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Few published articles reporting PPOR findings  Emphasis generally on blacks and whites PPOR may not be mentioned by name, but fetal- infant deaths are distributed using the PPOR matrix  Kitagawa analysis generally lacking  Other phase 2 analyses may be lacking Kansas City, Mo, Health Department has published four (4) papers in recent years

Report on PPOR for Kansas City, Mo  Kitagawa analysis  Other phase 2 analyses Restricted to non-Hispanic blacks and whites No discussion of community efforts other than mention of a limited FIMR project and a Child Fatality Review Program for one of the counties in which KCMo is situated  KCMo is part of 4 different counties

Restricted to non-Hispanic blacks and whites  Kitagawa analysis (methodology shown in Appendix)  Other phase 2 analyses Jackson County is 2 nd most populous county in Mo  Approximately 50% of population lives in Kansas City  Demography quite different between city residents and non-city residents Demonstrated geographic and racial differences in fetal- infant mortality  Geographic differences suggested that different intervention strategies may have to be used

Restricted to non-Hispanic blacks and whites in KCMo  Kitagawa analysis  Other phase 2 analyses Compared PPOR findings for to those for Demonstrated 30% reduction in excess fetal-infant mortality overall (17.0% for blacks, 66.7% for whites)  Nearly doubled the disparity ratio between the two groups

Used 5 county area of Missouri and Kansas  Kitagawa analysis Goal was to look at Hispanic fetal-infant mortality  92.4% of Hispanic population in the Kansas City-Overland Park- Kansas City, MO-KS, CSA resided in the 5 counties  7.8% of population in the 5 counties; 77.0% of Mexican heritage Hispanic and non-Hispanic white fetal-infant mortality rates similar; half that of non-Hispanic blacks  Excess Hispanic mortality (91%) concentrated in the MHP category  Interventions would have different focus

Perinatal Periods of Risk (PPOR): A Useful Tool for Analyzing Fetal and Infant Mortality PPOR analysis is an approach to investigating and monitoring causes of fetal and infant deaths. The purpose of PPOR analyses is to change in community direction and priorities for reducing fetal and infant deaths. Kitagawa analysis is to identify excess deaths due to birthweight distribution or due to birthweight-specific mortality. Mainly, it is used to partition the excess in Maternal Health/Prematurity 7

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Access and process fetal and infant death, live birth, and linked birth-infant death data files Quality of data: assess to miss % of gestational week, birthweight (grams), education, and race/ethnicity 9

Phase I Analysis:  Identifies subpopulations and periods of risk with the largest excess fetal and infant deaths Phase II Analysis:  Explains why the excess deaths occurred and directs prevention efforts 10

VariablesFetal Deaths Linked Birth- Infant DeathsLive Births Date birthsXX Date deathsXX Birthweight (gm)XXX Gestational ageXXX Mother’s ageXXX Mother’s educationXXX Race/ethnicityXXX Cause of deathXX 11

Table 3* using percentages of very low birthweight contribution instead of percentages of total excess MHPPercent attributable Percent attributable to Very low birthweight to birthweightbirthweight- specific (500-1,499 grams) distribution mortality White 93.7% (41.5/44.3)6.3% (2.8/44.3) Black 100% 0% Hispanic 90.8% (85.0/93.6) 9.2% (8.6/93.6) For example, among Hispanic, 91% is attributable to birthweight frequency, therefore, the target improvements should focus on reducing birthweight frequency. 12 Published in Public Health Reports *Table 3 is from page 715, Public Health Reports/ Sept-Oct. 2009/Volume 124

Enter Calculated BirthweightNumber of Live Births &Fetal Deaths Number of Feto-Infant Deaths Birthweight Distribution Feto-Infant Mortality Rates 500 ‑ % ‑ % ,000 ‑ 1, % ,250 ‑ 1, % ,500 ‑ 1, %49.1 2,000 ‑ 2, %21.9 2, %6.4 Total %14.6 Enter Calculated BirthweightNumber of Live Births &Fetal Deaths Number of Feto-Infant Deaths Birthweight Distribution Feto-Infant Mortality Rates 500 ‑ % ‑ % ,000 ‑ 1, % ,250 ‑ 1, %98.0 1,500 ‑ 1, %50.4 2,000 ‑ 2, %19.9 2, %2.7 Total %6.0 Kitagawa Table for birthweight—Target population Kitagawa Table for birthweight—Reference population

Actual Contribution to the Difference in Excess Mortality Rates Percentage Contribution to the Difference in Excess Mortality Rates Column (1)Column (2)Calculated (3)Calculated (4)Column (5)Column (6) Feto-Infant BirthweightMortality BirthweightMortality BirthweightDistributionRatesTotalDistributionRatesTotal %-5.7%18.9% %2.5%15.5% 1,000-1, %0.2%6.0% 1,250-1, %0.8%6.5% 1,500-1, %-0.3%7.6% 2,000-2, %1.2%10.0% 2,500-6, %39.0%35.5% Total %37.8%100.0% MH / Prem %-2.2%46.9% Birthweight-specific components for the absolute difference in overall feto ‑ infant mortality rates between populations due to birthweight distribution and feto ‑ infant mortality rates Birthweight-specific components for the percentage difference in overall feto ‑ infant mortality rates between populations due to birthweight distribution and feto ‑ infant mortality rates

Of the overall excess of 8.5, the majority (62.2%) is attributable to birthweight frequency in the target population. The high rate of live births and fetal deaths of grams birthweight alone contributes 24.7% to the overall excess. The overall contribution of VLBW is 4.0, of which 4.2 (100%) is attributable to difference in birthweight frequency and -0.2 – to negative difference in the birthweight-specific mortality. Clearly, in addressing Maternal Health/ Prematurity excess, special attention should be directed to reducing the percentage of very low birthweight. 15

Analysis of Feto-Infant Mortality Rates in Kansas City, Missouri, vs Perinatal Periods of Risk (PPOR) 16

g g Fetal Neonatal Post neonatal Maternal Health/ Prematurity Maternal Care CareNewborn Infant Health

Map Feto-Infant Deaths Blacks, KCMO, vs Maternal Health/ Prematurity 84 Infant Health 66 Maternal Care 37 Newborn Care fetal and infant deaths. Total fetal deaths and live births: 12,795 Maternal Health/ Prematurity 81 Infant Health 45 Maternal Care 40 Newborn Care fetal and infant deaths. Total fetal deaths and live births: 13,

Maternal Health/ Prematurity 6.5 Infant Health 5.2 Maternal Care 2.9 Newborn Care 1.8 Focus on Overall Feto-Infant Mortality Blacks, KCMO, vs Total feto-infant mortality rate: 16.4 =(210/12,795)x 1000 Maternal Health/ Prematurity 6.2 Infant Health 3.4 Maternal Care 3.0 Newborn Care 1.8 Total feto-infant mortality rate: 14.4 =(190/13,154)x

20 KCMO BlacksU.S. ReferenceExcess -= = KCMO BlacksU.S. ReferenceExcess -= =

21 Total Excess Deaths =136Total Excess Deaths =

22 A. Overall Excess RatesB. Maternal Health/Prematurity Excess Rates

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Selected risk factors Black (%) Reference (%)P value Smoking <0.001 First trimester care <0.001 No prenatal care7.51.7<0.001 Parity (>2) <0.001 Unintended pregnancy <0.001 Income <$40 K <0.001 Birth interval <18 m <0.001 Maternal diabetes4.34.0> Birthweight Distribution (VLBW Births: grams) in Kansas City, MO

Maternal Health and Prematurity (N=44) 43% Preterm labor 46% Smoking 32% Substance abuse 11% Alcohol use 34% 1 st trimester care 14% Teen mothers 73% multiple pregnancies 36% Maternal STDs 30% Maternal bacterial infection 18% Maternal HTN/diabetes 17% History of fetal/infant loss 25

From Dr. William M Sappenfield, CDC 26

Category Infant deaths*Rate**Infant deathsRate Infant Health SIDS Injury *Infant health (birth weight with g and post-neonatal infant deaths) **Infant death rate is per 1,000 fetal deaths and live births 27

Black Infant Mortality Rates, Infant Health Category, Kansas City, MO vs During , the rate remained 3.4 deaths per 1,000 live births at the same category. 28

Jinwen Cai, MD  Biostatistician, Office of Epidemiology & Community Health Monitoring   Gerald L Hoff, PhD, FACE  Epidemiologist & Manager, Office of Epidemiology & Community Health Monitoring  