perinatal periods of risk approach: the michigan experience bao-ping zhu, md, ms lead epidemiologist...

Perinatal Periods of Risk Approach:

The Michigan Experience

Bao-Ping Zhu, MD, MSLead 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

• Identifies gaps in community

• Targets resources for prevention

• Mobilizes the community to action

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

Perinatal Periods of Risk Approach:5 Major Steps


1) Engage community partners 2) Map feto-infant mortality3) Focus on reducing overall feto-infant

mortality4) Examine opportunity gaps5) Further investigations and prevention

efforts


• 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




efforts

Map Feto-Infant Mortality

Age at Death

Birth

weig

ht

500-1499 g

1500+ g

Fetal

(24+

wks

)

Neonat

al

Postneo

natal

1 2 3

54 6


500- 1499 g

1500+ g

Fetal NeonatalPost

neonatal

1 2 3

4 5 6

Age at Death

Birth

weig

ht


500-1499 g

1500+ g

Fetal NeonatalPost

neonatal

Maternal Health/ Maternal Health/ PrematurityPrematurity

Maternal Maternal CareCare

Newborn Newborn CareCare

Infant Infant HealthHealth

Map Connections to ActionMaternal Maternal Health/ Health/

PrematurityPrematurity

Pregnancy IntentionSmoking / Drinking / Drug AbuseRacial discrimination / Stress

Maternal Maternal CareCare

Prenatal Care Referral System High Risk OB Care

Newborn Newborn CareCare

Perinatal Management Perinatal System Pediatric Surgery

Infant Infant HealthHealth

Sleep Position Breast-Feeding Injury Prevention

Maternal Health/ Maternal Health/ Prematurity Prematurity

875 875

Maternal Maternal Care Care

245 245

Newborn Newborn Care Care

200 200

Infant Infant Health Health

262262

Map Feto-Infant DeathsMichigan Overall, 2000

1582 fetal or infant deaths

Total fetal deaths and live births: 137,496


327 327


67 67


43 43


9494

Map Feto-Infant DeathsBlacks, MI, 2000



Map Feto-Infant MortalityWhat Is Missing in the 6 Cells?

• Fetal deaths <24 wks

• Live births <500 g

• Spontaneous abortions

• Induced abortions


1) Engage community partners 2) Map feto-infant mortality3) Focus on reducing overall feto-

infant mortality4) Examine opportunity gaps5) Further investigations and prevention

efforts

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


327 327


67 67


43 43


9494

Feto-Infant DeathsBlacks, MI, 2000



Focus on Overall Mortality Cell- or Group-Specific Mortality Rates

Number of deaths in a cell or group

Total number of live births & fetal deaths

4e.g., for Blacks:

Maternal Health/

Prematurity: 327

e.g, for Blacks: 24,304


13.5 13.5


2.8 2.8


1.8 1.8


3.93.9

Focus on Overall Feto-Infant MortalityBlacks, MI, 2000

Total feto-infant mortality rate: 21.8 =(531/24,304)x 1000

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

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




efforts

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

Examine “Opportunity Gap” Reference Groups

Reference group for MI state-wide analysis

• Non-Hispanic white women in Michigan

• Aged 20+ years

• 13+ years of education

Simple optimal group

At least 15% of population


99 (1.9) 99 (1.9)

Maternal Maternal Care Care 64 (1.2) 64 (1.2)

Newborn Newborn Care Care 74 (1.4) 74 (1.4)

Infant Infant Health Health 47 (0.9)47 (0.9)


Reference: MI non-Hispanic white women aged 20+, with 13+ yrs education, 1999

Total feto-infant mortality rate: 5.4

Total live births or fetal deaths: 52,206

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

Excess Feto-Infant MortalityBlacks, 2000

- =

MI Blacks Reference Excess

13.513.5

2.82.8 1.81.8 3.93.9

21.8

1.91.9

1.21.2 1.41.4 0.90.9

5.4

11.611.6

1.51.5 0.40.4 3.03.0

16.5

- =

Excess Feto-Infant DeathsBlacks, 2000

=

Excess Deaths

281281

3737 99 7272

399

=

Excess Mortality

11.611.6

1.51.5 0.40.4 3.03.0

16.5 × 24,304 / 1000

×Total fetal or infant deaths

(24,304)



mortality4) Examine opportunity gaps5) Further investigations and

prevention efforts

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)

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

Major Findings

Maternal Health / Prematurity:

Largest opportunity gap

Programmatic Response


281 281

–Pregnancy intentionPregnancy intention–SmokingSmoking–DrinkingDrinking–Drug abuseDrug abuse–StressStress–Racial discriminationRacial discrimination–NutritionNutrition–Pregnancy intervalPregnancy interval–Preconceptional carePreconceptional care–Overall fitnessOverall fitness


7272

Major Findings

Infant Health: Second largest opportunity gap


281 281Infant Infant Health Health

7272

–Sleep positionSleep position–SmokingSmoking–BreastfeedingBreastfeeding–Medical homeMedical home–Injury preventionInjury prevention

Programmatic Response

Michigan PPOR “Software” Demonstration

perinatal periods of risk approach: the michigan experience bao-ping zhu, md, ms lead epidemiologist...

Documents

overall fetoinfant mortality

map fetoinfant mortality

map fetoinfant deaths

action slide

mdch slide

death birthweight slide

map connections

community partners