1

Few 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

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

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

Restricted 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

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

Perinatal 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

8

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

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

Variables Fetal DeathsLinked Birth-Infant Deaths Live Births

Date births X X

Date deaths X X

Birthweight (gm) X X X

Gestational age X X X

Mother’s age X X X

Mother’s education

X X X

Race/ethnicity X X X

Cause of death X X

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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.

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Published in Public Health Published in Public Health ReportsReports

*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% 6.06.0

Kitagawa Table for birthweight—Target population

Kitagawa Table for birthweight—Reference population

 Actual Contribution to the Difference in

Excess Mortality RatesPercentage 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

Of 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.

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Analysis of Feto-Infant Mortality Rates in Kansas City, Missouri, 1996-2000

vs. 2001-2005

Perinatal Periods of Risk (PPOR)Perinatal Periods of Risk (PPOR)

16

17

500-1499 g

1500+ g

Fetal NeonatalPost

neonatal

Maternal Health/ Maternal Health/ PrematurityPrematurity

Maternal Maternal

CareCare

NewbornNewborn

CareCare

Infant Infant HealthHealth

Map Feto-Infant DeathsBlacks, KCMO, 1996-2000 vs.

2001-2005

Maternal 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

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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

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20

KCMO Blacks U.S. Reference Excess

- =16.4 5.8 10.6

6.56.5

2.92.9 1.81.8 5.25.2

2.22.2

1.51.5 1.11.1 1.01.0

4.34.3

1.41.4 0.70.7 4.24.2

- =

KCMO Blacks U.S. Reference Excess

- =14.4 5.8 8.6

6.26.2

3.03.0 1.81.8 3.43.4

2.22.2

1.51.5 1.11.1 1.01.0

4.04.0

1.51.5 0.70.7 2.42.4

- =

1996-2000

2001-2005

21

Total Excess Deaths =136 Total Excess Deaths =113

1996-2000 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

Selected risk factors

Black(%)

Reference(%) P value

Smoking 20.8 10.7 <0.001

First trimester care 77.4 94.3 <0.001

No prenatal care 7.5 1.7 <0.001

Parity (>2) 35.5 19.9 <0.001

Unintended pregnancy

64.5 23.2 <0.001

Income <$40 K 69.5 12.0 <0.001

Birth interval <18 m

30.5 50.0 <0.001

Maternal diabetes 4.3 4.0 >0.0524

Birthweight Distribution (VLBW Births: 500-1499 grams) in Kansas City, MO 2001-2008

• 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

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Infant Health

Infant Health

SIDS

Injury

Infection

Anomalies

Perinatal

From Dr. William M Sappenfield, CDC 26

Category 1996-2000 2001-2005

Infant deaths*

Rate** Infant deaths

Rate

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

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Black Infant Mortality Rates, Infant Black Infant Mortality Rates, Infant Health Category, Kansas City, MO. Health Category, Kansas City, MO.

1996-2000 vs. 2001-20051996-2000 vs. 2001-2005During 2006-2008, the rate remained 3.4 deaths per 1,000 live births at the same category.

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Jinwen Cai, MD

Biostatistician, Office of Epidemiology & Community Health Monitoring

Jinwen_cai@kcmo.org 816.513.6044

Gerald L Hoff, PhD, FACE

Epidemiologist & Manager, Office of Epidemiology & Community Health Monitoring

Gerald_hoff@kcmo.org 816.513.6149

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