Using FIMR and PPOR to Identify Strategies for Infant Survival in Baltimore Meena Abraham, M.P.H. Baltimore City Perinatal Systems Review MedChi, The Maryland State Medical Society

Partners Baltimore City Health Department Baltimore City Healthy Start, Inc. MedChi, The Maryland State Medical Society Funded through the Improved Pregnancy Outcomes grant from the Center for Maternal and Child Health, DHMH. Other—March of Dimes, United Way, Family League of Baltimore

Baltimore City Population Population Size—632,680 Population Size—632,680 Racial Composition Racial Composition – –67% African American – –31% White – –2% Other Poverty Poverty –24% live at or below poverty in Baltimore. –9% live at or below poverty in Maryland.

Infant Mortality Rates Baltimore City, Maryland, and U.S., Source: Md Vital Statistics Administration

Infant Mortality Rates by Race Baltimore City, Source: Md Vital Statistics Administration

Initiative in Baltimore Background—High rates fetal-infant mortality. Purpose—To improve services to women at risk for a poor pregnancy outcome. Tools for Assessment/Monitoring—FIMR, PPOR Objectives –To identify women at risk for fetal-infant mortality, poor pregnancy outcome. –To identify strategies for improving services.

Baltimore’s Resources Institutions— high-tech care, clinical and public health expertise. Community-based Services Maternal & Infant Nursing HealthCare Access Baltimore City Healthy Start Success by 6 Health Commissioner— maternal/infant health priority.

Perinatal Periods of Risk Analysis Developed by Dr. Brian McCarthy, WHO and CDC collaborative. Simple, population-based approach to examine the contribution of birth weight and age at death to the fetal-infant mortality rate. Rates are per 1,000 live births + fetal deaths.

Exclusion Criteria Spontaneous or induced abortion. Fetal deaths <24 wks gestation. Live births and fetal deaths <500 gms. Births with unknown birth weight. Exclusions established to ensure comparability across regions and time periods through use of uniform reporting criteria.

g g Fetal Neonatal Post- neonatal Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Birthweight Age at Death PPOR Distribution of Fetal- Infant Mortality by Birthweight

Mapping Outcomes to Intervention Maternal Health/Prematurity Maternal Care Newborn Care Infant Health Prenatal Care Referral System High Risk OB Care Perinatal Management Perinatal System Pediatric Surgery Sleep Position Breast-Feeding Injury Prevention Preconception Health Health Behaviors Perinatal Care

Phase I PPOR Analysis What does our study population look like? Which births are excluded? What is the distribution of birth weight and mortality in our population? Are there differences in our population?

Distribution of Fetal and Infant Deaths African American vs White/Other Rates Maternal Health/ Prematurity 8.6 vs 3.6 Maternal Care 4.0 vs 1.8 Newborn Care 2.3 vs 1.5 Infant Health 3.4 vs 2.1 Total Rate: 18.2 vs 9.1 Baltimore City,

Distribution of Excess Mortality African American Compared to White/Other Excess Deaths Among African Americans = 182

Phase II PPOR Analysis What are the reasons for the disparity in birth outcomes? Birthweight distribution? Birthweight-specific mortality? Distribution of risk factors?

Excess Deaths By Birthweight and Birthweight-specific Mortality A. Overall Excess DeathsB. Excess Maternal Hlth/ Prematurity

PPOR Findings Greatest disparity is in maternal health/ prematurity and maternal care –Infant deaths <1500 g and fetal deaths 90% of excess mortality is due to birthweight distribution. Only 10% to birthweight-specific mortality – good systems for infant care.

PPOR Multi-variate Analysis Outcome: VLBW – live births <1500g Variables: maternal race, infant sex, age, education, marital status, parity, timing of entry into prenatal care, smoking, and medicaid enrollment

Birthweight Outcome by Race Baltimore City, Race VLBW <1500g n (%) LBW <2500g n (%) All Births N (%) African American716 (3.5)3,361 (16.5)20,349 (72) White/Other107 (1.3)670 (8.3)8,047 (28) Total Births823 (2.9)4,031 (14.2)28,396 Other race: n=78 (0.3%) Excluded births <500g and 4500g+

PPOR Findings African American women have 2.7 times the risk for VLBW. Maternal age – is lowest risk for whites but highest risk for A.A. Maternal education – not significant for whites but 9 to 11 yrs increased risk among A.A. Parity – first birth increase risk for A.A.

PPOR Findings Prenatal Care – none is high risk for all. Medicaid – no effect for whites, not enrolled and enrollment pending are high risk for A.A. Hypertension, multiple gestation, and other complications all precipitate preterm delivery and increase the risk.

Implications of PPOR Findings Focus efforts to prevent VLBW births and fetal deaths: –African American women 30 years+ –Women having their first pregnancy –Early enrollment in prenatal care –Early enrollment of eligible women in Medicaid

Fetal & Infant Mortality Review Mission: To improve the delivery of services to women and their families. Activities: Compile case histories from birth and death certificates, medical records, other sources. Conduct maternal interviews. Review cases and develop recommendations with a multi-disciplinary board. Work with partners/stakeholders to implement recommendations.

1998 Perinatal Outcomes Indicator African American White Births7,0362,352 Infant Mortality Neonatal Post-neonatal Fetal Mortality Source: Md Vital Statistics Administration

Review of 1998 Cases 165 fetal and 117 infant deaths reported. Case histories compiled on 204 pregnancies resulting in 220 deaths. Grouped cases by area of need—e.g. substance use, domestic violence, infections—and reviewed 3 to 4 cases at each meeting. Devoted 1 year to case reviews and 1 year to developing recommendations for each area of need.

Live Births & Fetal/Infant Deaths Outcome 1998* Live Births N=9,624 Fetal/Infant Deaths N=220 % LBW % VLBW % Preterm *Source: Md Vital Statistics Administration Baltimore City, 1998

FIMR Data Pregnancy History Pregnancy History –21% first pregnancy –Among those pregnant before— –Among those pregnant before—32% 4+ pregnancies, 12% LBW, 8% VLBW, 43% fetal or infant loss in the past as well, 49% elective abortion Infections – –23% STI – –46% perinatal infection

FIMR Data Health Conditions– 3% diabetes, 27% hypertension Complications– 14% placental abruptio, 32% PROM No prenatal care–13% Multiple gestation pregnancy–10% Substance use during pregnancy– 28% smoking, 10% alcohol, 25% drugs; 39% any Domestic violence–9% (not routinely screened)

Case Findings Post-loss Care Many women suffering a loss: – –have numerous health/psychosocial problems. – –do not understand contributing factors. – –try to conceive shortly after. – –receive inadequate immediate and long- term grief counseling.

Maternal Health—Preconception Care Case Findings Maternal Health—Preconception Care Many women: – –do not know how to access available services. – –do not understand the benefits of routine and preconception care. – –do not take a folic acid supplement or multi- vitamin prior to and during pregnancy.

Case Findings Maternal Health—Chronic Disease Many women: – –are not aware of their health conditions, nor their effect on pregnancy. – –do not recognize the signs of complications or need for immediate care. – –are underweight, overweight or have inadequate weight gain during pregnancy. – –do not understand how to improve their health status or pregnancy outcome.

Case Findings Maternal Health—Perinatal Infections Some women: – –have a sexually transmitted/other type of infection prior to and/or during pregnancy. – –have sexually transmitted infections more than once during pregnancy. – –become infected after their prenatal screening and do not get screened again or treated prior to delivery.

Case Findings Family Planning Many sexually active women: – –do not use contraception. – –do not use contraception effectively. – –face barriers in accessing and using effective methods of contraception. – –do not plan for their postpartum contraceptive needs during pregnancy.

Case Findings Prenatal Care Utilization A number of women: – –do not access prenatal care, or access care late in pregnancy, even w/social services. – –initiate prenatal care but do not maintain the recommended schedule of visits. – –with unplanned pregnancies are less likely to seek prenatal care. – –visit the emergency department during pregnancy, often with complications.

Case Findings Substance Use – –A number of women concurrently use alcohol, tobacco, and drugs. – –Many treatment programs do not cater to pregnant women or those with children. – –Many women lead chaotic lives and feel powerless to effect change. – –Pregnancy presents a “window of opportunity” to get a woman into treatment.

Multiple Gestation Pregnancy Case Findings Multiple Gestation Pregnancy – –Many women are not aware of the increased risks associated with multiple gestation pregnancies. – –Some providers do not provide increased monitoring to women with a multiple gestation pregnancy.

Case Findings Domestic Violence Many women: – –do not want to acknowledge their abuse or may believe it is warranted. – –do not have adequate supports to take action. – –and their providers, are unaware of resources. – –are not screened for domestic violence. – –with substance use, other mental health issues are at increased risk.

Case Findings Teen Pregnancy Many teens: – –do not use contraception effectively. – –have difficulty accessing health and family planning services. – –have, or are at risk for acquiring, sexually transmitted infections. – –do not get tested for pregnancy. – –have poor communication with their providers.

Key FIMR Findings Women have multiple risk factors for poor pregnancy outcome. Women are not always aware of their risks or ways to reduce them. Providers and pregnant women are often not aware of available services.

Summary of Four Priority Areas 1. Care of women following a perinatal loss to reduce repeat losses -Bereavement support -Medical assessment -Follow-up care -Care coordination -Interval between pregnancies

2. Perinatal infection -Early detection -Repeated screening -Provider education -Community education Summary of Four Priority Areas

3. Family planning and preconception/ inter-conception care -availability of contraceptive services -planning post-partum contraception -family planning waiver card -importance of primary care -follow-up services

Summary of Four Priority Areas 4. Adequate utilization of prenatal care -early enrollment in Medicaid -promote the value of prenatal care -early enrollment in prenatal care -”user-friendly” services -continuity of care

Strategies for Infant Survival Subcommittees to address priorities –Legislative and policy –Institutional and Health Systems –Provider Education –Community Education and Outreach

Activities to Improve Services Disseminate Report and Findings –Breakfast Seminar –Meetings, Conferences, Mailings –Press Conference –Presentations to Stakeholders

Activities to Improve Services Develop Health Education Materials –Perinatal Mortality Curriculum –Risk-reduction Fact Sheets –Perinatal Infections Curriculum

Activities to Improve Services Develop Institutional Protocols –Bereavement Services –Medical Assessment –Inter-conception Care

Activities to Improve Services Educate Providers Serving At-Risk Women –Grand Rounds—Findings/Recommendations –Training—Preterm Birth Prevention, Bereavement, Findings/Recommendations –Training—Perinatal Infections

Coordinated Services Delivery Home Visit, Case Management Providers –Incorporating FIMR, PPOR findings into strategic planning. –Restructuring services to target women with losses, VLBW. –Establishing referral for post-loss/inter- conception care to Maternal & Infant Nursing Program.

Conclusions FIMR and PPOR each contribute valuable information. PPOR provides the “what.” FIMR provides the “why.” Both approaches promote community action. FIMR and PPOR have been used successfully in Baltimore to develop strategies for systems change and improved infant survival.