2. Promising Tools to Improve Birth Outcomes: PPOR, FIMR, and LAMB Project Shin Margaret Chao, MPH, PhD Kevin Donovan MPH, Cathleen Bemis, MS, Sungching Glenn, MS Angel Hopson, MSN, MPH, RN, Cynthia Harding, MPH Los Angeles County Department of Public Health Maternal, Child and Adolescent Health

3. Today’s Presentation I.What is the problem? II.Our Response: - Perinatal Periods of Risk (PPOR) - Fetal & Infant Mortality Review (FIMR) - Los Angeles Mommy and Baby (LAMB)Survey III.Findings IV.From Data to Action

4. I. What is the problem ?

5. Antelope Valley? Health Service Planning Area (SPA 1) Relatively isolated from much of LAC Population size— 4,903 live births in 2002 Live births by mother’s race/ethnicity: 17% African American 46% Hispanic 33% White Poverty: 12% population with household income less than 100% of the federal poverty (vs. 20.1% in LAC) Antelope Valley (SPA 1)

6. Increasing Infant Death Rates in AV 1999-2002 The overall IM rates in LA county in 1999-2002 were 4.9 to 5.5 The infant mortality rate in AV more than doubled between 1999 and 2002 In 2002, there were 4903 live births and 53 infant deaths* in AV * Caution: Small numbers cause large changes in rates

7. The highest IM rate was experienced by African American mothers African American rate increased from 11.0 in 1999 to 32.7/1,000 live births in 2002

8. Our Responses

9. Promising Approaches Three promising approaches: PPOR Fetal Infant Mortality Review (FIMR) LAMB

10. PPOR/FIMR PPOR: Map Fetal-infant Mortality Calculate the excess Fetal-infant Mortality Rates FIMR: Used National FIMR forms to review 53 infant deaths that occurred in AV in 2002 PHNs conducted home interviews, abstracted prenatal care, labor and delivery, newborn records, etc. from hospitals and provider offices Findings are summarized according to each infant’s birth weight and age at death-PPOR

11. Population-based survey of women who recently delivered and resided in AV Population-based survey of women who recently delivered and resided in AV Identifies factors associated with poor birth outcomes Identifies factors associated with poor birth outcomes Self-administered survey on experiences before, during, and after pregnancy: Self-administered survey on experiences before, during, and after pregnancy: – Pre- and inter-conception care – Prenatal care – Maternal medical conditions – Psychosocial factors – Risk taking behaviors Los Angeles Mommy and Baby(LAMB) Project

12. III. Findings

13. PPOR Findings

14. FIMR/PPOR Findings 27 Neonatal Deaths (<1500 g0-28 days) 27 Neonatal Deaths (<1500 g, 0-28 days) Mother: All had at least one risk factor for poor birth outcome 65% had psychosocial issues 54% had an infection – most common were UTI and STD 35% started prenatal care after 12 th week Infant: 22% had a documented infection 15% had congenital birth defect

15. FIMR Findings -continued- 13 Infant Deaths (> 1500 g, 29-365 days): Mother: 85% had at least one risk factor for poor birth outcome 77% had psychosocial issues 54% started prenatal care after 12th week Infant: 54% had issues related to safety, including injury, co-sleeping, and lack of supervision 46% had a congenital birth defect

16. LAMB Findings: Results from 366 moms who gave birth in AV between May-July 2004 (response rate 54%): 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)  Reported feeling less happy during pregnancy (OR=1.92; p= 0.02)  Smoked during pregnancy (OR=3.19; p= 0.005)  Described their neighborhood as unsafe (OR=2.45; p= 0.02)

17. IV. From Data to Action

18. Antelope Valley Best Babies Collaborative Meeting More than 50 community partners attended to review the findings and identify intervention strategies Findings from FIMR/PPOR/LAMB were presented 12 short-term interventions and 4 long-term interventions were identified

19. 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 ? ?

20. 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.

22. Post Script From 2002 to 2004, the infant mortality rate in the Antelope Valley decreased, from 10.6 to 5.6 per thousand live births Community efforts, such as the resources/efforts funded by First Five, AV HBLC, the implementation of the BIH Program (2002), etc. will continue to improve the birth outcomes in the AV. In 2006, LAC Preconception Health Collaborative was formed to promote the integration of preconception health policies and practices into public health programs

23. Infant Death Rate by Race/Ethnicity Antelope Valley, 1996-2004

24. Infant Death Rate by Race/Ethnicity LA County, 1996-2004