1. Translating Data into Action: Using PPOR, FIMR, and the LAMB Project to Reduce Infant Mortality Cynthia Harding, MPH Giannina Donatoni, PhD Los Angeles County Department of Public Health Maternal, Child and Adolescent Health Programs

2. Special Thanks to: Cathleen Bemis, MS Shin Margaret Chao, PhD, MPH Kevin Donovan, MPH Sunching Glenn, MS Angel Hopson, MSN, MPH, RN Laurin Kasehagen, PhD, MA McKinley Kemp, MBA Grace Lubwama, MPH

3. Today’s Presentation Data tools  Perinatal Periods of Risk (PPOR)  Fetal and Infant Mortality Review (FIMR)  Los Angeles Mommy and Baby (LAMB) Project Findings Data to

4. Los Angeles, California 1

5. Antelope Valley (AV)  Relatively isolated  4,903 live births in 2002  Mother’s race/ethnicity:  17% African American  46% Hispanic  33% White  Income of 1 in 8 households less than Federal Poverty Level (1 in 5 in LAC).

6. Increasing Infant Mortality in AV 1999-2002  Countywide IM rates were 4.9 to 5.5 from 1999-2002  AV IM rate more than doubled between 1999 and 2002  In 2002, there were 4903 live births and 53 infant deaths in AV* * Small numbers cause large changes in rates

7. Highest Rates in African Americans  African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002

8. Response

9. PPOR Focus Area Potential Community/PH Interventions Maternal Health/Prematurity Preconceptual Health Health Behaviors Perinatal Care Maternal Care Prenatal Care Referral System High Risk OB Care Newborn Care Perinatal Management Perinatal System Pediatric Surgery Infant Health Sleep Position Breast-Feeding Injury Prevention Data Source: Birth Cohort data, California Department of Health Services, Center for Health Statistics, Vital Statistics, 2002.

10. Fetal Infant Mortality Review (FIMR) / PPOR  National FIMR forms to review 2002 AV infant deaths (N=53)  PHNs conducted home interviews, abstracted hospital and provider records.  PPOR framework to summarize findings by each infant’s birth weight and age at death.

11.  Population-based, case control  Resided in AV  Factors linked with poor birth outcomes  Events before, during, and shortly after pregnancy  Pre-interconception care  Prenatal care  Maternal medical conditions  Psychosocial factors  Risk taking behaviors Los Angeles Mommy and Baby (LAMB) Project

12. FIMR/PPOR Findings  27 Neonatal Deaths (<1500 g, 0-28 days) Mother:  All had at least one risk factor for poor birth outcomes  65% had psychosocial issues  54% had an infection – mostly UTI and STD  35% began prenatal care after 12 th week Infant:  22% had documented infection  15% had congenital birth defect

13. FIMR/PPOR Findings (continued)  13 Infant Deaths (> 1500 g, 29-365 days) Mother:  85% had at least one risk factor for poor birth outcomes  77% had psychosocial issues  54% began prenatal care after 12th week Infant:  54% had issues related to safety  46% had a congenital birth defect

14. LAMB Findings Moms with poor birth outcomes tend to have:  No insurance before pregnancy (OR=2.3; p = 0.004)  Previous low birth weight/preterm infant (OR=3.67; p = 0.0003)  High blood pressure during pregnancy (OR=3.44; p=0.06)  Inadequate prenatal care (OR=2.34; p= 0.01)  Early labor pain, water broke early (OR=2.54/10.93; p <0.001)  Felt less happy during pregnancy (OR=1.92; p= 0.02)  Smoked during pregnancy (OR=3.19; p= 0.005)  Unsafe neighborhood (OR=2.45; p= 0.02)

15. Data Framework PPOR, Infant Death Review and LAMB PPOR Identify groups with excess mortality. Link births with deaths. Mortality Review Maternal interviews & chart reviews Share findings with stakeholders at local community meetings LAMB Population-based case control study Calculate prevalence of problems Identify factors assoc with LBW/PT births Community consensus on recommended actions

16. Where do we intervene?

17. Maternal Health/ Prematurity 1. Preconception care 2. Interconception care 3. Prenatal care 4. High risk Ob care Infant Health 1. Safety issues (sleep position, injury prevention, etc) 2. Breast-feeding 3. Family and parenting issues ? ? Areas for Strategic Intervention

18. Maternal Health/ Prematurity 1. Preconception care 2. Interconception care 3. Prenatal care 4. High risk Ob care Infant Health 1. Safety issues (sleep position, injury prevention, etc) 2. Breast-feeding 3. Family and parenting issues 12 Short-term Interventions 1.Increase access to high-risk Ob care and related ancillary services, such as labs; access is particularly difficult for Medi-Cal recipients. 2.Arrange faith-based youth services to provide health services. 3.Promote “100 Acts Kindness” for pregnant women. 4.Increase access to transportation for pregnant moms and advocate politically for trans. improvement. 5.Arrange male support groups to address the ”Role of Men”. 6.Present this data to local Ob and pediatric providers and staff to increase awareness. 7.Provide comprehensive assessment for newborns, especially for high risk ones. 8.Provide immediate information and planned follow-up for high-risk infants/moms. 9.Provide newborn infant care classes to new moms before they are discharged from the hospital. 10.Establish a 24-hour lactation team. 11.Provide education for breastfeeding and infant care during prenatal care. 12.Bring providers and volunteers together to identify best practices.

19. Translating Data to Action Service Expansion and Linkages  Antelope Valley Best Babies Collaborative  Faith-Based Efforts  Better hospital discharge planning  Better linkage to MCAH Programs  Nurse Family Partnership  Black Infant Health  CPSP

20. Preconception Health Efforts  Perinatal Summit  Preconception Health Collaborative  Community Engagement  Training for Providers  Integration with existing public health practice Maternal Health/ Prematurity

21. Community Engagement  Brochures on the Web  Pregnancy & Family Friendly Workplace Policies Brief  Breastfeeding-Friendly Workplace Policies Brief  How healthy are you?  Reproductive Life Plan toolkit  Your Health, Your Life Plan: A Reproductive Health Life Planner for all Ages

22. Community Engagement  Palm cards, posters, and DVDs  I Want my 9 Months  Don’t U Dare  Are You Ready for a Makeover?  Nine Questions to ask Before Becoming Pregnant  Folic Acid is Good for Me / Folic Acid is Good for Us  Community grants and awards  Advocacy network

23. Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2005

24. Contact Us: Los Angeles County Department of Public Health Maternal, Child, and Adolescent Health Programs Cynthia A. Harding, MPH, Director charding@ph.lacounty.gov Giannina Donatoni Gdonatoni@ph.lacounty.gov