1. Fetal and Infant Mortality Review (FIMR) Marion County Health Department

2. Perinatal Periods of Risk: The PPOR Map Developed over a decade ago to: –Monitor and investigate fetal-infant mortality. –Identify community gaps/challenges in perinatal health. –Develop interventions to address these challenges. Operates in a cycle to: –Assess the problems. –Identify strategies. –Create and implement an action plan. –Monitor and evaluate progress. –Apply lessons learned and continue commitment in a sustained fashion.

3. Why does the PPOR Map Work? It is strategic. –It’s a plan. It is consistent. –It sets a standard for terminology and formulas. –Can now compare statistics no matter where you are. It is data driven. –It uses real-time statistics. –We are no longer guessing. It is formal and provides: –Who –Where –Why –Now know who to target for future efforts

4. Understanding the PPOR Map of Fetal-Infant Mortality

5. Connecting Results to Actions PPOR Focus Area Potential Action Areas for Community Interventions to Decrease Deaths in this Category 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

6. PPOR Map Examples: Example 1: Age at death = Neonatal Birthweight = 1,600 grams This means = Newborn Care PPOR Focus AreaPotential Action Area Newborn Care Perinatal Management Perinatal System Pediatric Surgery

7. PPOR Map Examples: Example 2: Age at death = Post-Neonatal Birthweight = 1,700 grams This means = Infant Health PPOR Focus AreaPotential Action Area Infant Health Sleep Position Breast-Feeding Injury Prevention

8. The Tale of Three Cities: The PPOR in Action. From 1995 to 1997 three cities had an IMR of: City 1- 12.5 City 2- 12.0 City 3- 12.8 Looking at these rates: Do we know at what age in the perinatal period that babies are dying the most? Do we know where it is happening or who it is happening to? Do we know why it is happening? Do we know what interventions can be done to improve each cities infant mortality rate?

9. Plugging in the Numbers… 12.512.012.8 City 2City 3 First we calculate the IMR for each of the four primary PPOR categories and plug it into the PPOR: Maternal Health/Prematurity Maternal Care Newborn Care Infant Health City 1 4.7 3.4 1.7 2.7 City 1 5.2 3.0 1.9 2.0 City 1 5.0 2.2 2.2 3.5 City 1 The total score =

10. Fetal-Infant Mortality National Reference Group Rates* for 1998-2000 Compared to Marion County Reference group Rates per 1,000 pregnancies and (total deaths) 500-1499 g 1500+ g Fetal Death Neonatal Post- neonatal 2.2 (8,671) 1.5 (6,002) 1.1 (4,437) 1.0 (3,944) *Total number of pregnancies=3,907,458, overall rate=5.9 ** PPOR reference group data at www.citymatch.org/ppor. National data uses cities withwww.citymatch.org/ppor >250,000 population by state. 1.93 (27) United States ratesMarion County rates 1.00 (14) 1.15 (16).93 (13)

11. Marion County, Indiana Fetal-Infant Mortality 1999-2003 Birth Cohort Data Rates per 1,000 pregnancies and (total number of deaths) 500-1499 g 1500+ g Fetal Death Neonatal Post- neonatal 3.88 (273) 2.09 (147) 1.42 (100) 2.31 (163) Total number of pregnancies=70,431 Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, IN 9.70

12. Excess (Preventable) Infant Mortality Rates for Marion County, Indiana 9.70 5.014.69 All Races*ReferenceExcess/Preventable Total number of pregnancies + 13.955 overall rate = 5.02 *Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, In City 1 3.88 2.09 1.42 2.31 City 1 1.93 1 1.15.93 City 1 1.95 1.09.27 1.38

13. What to do with PPOR Map data: We can see that the highest IM rate falls into the Maternal Health/Prematurity Category. We can evaluate the demographics of the category to find out more about the mothers and their stories. We can target these women in the community and educate or assist them. We can focus our efforts on the areas listed in the corresponding potential action area to decrease future infant mortality. City 1 3.88 2.09 1.42 2.31 Marion County Potential Action Area Preconceptual Health Health Behaviors Perinatal Care

14. PPOR Map Results for Excess Deaths in Marion County, Indiana Maternal Health/Prematurity Category This category had the largest number of excess deaths in Marion County (Fetal, Neonatal, Post neonatal deaths of infants 500-1,499 g) Category Demographics Part 1: Mothers with the highest rate of excess deaths in category: African American women and women age 20 to 34 years old. Top zip code areas with the highest rates for VLBW in category: 46202, 46205, 46208, 46214, 46218, 46226, 46228 Mothers with >40% chance of mortality due to birth-weight: Black women and women age 20 to 34 years old.

15. PPOR Map Results for Excess Deaths in Marion County, Indiana Maternal Health/Prematurity Category This category had the largest number of excess deaths in Marion County (Fetal, Neonatal, Post neonatal deaths of infants 500-1,499 g) Category Demographics Continued: Mothers with the highest probability of having a VLBW infant: Single women with an education of 12 years or less, women who smoked during pregnancy, Black women and women age 24 or younger. Risk Factors for this category of having a VLBW birth: Black women were 1.9 times more likely to have an intermediate- level/amount of prenatal care than the reference group. Women age 20 to 34 years were 1.7 times more likely than the reference group. Potential Action Area Preconceptual Health Health Behaviors Perinatal Care

16. Category Demographics: Suffocation Related Deaths and Racial Differences: Blacks were mentioned as having been found on an adult bed 2.5 times more than Whites. Whites were mentioned as sleeping with multiple family members (bed sharing) 3 times more than Blacks. Causes of Infant Deaths For Category: Highest category is injury (39%), with most being suffocation deaths. Largest number of deaths occurred while co-sleeping on an adult bed or sofa. PPOR Map Results for Excess Deaths in Marion County, Indiana Infant Health Category (Post neonatal deaths of infants weighing 1,500 g or more at birth) This category had the second largest number of excess deaths in Marion County Potential Action Area Sleep Position Breast Feeding Injury Prevention

17. Category Demographics: Causes of Fetal Death: Perinatal Conditions contributed largely (74%) with the top contributor “fetal death of unspecified cause” (35%). Potential Action Area Prenatal Care High Risk Referral Obstetric Care PPOR Map Results for Excess Deaths in Marion County, Indiana Maternal Care Category (Fetal deaths of infants weighing 1,500 g or more at birth) This category had the third largest number of excess deaths in Marion County

18. To date, the data for this category has not been examined. PPOR Map Results for Excess Deaths in Marion County, Indiana Newborn Care Category (Neonatal deaths of infants weighing 1,500 g or more at birth) This category had the least number of excess deaths in Marion County Potential Action Area Perinatal Management Neonatal Care Pediatric Surgery

19. PPOR Will Allow FIMR to: Focus FIMR activities on the group contributing to the gap. Describe in greater depth the risk factors, events or services that may contribute to the gap. Validate the quality of vital records and other information. Paint the faces behind the numbers.