Perinatal Periods of Risk Approach: The Michigan Experience Bao-Ping Zhu, MD, MS Lead Epidemiologist...
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Transcript of 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
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
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
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
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
Map Feto-Infant Mortality
500- 1499 g
1500+ g
Fetal NeonatalPost
neonatal
1 2 3
4 5 6
Age at Death
Birth
weig
ht
Map Feto-Infant Mortality
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
Maternal Health/ Maternal Health/ Prematurity Prematurity
327 327
Maternal Maternal Care Care
67 67
Newborn Newborn Care Care
43 43
Infant Infant Health Health
9494
Map Feto-Infant DeathsBlacks, MI, 2000
531 fetal or infant deaths
Total fetal deaths and live births: 24,304
Map Feto-Infant MortalityWhat Is Missing in the 6 Cells?
• Fetal deaths <24 wks
• Live births <500 g
• Spontaneous abortions
• Induced abortions
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
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
Maternal Health/ Maternal Health/ Prematurity Prematurity
327 327
Maternal Maternal Care Care
67 67
Newborn Newborn Care Care
43 43
Infant Infant Health Health
9494
Feto-Infant DeathsBlacks, MI, 2000
531 fetal or infant deaths
Total fetal deaths and live births: 24,304
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
Maternal Health/ Maternal Health/ Prematurity Prematurity
13.5 13.5
Maternal Maternal Care Care
2.8 2.8
Newborn Newborn Care Care
1.8 1.8
Infant Infant Health Health
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
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
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
Maternal Health/ Maternal Health/ Prematurity Prematurity
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)
284 fetal or infant deaths
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)
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
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
Maternal Health/ Maternal Health/ Prematurity Prematurity
281 281
–Pregnancy intentionPregnancy intention–SmokingSmoking–DrinkingDrinking–Drug abuseDrug abuse–StressStress–Racial discriminationRacial discrimination–NutritionNutrition–Pregnancy intervalPregnancy interval–Preconceptional carePreconceptional care–Overall fitnessOverall fitness
Infant Infant Health Health
7272
Major Findings
Infant Health: Second largest opportunity gap
Maternal Health/ Maternal Health/ Prematurity Prematurity
281 281Infant Infant Health Health
7272
–Sleep positionSleep position–SmokingSmoking–BreastfeedingBreastfeeding–Medical homeMedical home–Injury preventionInjury prevention
Programmatic Response
Michigan PPOR “Software” Demonstration