1. 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

2. 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

3. 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.

4. Infant Mortality Rates Baltimore City, Maryland, and U.S., 1998 - 2002 Source: Md Vital Statistics Administration

5. Infant Mortality Rates by Race Baltimore City, 1998 - 2002 Source: Md Vital Statistics Administration

6. 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.

7. 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.

8. 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?

9. 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, 1997-1999

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

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

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

13. 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.

14. 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

15. PPOR Findings African American women have 2.7 times the risk for VLBW. Maternal age – 30-39 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.

16. 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.

17. 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

18. 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.

19. Comprehensive Case Review 165 fetal & 117 infant deaths reported in 1998. 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.

20. 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

21. 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)

22. 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.

23. 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

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

25. 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

26. 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

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

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

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

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

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

32. 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.

33. 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.