ppor literature
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Perinatal Periods of RiskOffice of Epidemiology & Community Health Monitoring
Kansas City, Mo, Health Department 1
PPOR LiteratureFew 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
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
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
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):1450-1456Restricted 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
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
PPOR Analytic PurposePerinatal 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
7
PPOR Analytic Methods
8
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
9
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
10
Selected basic variables for PPOR phase I and II
analysisVariables Fetal Deaths
Linked Birth-Infant Deaths Live Births
Date births X XDate deaths X XBirthweight (gm) X X XGestational age X X XMother’s age X X XMother’s education
X X X
Race/ethnicity X X XCause of death X X
11
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 birthweightbirthweight- 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.
12
Published in Public Health Reports
*Table 3 is from page 715, Public Health Reports/ Sept-Oct. 2009/Volume 124
Enter Enter Calculated CalculatedBirthweight Number of Live
Births&Fetal Deaths
Number of Feto-Infant
Deaths
Birthweight Distribution
Feto-Infant Mortality Rates
500‑749 78 35 0.6% 448.7750‑999 81 24 0.6% 296.31,000‑1,249 79 11 0.6% 139.21,250‑1,499 99 11 0.8% 111.11,500‑1,999 326 16 2.5% 49.12,000‑2,499 914 20 7.0% 21.92,500+ 11464 73 87.9% 6.4Total 13041 190 100.0% 14.6
Enter Enter Calculated CalculatedBirthweight Number of Live
Births&Fetal Deaths
Number of Feto-Infant
Deaths
Birthweight Distribution
Feto-Infant Mortality Rates
500‑749 7008 4019 0.2% 573.5750‑999 7961 1945 0.2% 244.31,000‑1,249 9383 1263 0.2% 134.61,250‑1,499 11075 1085 0.3% 98.01,500‑1,999 43178 2178 1.1% 50.42,000‑2,499 128439 2552 3.4% 19.92,500+ 3566957 9690 94.5% 2.7Total 3774001 22732 100.0% 6.0
Kitagawa Table for birthweight—Target population
Kitagawa Table for birthweight—Reference population
Actual Contribution to the Difference in Excess Mortality Rates
Percentage Contribution to the Difference in Excess Mortality Rates
Column (1) Column (2) Calculated (3) Calculated (4) Column (5) Column (6) Feto-Infant Feto-Infant Birthweight Mortality Birthweight Mortality
Birthweight Distribution Rates Total Distribution Rates Total500-749 2.1 -0.5 1.6 24.7% -5.7% 18.9%750-999 1.1 0.2 1.3 13.0% 2.5% 15.5%1,000-1,249 0.5 0.0 0.5 5.7% 0.2% 6.0%1,250-1,499 0.5 0.1 0.6 5.7% 0.8% 6.5%1,500-1,999 0.7 0.0 0.6 7.9% -0.3% 7.6%2,000-2,499 0.8 0.1 0.9 8.8% 1.2% 10.0%2,500-6,499 -0.3 3.3 3.0 -3.5% 39.0% 35.5%Total 5.3 3.2 8.5 62.2% 37.8% 100.0%MH / Prem. 4.2 -0.2 4.0 49.1% -2.2% 46.9%
Birthweight-specific components for the absolute difference in 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
ConclusionOf 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.
15
Analysis of Feto-Infant Mortality Rates in Kansas City, Missouri, 1996-2000
vs. 2001-2005
Perinatal Periods of Risk (PPOR)
16
Map Feto-Infant Mortality
17
500-1499 g
1500+ g
Fetal NeonatalPost
neonatal
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Map Feto-Infant DeathsBlacks, KCMO, 1996-2000 vs.
2001-2005Maternal Health/Prematurity 84
InfantHealth 66
MaternalCare 37
NewbornCare 23
210 fetal and infant deaths. Total fetal deaths and live births: 12,795
Maternal Health/Prematurity 81
InfantHealth 45
MaternalCare 40
NewbornCare 24
190 fetal and infant deaths. Total fetal deaths and live births: 13,154
1996-2000
2001-2005
18
Maternal Health/Prematurity 6.5
InfantHealth 5.2
MaternalCare 2.9
NewbornCare 1.8
Focus on Overall Feto-Infant Mortality
Blacks, KCMO, 1996-2000 vs. 2001-2005
Total feto-infant mortality rate: 16.4 =(210/12,795)x 1000
Maternal Health/Prematurity 6.2
InfantHealth 3.4
MaternalCare 3.0
NewbornCare 1.8
Total feto-infant mortality rate: 14.4 =(190/13,154)x 1000
1996-2000
2001-2005
19
Excess Feto-Infant MortalityBlacks, 1996-2000 vs. 2001-2005
20
KCMO Blacks U.S. Reference Excess
- =16.4 5.8 10.6
6.5
2.9 1.8 5.2
2.2
1.5 1.1 1.0
4.3
1.4 0.7 4.2
- =
KCMO Blacks U.S. Reference Excess
- =14.4 5.8 8.6
6.2
3.0 1.8 3.4
2.2
1.5 1.1 1.0
4.0
1.5 0.7 2.4
- =
1996-2000
2001-2005
Percentage of Excess Black Feto-Infant Mortality, KCMO.
1996-2000 vs. 2001-2005
21
Total Excess Deaths =136 Total Excess Deaths =113
1996-2000 2001-2005
Feto-Infant Mortality: Contribution of the Birthweight Distribution and Birthweight-Specific Mortality-Blacks
KCMO. 1996-2000 vs. 2001-2005
22
A. Overall Excess Rates B. Maternal Health/Prematurity Excess Rates
1996-2000
2001-2005
Maternal Health/ Prematurity
Maternal Health/Prematurity
Smoking
Prenatal care
Parity
Unintended pregnancy
Maternal diabetes
23
Phase 2 Analysis: Maternal Health /Prematurity Risk and Preventive Factors
Selected risk factors
Black(%)
Reference(%) P value
Smoking 20.8 10.7 <0.001First trimester care 77.4 94.3 <0.001No prenatal care 7.5 1.7 <0.001Parity (>2) 35.5 19.9 <0.001Unintended pregnancy
64.5 23.2 <0.001
Income <$40 K 69.5 12.0 <0.001Birth interval <18 m
30.5 50.0 <0.001
Maternal diabetes 4.3 4.0 >0.05 24
Birthweight Distribution (VLBW Births: 500-1499 grams) in Kansas City, MO 2001-2008
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
Infant Health
Infant Health
SIDS
Injury
Infection
Anomalies
Perinatal
From Dr. William M Sappenfield, CDC 26
Black Infant Health KCMO 1996-2000 vs. 2001-2005
Category 1996-2000 2001-2005Infant
deaths*Rate** Infant
deathsRate
Infant Health
66 5.2 45 3.4
SIDS 35 2.7 20 1.5
Injury12 0.9 7 0.5
*Infant health (birth weight with 1500+ g and post-neonatal infant deaths)
**Infant death rate is per 1,000 fetal deaths and live births
27
Black Infant Mortality Rates, Infant Health Category, Kansas City, MO.
1996-2000 vs. 2001-2005During 2006-2008, the rate remained 3.4 deaths per 1,000 live births at the same category.
28
Contact InformationJinwen Cai, MD Biostatistician, Office
of Epidemiology & Community Health Monitoring
[email protected] 816.513.6044
Gerald L Hoff, PhD, FACE Epidemiologist &
Manager, Office of Epidemiology & Community Health Monitoring
[email protected] 816.513.6149
29