Using PPOR and FIMR to lead to

SCIENCE-BASED ACTIONIn Omaha, Nebraska

November 25th 2008

David Busse, Teresa Hergott, Carol Gilbert

Objectives

• Discuss mission and purpose of local BBC Collaborative

• PPOR analysis:

– Phase 1: EXCESS MORTALITY in Douglas County

– Phase 2: Reasons and potential solutions

• Identify FIMR as an addition to local community strategy

• Demonstrate taking recommendations to action

2

Baby Blossoms CollaborativeEliminate factors that contribute to health disparities though efforts to strengthen the community capacity by:

1) identifying the contributing factors that lead to racial, geographic and economic disparities.

2) reducing overall feto-infant mortality.

3) building on the strengths of our community.

4

BBC PartnersAlegent HealthBabies R UsBig Picture ProductionsBlue Cross Blue Shield of

NebraskaCharles Drew Health Center/ Omaha Healthy StartChildren’s HospitalCityMatCHCollege of Saint Mary’sDouglas County Coroner’s OfficeEarly Childhood Consortium

of the Omaha AreaEarly Childhood Training CenterEssential Pregnancy ServiceFred Leroy Health CenterHope Medical Outreach CoalitionMarch of Dimes Nebraska Methodist Physicians ClinicMetro Omaha Medical SocietyMinisterial Alliance

NE Children and Families FoundationNE Health and Human Services System NE Medical CenterNE Methodist Health SystemNE Midwives Association NE SIDS FoundationOffice of Minority HealthOmaha District Dietetic AssociationOmaha Police DepartmentOmaha Public SchoolsOur Healthy Community PartnershipProject HarmonyRegion 6 Mental HealthSalem Baptist ChurchSalvation ArmyUnited Health CareUniversity of Creighton Medical Center University of Nebraska at OmahaUrban League of NebraskaVisiting Nurse Association

PPOR Analysis

• Phase 1: IDENTIFIES the populations and periods of risk with the most excess mortality

• Phase 2: examines REASONS for the excess deaths through further epidemiologic studies, death reviews, program and policy reviews and other community assessments.

Map of Feto-Infant Deaths

103 fetal deaths + 167 deaths of live born infants=270 Feto-infant deaths

Divided by 33,046 live births and fetal deaths

=8.2 overall feto-infant

mortality rate

Douglas County, All Races2003-2006

111/ 3.4Maternal Health/ Prematurity

(44 fetal deaths, 67 live births)

59/1.8

Maternal Care

(fetal deaths)

39/1.2

Newborn Care

(live births)

61/1.8

Infant Health

(live births)

N=21,190 live births+fetal deaths

2.6

1.7 1.0 1.3

Non-Hispanic White Feto-Infant Rate = 6.6

N=4,797 live births+fetal deaths

2.5 3.82.1

5.8

Non-Hispanic Black Feto-Infant Rate = 14.2

PPOR Map of Feto- Infant Mortality

Douglas County, By Race, 2003-2006

Map of Feto-Infant Mortality Rates 1993-2006

Douglas County, NE, All Races

4.0

2.3 1.4 2.9

Feto-Infant Rate = 10.710.7

4.1

1.8 1.9 4.0

1.4 1.8

2.5

1.9

Feto-Infant Rate = 10.3

Feto-Infant Rate = 9.19.1

1993-1996

1997-2000

2001-2004

3.4

1.2 1.81.8

Feto-Infant Rate = 8.2

2003-2006

9

Feto-Infant Mortality Ratesfor External Comparison GroupWhite non-Hispanic Mothers age 20 or older, with more

than a high school education USA 2000-2002

2.2Maternal Health/ Prematurity

(fetal deaths, live births)

1.5 Maternal

Care (fetal deaths)

1.1 Newborn

Care (live births)

0.9Infant Health

(live births)

Total 5.7 Deaths Per thousandLive Births And Fetal Deaths

10

Excess Feto-Infant Mortality Rates Using External Comparison Group

Douglas County, NE 2003-2006

3.4 – 2.2 = 1.2 excess

1.8 - 1.5

=0.3exces

s

1.2 – 1.1 = 0.1

excess

1.8-0.9 =

0.9excess

Overall8.2 – 5.7=2.5 excess

11

Excess Feto-Infant Mortality Translated into estimated numbers

of preventable deathsDouglas County, NE 2003-2006

39Maternal Health/ Prematurity

(fetal deaths, live births)

10 Maternal Care

(fetal deaths)

3 Newborn

Care (live births)

30Infant Health

(live births)

12

N=21,190 live births+fetal deaths

0.4

0.2 -.1 0.4

Non-Hispanic White Feto-Infant Rate = .9

N=4,797 live births+fetal deaths

1.4 2.90.6

3.6

Non-Hispanic Black Feto-Infant Rate = 8.5

Excess Feto- Infant Mortality

Douglas County, By Race, 2003-2006

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Phase 1 Conclusions

• Rates have improved in all four periods of risk

• Highest excess mortality rates are in the Maternal Health/Prematurity Period and Infant Health Periods

• Black mothers continue to have higher rates than White mothers, especially in those two periods of risk

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FIMR Process

An action-oriented community process that leads to

systems change

15

What is unique about FIMR?

• Utilize a 2-pronged approach– Case Review Team (CRT)– Community Action Team (CAT)

• Only fetal and infant death review that makes community recommendations

• Only review process that includes a home visit with Mom

16

Value of Mom’s Story

“I am the only one who can tell the story of my life. I say what it means.”

Dorothy Allison

17

Baby Blossoms CAT“Creative thinkers”

• Review initial recommendations

•Prioritize and implement recommendations

•Connect to community stakeholders

18

Prioritizing Recommendations

All CAT’s face the tough decision of identifying which of the many recommendations will have priority for implementation

19

PPOR Phase 2 Analysis What are the reasons?

How can we fix it?

20

Excess Deaths – Infant Health Period

Douglas County, NE 2003-2006 vs. National Reference Group  DEATHS PER 1,000 LIVE BIRTHS – BY CAUSE  

 

Con-genita

l Anom-alies

Ill-define

d Condi-tions

Infec-tious Diseases

Acci-dental Injury

Peri-natal Condi-tions SIDS Other Total

Douglas County 0.243 0.061 0.000 0.030 0.030 1.032 0.455 1.852

Nat'l Ref Grp 0.263 0.069 0.037 0.100 0.031 0.218 0.232 0.951

Excess Mortality Rate  -.020  -.008  -.037  -.07  -.001 0.814  0.223   0.901

Estimated Excess Deaths -1 0 -1 -2 0 27 7 30

21

Excess SIDS Deaths by Race – Infant Health Period of Risk

Douglas County, NE 2003-2006 vs. National Reference Group

  SIDS RateNat'l Ref

GrpExpected Deaths

Excess Deaths

Douglas County White, not Hispanic 0.710 0.218 5 10

Douglas County Black, not Hispanic 2.517 0.218 1 11

Non-Hispanic White and Non-Hispanic Black infants accounted for 77.8% of the excess SIDS deaths during this period. Non-Hispanic Black infants were 3.5 times as likely to die from SIDS as a Non-Hispanic White infant.

22

18

48

2015

2724

0

20

40

60

White

Black

Nativ

e Am

er.

Asian

/Pac

if.

Hispan

icTota

l

Safe Sleep (Percent NOT sleeping on back)Nebraska PRAMS, Douglas County 2004-2006

23

0

10

20

30

40

50

2000 2001 2002 2003 2004 2005 2006 2007

Per

cen

tBaby NOT Sleeping on Back

(and 95% confidence intervals)

Nebraska PRAMS, Douglas County 2004-2006

24

Phase 2 Green box conclusions

• Green Box– the bulk of the excess mortality is due to “SIDS” ICD-10 R95. Black/African American babies are more likely to die from SIDS than White babies. [We plan to begin to looking at accidental suffocation (W75) and Cause Unknown/Unspecified (R99) as well]

• PRAMS—Black babies are less likely to be sleeping on backs

• PRAMS—unsafe sleep position prevalence is decreasing.

25

Priority FIMR Recommendation

There will be an increase in community awareness regarding risks associated with bed sharing

– Adult co-sleeping with infant

– Infant sleeping non back position on soft surface

– Autopsy unable to rule out suffocation as cause of death

– Poor provider communication regarding suffocation vs. SIDS

26

Taking Recommendations to Action

Safe Sleep Initiative

Maternal Health/ Maternal Health/ PrematurityPrematurity

Birthweight Distribution

Birthweight- Specific Mortality

Phase 2 Analysis: Maternal Health/Prematurity Period

28

Excess Deaths – Maternal Health/Prematurity

Douglas County, NE 2003-2006 vs. National Reference Group

• due primarily (67%) to a higher than normal proportion of very small babies• due partly (33%) to lower than normal survival rates of very small babies

Specific Mortality

33%

Birthweight Distribution

67%

29

Local, population-based data on risk factors for Prematurity

(need for pre-conception care)

% Among

White

% Among

Black

% Among

All

Unintended Pregnancy 38 67 44

Late or no Prenatal Care 11 31 18

No insurance prior to preg. 14 30 25

Overweight/Obese prior (PRAMS 2004-2006)

33 44 35

Mother < 19 years old 2 14 5

Nebraska PRAMS, Douglas County 2004-2006(all but smoking are statistically significant by race/ethnicity)

30

Local, population-based data on risk factors for Prematurity

(need for prenatal care, screening)

Nebraska PRAMS, Douglas County 2004-2006(all but smoking are statistically significant by race/ethnicity)

% Among

White

% Among

Black

% Among

All

Previous Preterm 4 11 6

Below 200% Poverty Level 27 84 43

Smoking prior to pregnancy 26 27 22

Stress (4 or more events PRAMS 2004-2006)

16 35 19

Physical Abuse 7 13 9

31

Mental Health and Depression,Prenatal and Post-partum

Nebraska PRAMS, Douglas County 2004-2006

0

5

10

15

20

25

Whit

eBlac

k

Native

Am

er.

Asian/

Pac

Hispan

ic All

Pe

rce

nt

Sought help for depression during pregnancyFelt depressed post-partum--always or oftenFelt no interest post-partum--always or often

32

Taking Recommendations to Action

BBC members were informed and educated on ACOG standards for prenatal risk assessment

Tobacco prevention education incorporated into Now and Beyond preconception health education program

33

Smoking and Prematurity(attributable risk example)

• The odds of having a preterm birth if a woman smokes is 1.5 times the odds of having a preterm birth if she doesn’t (Creasy et al., 2004)

• The prevalence of smoking during the last three months of pregnancy in Douglas County 2000-2003 was 14% (PRAMS Nebraska 2004-2006).

Population Attributable Risk= PARP = PREV*(OR-1)/[PREV*(OR-1) + 1] =6.5% (we could eliminate 6.5% of prematurity by not smoking)

34

Priority FIMR Recommendation

Tobacco cessation services and resources will be covered and available for women of child bearing age, their families and involved significant others. – Maternal tobacco use before, during and after

pregnancy– Tobacco use of involved significant others in

home– Lack of resources/ services for tobacco

cessation with pregnant Moms

35

Priority FIMR Recommendation

Every pregnant woman should receive early prenatal risk assessment that identifies physical, psychosocial, economic and cultural/ linguistic issues– Previous preterm birth– Pre-existing maternal health conditions– Late entry to prenatal care

36

Priority FIMR Recommendation

Mental health services/ resources will be available to women of child bearing age, involved significant other and their families– Multiple life stressors/ social chaos for Mom and

family prior to pregnancy– Maternal history of mental illness before pregnancy– Lack of mental health services prior to and after

pregnancy

37

Priority FIMR Recommendation

Every woman should receive preconception education including birth spacing– Short pregnancy spacing– Previous poor pregnancy outcome with preterm

delivery– Unintended pregnancy

38

Supported by theDouglas County

Health Department

Taking Recommendations to Action

39

What FIMR and PPOR can Accomplish

• Vital records narrow the focus to problem areas, and justify starting FIMR.

• Population-based data help find likely causes.

• FIMR promotes better understand of contributing factors, and discovers information not previously measured.

• Population-based data support and prioritize FIMR recommendations.

40

FIMR and PPOR both rely on community / stakeholder engagement to . . .

• Ensure priority recommendations are translated into science-based action

• Build on existing resources and strengths in community

41

Thank you.