late to initiate prenatal care if the mother has had a previous VLBW infant.

44. Interpregnancy Care • Primary health care from delivery of one child until conception of the next.

45. The Interpregnancy Care Program Interpregnancy Primary Care and Social Support for African-American Women at risk for recurrent very-low-birthweight delivery: A Pilot Evaluation Accepted for Publication - July, 2007 in Maternal and Child Health Journal