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Transcript of World Health Organization Collaborating Center in Reproductive Health Promoting Healthy Birth...
World Health OrganizationCollaborating Center in Reproductive
HealthPromoting Healthy Birth Outcomes
October 27-28, 2009
Emory UniversityWoodruff 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, DirectorWoodruff Health Sciences CenterEmory University
Brian McCarthy, MD, Principal InvestigatorThe National Centers for Disease Control
and Prevention
WHO Collaborating CenterCountries Receiving HSR Support
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
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.
Health Services Research
Expertise required-*Clinical Practice *P.H. Program Management *Epidemiology *Cultural and Social
*Behavioral Science Aspects of Health*Public Policy *Country or state-specific Knowledge
Infant Mortality and Per Capita GNP
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.
Georgia Perinatal Surveillance
• Total cohort accountability begins with the reporting of all products of
conception.
Georgia Perinatal Surveillance
• Feto-infant mortality (FIMR) is used as the measure of mortality rather than infant mortality.
Georgia Perinatal Surveillance
• Five hundred grams (500gm) or twenty week gestation is used as the starting point for counting feto-infant deaths.
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.
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
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.
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
TotalDeaths
3936
Number of Feto-Infant Deaths
Data Rich, Information Poor
TotalDeaths
3936
Number of Feto-Infant DeathsData Rich, Information Poor
Age at Death
BirthWeight
1
5
9
13
2
6
10
14
3
7
4
8
1211
15 16
Birthweight and Age at DeathLate
Fetal Death
(28+ wks)
Early Neontal Death
(<7 days)
Late Neonatal
Death(7-27days)
Post Neonatal
Death(28+ days)
VVLBW(500 - 999gms)
VLBW(999-1499 gms)
IBW(1499-2499 gms)
NBW(2500+ gms)
Interventions for Reducing Mortality
Women’s and Maternal Health
Maternal and Fetal Care
Neonatal Care
Infant Care
W & MHealth
1
W & MHealth
5
M & FCare
9
M & FCare13
W & MHealth
2
W & MHealth
6
NewbornCare10
NewbornCare14
W & MHealth
3
W & MHealth
7
W & MHealth
4
W & MHealth
8
InfantCare12
NewbornCare11
InfantCare15
InfantCare16
Birthweight and Age at DeathLate
Fetal Death
(28+ wks)
Early Neontal Death
(<7 days)
Late Neonatal
Death(7-27days)
Post Neonatal
Death(28+ days)
VVLBW(0-999gms)
VLBW(999-1499 gms)
IBW(1499-2499 gms)
NBW(2500+ gms)
Summary of Perinatal Health Care Interventions
• Reproductive Awareness• Preconception Care• Child Spacing• Nutrition• Micronutrients• STDs• Substance Abuse• Domestic Violence•
• Pregnancy Identification• Prenatal Surveillance & Care• Anticipatory Guidance• Intrapartum Monitoring• “ART” for complications • Surgical Services• High Risk Maternal Followup
Women’s & Maternal HealthInterventions:
Maternal & Fetal CareInterventions:
Newborn CareInterventions:
• Clean Delivery• Resuscitation• Thermal Control• Breast Feeding• “ART” for the At-Risk-Infant• “Baby Friendly” Concept• Parenting Skill Education
Infant CareInterventions:
• 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
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
4.3
3.2
4.6
4.2
4.1
7.4
Atlanta Augusta Macon
Columbus Savannah Albany
1.40.3
0.7 1.01.2
1.80.5
1.0
2.5
2.4
1.11.02.6
0.80.3
1.5
0.90.6
Total=5.6 Total=8.2 Total=11.4
Total=7.3 Total=8.3 Total=8.6
Excessive Mortality Rate by RegionGeorgia, 1991-1993
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.
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.
Analysis of Sociodemographic Risks
Sub-group Age Education DeathRate
ExcessRate
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
Deaths per 1,000 live births
Calculating “The Opportunity Gap” = Excess Mortality
Excess Mortality = BWPR TARGETPOPULATION
- BWPRSTANDARD
Birthweight Proportionate Rate (BWPR)
BWPR =Number of deaths in a given weight group
Total Number of births in all weight groupsx 1000
ORMaternalHealth# of
Deaths
W & MHealth
W & MHealth
M & FCare
M & FCare
W & MHealth
W & MHealth
NewbornCare
NewbornCare
W & MHealth
W & MHealth
W & MHealth
W & MHealth
InfantCare
NewbornCare
InfantCare
InfantCare
(# in cells)
(# in entire table)
x 1000
Analysis of Sociodemographic Risks
Sub-group Age Education DeathRate
ExcessRate
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
Deaths per 1,000 live births
TotalFeto-Infant
Deaths
3936ExcessiveFeto-Infant
Deaths
2314
Calculating “The Opportunity Gap” = Excess Mortality
Excess Mortality = BWPR TARGETPOPULATION
- BWPRSTANDARD
Birthweight Proportionate Rate (BWPR)
BWPR =Number of deaths in a given weight group
Total Number of births in all weight groupsx 1000
ORMaternalHealth# of
Deaths
W & MHealth
W & MHealth
M & FCare
M & FCare
W & MHealth
W & MHealth
NewbornCare
NewbornCare
W & MHealth
W & MHealth
W & MHealth
W & MHealth
InfantCare
NewbornCare
InfantCare
InfantCare
(# in cells)
(# in entire table)
x 1000
2.1
0.8
1.20.9
Total = 5.0
Feto-Infant Mortality RateWhite Group I, Atlanta Region
7.2
0.3
8.3
1.6
8.7
3.6
Excessive Mortality Rate by Sociodemographic GroupGeorgia, 1991-1993
White Group 1 White Group 2 White Group 3
Black Group 1 Black Group 2 Black Group 3
0.20.1
0.1 0.40.5
1.50.4
0.9
3.4
3.3
1.11.42.8
1.21.7
0.8
0.50.5
Total=0.7 Total=4.0 Total=8.3
Total=9.0 Total=14.0 Total=14.5
Interventions for Reducing Mortality
Women’s and Maternal Health
Maternal and Fetal Care
Neonatal Care
Infant Care
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
Areas of Concentration to Reduce Infant Mortality
Area Potential for Improvement
WOMEN’S & MATERNAL HEALTH 60%
Maternal Fetal Care 10%
Neonatal Intensive Care 9%
POSTNATAL CARE 21%
LOW HIGH
Figure 1: Percent of Births According to Sociodemographic group for Georgia, 1981-83, 1991-93, 2001-03
0%
5%
10%
15%
20%
25%
30%
35%
40%
Age 20+, Educ.13+ yrs.
Age 20+, Educ.<13 yrs.
Age <20, Educ.<13 yrs.
Age 20+, Educ.13+ yrs.
Age 20+, Educ.<13 yrs.
Age <20, Educ.<13 yrs.
White NH Grp 1 White NH Grp 2 White NH Grp 3 Black NH Grp 1 Black NH Grp 2 Black NH Grp 3
Sociodemographic Group
Perc
ent o
f birt
hing
pop
ulat
ion
1981 - 1983
1991 - 1993
2001 - 2003
Time Period:
Figure 2: Comparison of Sociodemographic Group Specific Feto-Infant (20+ Weeks) Moratlity Rates for Georgia, 1981-83, 1991-93, 2001-03
12.8
18.8
26.228.4
35.739.1
24.6
7.711.9
18.122.1
26.028.7
16.7
5.19.8
12.3 11.5
18.0 17.9
10.5
0
5
10
15
20
25
30
35
40
45
50
Age 20+, Educ.13+ yrs.
Age 20+, Educ.<13 yrs.
Age <20, Educ.<13 yrs.
Age 20+, Educ.13+ yrs.
Age 20+, Educ.<13 yrs.
Age <20, Educ.<13 yrs.
White NH Grp 1 White NH Grp 2 White NH Grp 3 Black NH Grp 1 Black NH Grp 2 Black NH Grp 3 Total
Sociodemographic Group
FIM
R pe
r 100
0
1981-83
1991-93
2001-03
Figure 4: Sociodemographic Group Specific LBWR/TB for Georgia 1981-83, 1991-93, 2001-03
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
White NHGrp 1
White NHGrp 2
White NHGrp 3
Black NHGrp 1
Black NHGrp 2
Black NHGrp 3
Sociodemographic Group
% L
BW
R/T
B 1981-831991-932001-03
Figure 4: SES Group Specific Birthweight Specific Mortality Rates
800.8639.9
425.2
218.9
135.2112.0
50.2
31.0 26.4
7.04.6
3.7
1
10
100
1000
1981-83 1991-93 2001-03
Time Period
BW
SM
R p
er
10
00
TB
< 1000
1000-1499
1500-2499
2500+
Linear (< 1000)
Summary of Perinatal Health Care Interventions
• Reproductive Awareness• Preconception Care• Child Spacing• Nutrition• Micronutrients• STDs• Substance Abuse• Domestic Violence•
• Pregnancy Identification• Prenatal Surveillance & Care• Anticipatory Guidance• Intrapartum Monitoring• “ART” for complications • Surgical Services• High Risk Maternal Followup
Women’s & Maternal HealthInterventions:
Maternal & Fetal CareInterventions:
Newborn CareInterventions:
• Clean Delivery• Resuscitation• Thermal Control• Breast Feeding• “ART” for the At-Risk-Infant• “Baby Friendly” Concept• Parenting Skill Education
Infant CareInterventions:
• 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
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%
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.
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%
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.
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.
Background
• Pregnancy is too late to initiate
prenatal care if the mother has had
a previous VLBW infant.
Interpregnancy Care
• Primary health care from delivery of one child until conception of the next.
The Interpregnancy Care ProgramThe 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