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Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,

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Presentation on theme: "Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker,"— Presentation transcript:

1 Revealing Disparities in Pregnancy Outcomes Using PPOR and FIMMRR Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD, MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA Center for Maternal and Child Health State University of New York Upstate Medical University Department of Obstetrics and Gynecology Supported by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private foundation with a mission to improve the health and health care of the people of Western and Central New York. February 2010

2 Objective To examine the relationship of poor socioeconomic condition, as reflected by Medicaid status, to poor outcomes of pregnancy.

3 The Central New York Region consists of a 13 county area spanning from St. Lawrence County in the North to Broome and Tioga counties in the South and includes 21 birth hospitals.

4 Statewide Perinatal Data System (SPDS) Population-based birth registry that captures information on all live births in New York State. It consists of the New York State Electronic Birth Certificate (EBC) and additional voluntary questions, e.g., such as the content of prenatal care, intentions of pregnancy, and perinatal depression, that are expected to be used for quality improvement purposes. The SPDS contains data on: maternal demographics; obstetrical history; prenatal care; labor and delivery information; and birth outcomes. Population-based birth registry that captures information on all live births in New York State. It consists of the New York State Electronic Birth Certificate (EBC) and additional voluntary questions, e.g., such as the content of prenatal care, intentions of pregnancy, and perinatal depression, that are expected to be used for quality improvement purposes. The SPDS contains data on: maternal demographics; obstetrical history; prenatal care; labor and delivery information; and birth outcomes.

5 SPDS: Pay Source Coding  Medicaid – select this choice if the mother’s care was paid for by Medicaid, PCAP, MOMS, Child Health Plus A, Medicaid Managed Care, or Family Health Plus (39.8%)  Private Insurance – select this item if the mother’s care was paid for by private insurance including indemnity insurance and/or managed care insurance (51.2%)  Self-pay – select this item if the mother had no health insurance (1.1%)  Indian Health Service (0.1%)  CHAMPUS/TRICARE (Military and dependents) (5.0%)  Other government (e.g. Child Health Plus B, Veteran’s Administration) (1.0%)  Other (1.8%)  Unknown (0.1%) Medicaid group also applies to Medicaid as secondary payor. (5.5%)

6 Fetal-Infant Mortality/Morbidity Review/Registry (FIMMRR) Clinically oriented, community based registry to capture detailed data on mortalities/ morbidities for the 21 birth hospitals in the Central New York Region. By evaluating data from chart reviews of all fetal and infant mortalities (≥ 300 grams) as well as major morbidities, patterns have been identified which have informed recommendations for improvements (both social and medical).

7 FIMMRR: Maternal Risk Factors ____ Major pre-pregnancy medical problems: ________________ ____ Poor OB History: ____ Adolescent pregnancy (≤ 16 y.o.) ____ History of infertility____ Advanced maternal age (≥ 35 y.o.) ____ 2 Prior losses before 20 weeks____ Housing problems ____ Prior loss after 20 weeks____ Mental illness (past or present) ____ History of preterm delivery(<37 Wks)____ Maternal stress: ____ History of previous SGA/IUGR birth____ Emotional stress (at work or home) ____ Poor nutrition, BMI__________ Physical stress (at work or home) (circle) Obese, underweight____ Loss of partner (circle) ____ Poor Care Seeker (circle)Divorce, Separation, Death, Military Deployment, Other Second Trimester, Third Trimester, No Prenatal Care ____ Death of family member ____ Poor compliance with prenatal visits (missed >2) ____ Pt or partner incarcerated/Legal problems ____ Substance abuse (circle) ____ Other Tobacco, alcohol, marijuana, prescription drugs, other ____ Family violence ____ Poor social setting (in present pregnancy): ____ Cultural problems: ____ < 12th Grade education completed and no GED____ Recent immigrant (Non-Western origin) ____ Partner uninvolved____ Language barrier (written or verbal) ____ History of parenting problems____ Cultural/Religious belief system limits or ____ Other prohibits medical interventions ____ Transportation problems____ Other ____ Occupational problems____ Less than 6 months since last birth ____ Family planning problems____ Current pregnancy result of Assisted ____ Economic issues: Reproductive Technology ____ Unemployed/ partner unemployed____ Other ____ Medicaid Insurance ____ Needs public assistance (housing, healthcare, etc.) ____ WIC referral ____ Other

8 FIMMRR: Causes of Fetal Death / Prenatal/Intrapartal Factors Contributing to Infant Death _____ Abruptio Placenta/Placental Infarct_____ Perinatal TORCH Infection __________ _____ Antiphospholipid/SLE Syndrome _____ Intrapartal asphyxia _____ Blood Factor Sensitization_____ Intrauterine Growth Restriction _____ Chorioamnionitis (bacterial)_____ Maternal Trauma – Type ____________ _____ Chronic hypertension/Pre-eclampsia_____ Non-Immune Hydrops _____ Cocaine Abuse_____ Termination of Pregnancy, _____ Diabetes: Class ___, Type ___ Indication__________________ _____ Fetal Anomaly/Chromosomal Abnormality _____ Twin-Twin Transfusion Syndrome _____ Feto-Maternal Hemorrhage _____ Other ________________

9 FIMMRR: Causes of Infant Death Circle single dominant cause, check all others noted: _____Congenital Anomaly/Chromosomal Abnormality If SIDS, check-off appropriate items: _____Metabolic Disorder_____Co-sleeping _____Sepsis – Bacterial _____ Smoking Household _____Perinatal Viral Infection _____ Substance Abuse in Household _____Perinatal asphyxia _____ Use of Any Impairing Substance _____Hyaline Membrane Disease _____ Unsafe Sleep Environment _____Blood Factor Sensitization _____ Exclusive Breastfeeding _____CNS hemorrhage _____ Any Breastfeeding _____SIDS_____Unsafe Sleep Environment _____Trauma – accident_____Smoking Household _____Termination of Pregnancy, Indication_____Substance Abuse in Household _____Overwhelming Immaturity_____Prone Sleeping _____Unexplained_____Other _______________ _____Physical Abuse/Neglect _____Other _____________________

10 FIMMRR: Causes of Death-ICD10 _____Congenital malformations, deformations and chromosomal abnormalities _____Disorders related to short gestation, low birth weight, not elsewhere classified _____Sudden infant death syndrome _____Newborn affected by maternal complications of pregnancy _____Newborn affected by complications of placenta, cord and membranes _____Accidents (unintentional injuries) _____Respiratory distress of newborn _____Bacterial sepsis of newborn _____Neonatal hemorrhage _____Intrauterine hypoxia and birth asphyxia _____All other causes

11 Data Notes Statewide Perinatal Data System (SPDS)  primary source for population characteristics  secondary source for identification of neonatal and post neonatal deaths Fetal Infant Morbidity/Mortality Review/Registry (FIMMRR)  only source for detailed data on fetal deaths  primary source for detailed data on neonatal and post neonatal deaths

12 Population Characteristics Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured p value Live Births + Fetal Deaths Live Births Maternal Age (<17 y) 1.2%0.3%2.2% <.001 Maternal Race (non-white) 14.7%9.4%21.0% <.001 Maternal Education (< 12 y) 16.0%4.3%30.2% <.001 Marital Status (not married) 42.5%17.8%72.2%<.001

13 Population Characteristics Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured p value Live Births + Fetal Deaths Live Births Early Prenatal Care 75.3%84.4%64.3% <.001 Adequate Prenatal Care 82.5%88.4%75.4% <.001 Smoking During Pregnancy Pregnancy21.8%10.3%35.6% <.001 Illegal Drug Use 2.1%0.5% 4.1% 4.1% <.001 Obese (prepregnancy BMI>30) 27.1%25.8% 28.7% 28.7% <.001 Breastfeeding67.6%76.8% 56.6% 56.6% <.001

14 Despite increased risk factors for the Medicaid insured women, most birth outcomes in the Central New York Region are not significantly different between Medicaid and Non-Medicaid insured women. Birth Outcomes

15 Gestational Age Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured p value Live Births + Fetal Deaths Live Births Preterm9.7%9.8%9.5%NS <24 weeks <24 weeks0.2%0.2%0.2%NS weeks weeks0.5%0.4%0.5%NS weeks weeks1.0% 1.0% 1.0%0.9%NS weeks weeks8.0%8.1%7.9%NS 37+ weeks 37+ weeks90.3%90.2%90.4%NS

16 Birthweight/Intrauterine Growth Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured p value Live Births + Fetal Deaths Live Births LBW (<2500 grams) 7.7%7.3% 8.2% 8.2% <.001 VLBW (<1500 grams) 1.4%1.5% 1.4% 1.4%NS ELBW (< 1000 grams) 0.6% 0.7% 0.7%0.7%NS Small for Gestational Age 10.6%7.0%13.4% <.001 Large for Gestational Age 9.1%10.8%8.2% <.001

17 Rates of LBW and especially Small for Gestational Age are significantly higher in Medicaid Insured births. Morbidity

18 Using the Fetal-Infant Morbidity/Mortality Review/Registry (FIMMRR), we also explored the Fetal/Infant death rates among Medicaid and Non-Medicaid insured women. Mortality

19 Overall number of total deaths/total live births + fetal deaths Fetal number of intrauterine deaths/total live births + fetal deaths Neonatal number of deaths ≤ 28 days of life/total live births Post-Neonatal number of deaths days of life/total live births Infant Neonatal + Post-Neonatal Standard Calculation of Death Rates (all ≥ 300 grams)

20 Central New York Region Total Live Births + Fetal Deaths = rate/1000 * * * * p<.001 Non-Medicaid Insured vs Medicaid Insured

21 ≥ 300 grams OverallFetalNeonatal Post Neonatal Infant Total Non-Medicaid Medicaid Central New York Region Total Live Births + Fetal Deaths = 38962

22 The significant difference in mortality is concentrated within the Infant Deaths, most strikingly the Post- Neonatal Deaths. The lack of a significant difference in mortality for both Fetal and Neonatal Deaths, suggests a potential protective effect by Medicaid. Further analysis, using the Perinatal Periods of Risk approach, provided a different prospective. Findings

23 g g Fetal DeathNeonatalPost- neonatal Maternal Health/ Prematurity 6.9 Maternal Care 1.9 Newborn Care 1.4 Infant Health 1.1 Age at Death Birthweight Central New York Region Live Births + Fetal Deaths = Overall Fetal-Infant Mortality Rate 11.3 per 1, 000 Live Births & Fetal Deaths Total

24 g g Maternal Health/ Prematurity 6.1 Maternal Care 2.0 Newborn Care 0.9 Infant Health 0.4 Age at Death Birthweight Central New York Region Live Births + Fetal Deaths = Overall Fetal-Infant Mortality Rate 9.4 per 1, 000 Live Births & Fetal Deaths Fetal DeathNeonatalPost- neonatal Non-Medicaid Insured

25 g g Maternal Health/ Prematurity 8.0 Maternal Care 1.8 Newborn Care 1.9 Infant Health 2.0 Age at Death Birthweight Central New York Region Live Births + Fetal Deaths = Overall Fetal-Infant Mortality Rate 13.7 per 1, 000 Live Births & Fetal Deaths Fetal DeathNeonatalPost- neonatal Medicaid Insured

26 Perinatal Periods of Risk (PPOR) ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsuredsig Live Births + Fetal Deaths Live Births Overall Fetal-Infant Mortality Rate S Maternal Health/Prematurity Maternal Health/Prematurity S Maternal Care Maternal Care NS Newborn Care Newborn Care NS Infant Health Infant Health S Central New York Region

27 Perinatal Periods of Risk (PPOR) ≥ 300 grams Total Reference Group Non-ReferenceGroupsig Live Births + Fetal Deaths Live Births Overall Fetal-Infant Mortality Rate S Maternal Health/Prematurity Maternal Health/Prematurity S Maternal Care Maternal Care NS Newborn Care Newborn Care NS Infant Health Infant Health S Central New York Region

28 Perinatal Periods of Risk (PPOR) Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsuredReferenceGroup Live Births + Fetal Deaths Live Births Overall Fetal-Infant Mortality Rate Maternal Health/Prematurity Maternal Health/Prematurity Maternal Care Maternal Care Newborn Care Newborn Care Infant Health Infant Health

29 Perinatal Periods of Risk (PPOR) Central New York Region ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured Overall Fetal-Infant Mortality Rate Maternal Health/Prematurity Maternal Health/Prematurity Maternal Care Maternal Care Newborn Care Newborn Care Infant Health Infant Health Excess Mortality Rates in comparison with Reference Group

30 Perinatal Periods of Risk (PPOR) Central New York Region Excess Mortality Numbers in comparison with Reference Group ≥ 300 grams TotalNon-MedicaidInsuredMedicaidInsured Overall Fetal-Infant Mortality Rate Maternal Health/Prematurity Maternal Health/Prematurity39437 Maternal Care Maternal Care440 Newborn Care Newborn Care8-612 Infant Health Infant Health16-623

31 Comparison to Reference Group supports our previous Findings. It is also useful to examine the distribution of various causes of death in each PPOR category. Perinatal Periods of Risk (PPOR) Central New York Region

32 Fetal-Infant Morbidity/Mortality Review & Registry Central New York Region Dominant Cause of Death: Fetal-Infant Morbidity/Mortality Review & Registry Central New York Region Dominant Cause of Death: rate/1000 live births + fetal deaths ≥ 300 grams Maternal Health/PrematurityMaternal Care Non-Medicaid 6.1 Medicaid 8.0 Non-Medicaid 2.0 Medicaid 1.8 Abruptio/Placental Infarct Other Placental Problems Cord Accident/Prolapse Congenital Anomaly/ Chromosomal Abnormality Prematurity Overwhelming Immaturity Other Sepsis SIDS/SUID Trauma Unexplained

33 Fetal-Infant Morbidity/Mortality Review & Registry Central New York Region Dominant Cause of Death: Fetal-Infant Morbidity/Mortality Review & Registry Central New York Region Dominant Cause of Death: rate/1000 live births + fetal deaths ≥ 300 grams Newborn CareInfant Health Non-Medicaid 0.9 Medicaid 1.9 Non-Medicaid 0.4 Medicaid 2.0 Abruptio/Placental Infarct0000 Other Placental Problems Cord Accident/Prolapse Congenital Anomaly/ Chromosomal Abnormality Prematurity0000 Overwhelming Immaturity0000 Other Sepsis SIDS/SUID Trauma Unexplained0000

34 Cause of Death Conclusions These findings support our earlier Findings that pre-pregnancy and early pregnancy factors, along with post neonatal factors play the largest role in the disparity between death rates among Medicaid and Non-Medicaid insured women. A protective effect of Medicaid Status is suggested regarding Fetal and Neonatal deaths.

35 Sharing the Results CNY Regional Perinatal Forum CNY Regional Perinatal Program/Affiliate Hospitals Onondaga County Health Department/Syracuse Healthy Start SUNY Upstate Medical University Departmental Grand Rounds (OB-GYN/Pediatrics) Masters in Public Health courses

36 Resultant Targeted Interventions  Improve preconceptional/interconceptional care  Facilitate access to early/quality prenatal care  Implement stronger smoking cessation programs  Improve maternal post partum supports and counseling about importance of Safe Sleep Environment

37 Contact Information: Center for Maternal & Child Health  Richard H. Aubry, MD, MPH  Pamela Parker,  Kristen Luke-Houseman, RN, Preliminary Data. Not for release without permission.


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