1. Perinatal Periods of Risk Approach: The Michigan Experience Bao-Ping Zhu, MD, MS Lead Epidemiologist Division of Reproductive Health, CDC Chief MCH Epidemiologist, MDCH

2. Why a New Approach to Infant Mortality? Simple approach – easy for communities nationwide to use Identifies gaps in community Targets resources for prevention Mobilizes the community to action

3. 1) Engage community partners early to gain consensus and support 2) Map feto-infant mortality by birthweight & age at death 3) Focus on reducing overall feto-infant mortality 4) Examine potential opportunity gaps 5) Target further investigations and prevention efforts on gaps Perinatal Periods of Risk Approach: 5 Major Steps

4. 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

5. Perinatal Periods of Risk Approach: 5 Major Steps Improving feto-infant mortality requires mobilization and change in many sectors and by many individuals in community Consensus about and ownership of problem essential in developing community support Monitoring the problem and the solutions and necessary strategy adjustments require effort by many partners

6. Perinatal Periods of Risk Approach: 5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

7. Map Feto-Infant Mortality Age at Death Birthweight 500-1499 g 1500+ g Fetal (24+ wks) NeonatalPostneonatal 123 546

8. Map Feto-Infant Mortality 500- 1499 g 1500+ g Fetal Neonatal Post neonatal 123 456 Age at Death Birthweight

9. Map Feto-Infant Mortality 500-1499 g 1500+ g Fetal Neonatal Post neonatal Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health

10. Map Connections to Action Maternal Health/ Prematurity Pregnancy Intention Smoking / Drinking / Drug Abuse Racial discrimination / Stress 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

11. Maternal Health/ Prematurity 875 Maternal Care 245 Newborn Care 200 Infant Health 262 Map Feto-Infant Deaths Michigan Overall, 2000 1582 fetal or infant deaths Total fetal deaths and live births: 137,496

12. Maternal Health/ Prematurity 327 Maternal Care 67 Newborn Care 43 Infant Health 94 Map Feto-Infant Deaths Blacks, MI, 2000 531 fetal or infant deaths Total fetal deaths and live births: 24,304

13. Map Feto-Infant Mortality What Is Missing in the 6 Cells? Fetal deaths <24 wks Live births <500 g Spontaneous abortions Induced abortions

14. Perinatal Periods of Risk Approach: 5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto- infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

15. 3. Focus on Reducing Overall Feto-Infant Mortality Rate Include fetal deaths - often excluded Calculate group specific mortality rates - add up to total feto-infant mortality rate Calculate excess mortality rates and numbers - relate to total feto-infant rate

16. Maternal Health/ Prematurity 327 Maternal Care 67 Newborn Care 43 Infant Health 94 Feto-Infant Deaths Blacks, MI, 2000 531 fetal or infant deaths Total fetal deaths and live births: 24,304

17. Focus on Overall Mortality Cell- or Group-Specific Mortality Rates Number of deaths in a cell or group Total number of live births & fetal deaths 4 e.g., for Blacks: Maternal Health/ Prematurity: 327 e.g, for Blacks: 24,304

18. Maternal Health/ Prematurity 13.5 Maternal Care 2.8 Newborn Care 1.8 Infant Health 3.9 Focus on Overall Feto-Infant Mortality Blacks, MI, 2000 Total feto-infant mortality rate: 21.8 =(531/24,304)x 1000

19. Focus on Overall Mortality Learn by Comparisons Compare within community feto-infant mortality rates by examining 4 group rates Compare overall and group rates over time Compare overall and group rates between different population groups

20. Focus on Overall Mortality Comparison of Socio-Demographic Groups Maternal Race and Ethnicity –Race: white, black, other racial groups –Ethnicity: Hispanic, Arabic Maternal Age and Education –<20 years of age –20+ years and <13 years of education –20+ years and 13+ years of education Geography: SE vs. Non-SE; County; City Health Care Payment Source

21. Perinatal Periods of Risk Approach: 5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

22. 4. Examine “Opportunity Gap” Between Population Groups To identify potential for reduction in community Involves: –Decide on reference groups –Calculate excess deaths and mortality rates by components

23. Examine “Opportunity Gap” Reference Groups Reference group for MI state-wide analysis Non-Hispanic white women in Michigan Aged 20+ years 13+ years of education  Simple optimal group  At least 15% of population

24. Maternal Health/ Prematurity 99 (1.9) Maternal Care 64 (1.2) Newborn Care 74 (1.4) Infant Health 47 (0.9) 284 fetal or infant deaths Reference: MI non-Hispanic white women aged 20+, with 13+ yrs education, 1999 Total feto-infant mortality rate: 5.4 Total live births or fetal deaths: 52,206

25. Examine the “Opportunity Gap” Examine excess overall mortality, both rate and number Examine excess mortality across four groups Calculate contribution to overall excess mortality by socio-demographic groups

26. Excess Feto-Infant Mortality Blacks, 2000 - = MI BlacksReferenceExcess 13.5 2.81.83.9 21.8 1.9 1.21.40.9 5.4 11.6 1.50.43.0 16.5 - =

27. Excess Feto-Infant Deaths Blacks, 2000 = Excess Deaths 281 37972 399 = Excess Mortality11.6 1.50.43.0 16.5 × 24,304 / 1000 × Total fetal or infant deaths (24,304)

28. Perinatal Periods of Risk Approach: 5 Major Steps 1) Engage community partners 2) Map feto-infant mortality 3) Focus on reducing overall feto-infant mortality 4) Examine opportunity gaps 5) Further investigations and prevention efforts

29. 5. Target Investigations & Prevention Efforts on the Gap Focus more effort and attention to group(s) contributing most to the gap Conduct further studies or mortality reviews on group(s) contributing to the gap (Phase 2 studies) Examine current prevention efforts on group(s) contributing to the gap (Phase 2 policy/program reviews)

30. MI Activities Infant Mortality Summit – one of the main themes Workshops at various conferences, county health departments Spreadsheet program for calculation Infant Mortality Workbook MCH County Profiles

31. Major Findings Maternal Health / Prematurity: Largest opportunity gap

32. Programmatic Response Maternal Health/ Prematurity 281 –Pregnancy intention –Smoking –Drinking –Drug abuse –Stress –Racial discrimination –Nutrition –Pregnancy interval –Preconceptional care –Overall fitness Infant Health 72

33. Major Findings Infant Health: Second largest opportunity gap

34. Maternal Health/ Prematurity 281 Infant Health 72 –Sleep position –Smoking –Breastfeeding –Medical home –Injury prevention Programmatic Response

35. Michigan PPOR “Software” Demonstration