1. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR CityMatCH PPOR Level 2 Learning Network Seminar Call, June 20, 2007

2. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 The Decision to integrate PPOR and FIMR  The integration of FIMR and PPOR is not necessary in order to achieve the benefits of each approach.  Combining parts of these processes can save time, energy, and community resources.  Each process can add value to/benefit the other.

3. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 The pathway to FIMR/PPOR integration depends on where you begin. City has FIMRCity does NOT have FIMR City has PPOR(1) Merge existing PPOR and FIMR programs (2) Add FIMR to existing PPOR program City does NOT have PPOR (3) Add PPOR to existing FIMR program (4) Begin both programs simultaneously

4. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 When a both PPOR and FIMR already exist in the community...  Each program has something to teach and something to learn from the other  In times of scarce resources, efficiencies MAY be gained from Using PPOR “gaps” to target FIMR case reviews Combining some aspects of community committees

5. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 When a community has an established PPOR program...  PPOR stakeholders can become the FIMR program planning committee and can serve on the FIMR Case Review and Community Action Teams (CAT).  “Many communities already have a functioning group that has the characteristics necessary to fulfill the role of the CAT. … It is most important not to form a new and separate FIMR CAT unless no other comparable group exists in the community …” --Fetal and Infant Mortality Review Manual: A Guide For Communities

6. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 When a community has an established FIMR Program...  The FIMR CAT includes those with the political will and fiscal resources to create large-scale system change members who can define a community perspective and know how to best to create the desired change in the community  This team can provide the core community partnership necessary to implement PPOR analysis and understand and utilize the results.

7. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 PPOR Brings to the Table…  A framework in which the Case Review Team (CRT) and CAT better understand individual cases.  Other criteria to use in looking for patterns across cases.  Alternative strategies for case selection....

8. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Limitations of PPOR  Observational data cannot prove cause and effect, only correlation or association  When number of deaths is small, random variation can cause large year-to-year changes in rates, i.e. data can be “unreliable”.  Vital records and other population- based data sources only collect variables we already KNOW correlate with birth outcomes. What about factors we DON’T know about yet?

9. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 FIMR Brings to the Table…  Information not found on vital records or in any other data source.  Improved understanding of causal relationships, when quantitative data can only show correlation  Case review data can become part of PPOR Phase 2 analysis

10. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Limitations of FIMR  In many locations, only a small fraction of the deaths are reviewed by the FIMR team. Users must remember that their objective is not to make epidemiological estimates about the population, but to generate ideas and new information  When the number of deaths is small, FIMR results can also fluctuate from year to year due only to random variation.

11. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR --- Community Involvement --- PPOR Steps Parallel Components FIMR Steps Community Engagement and Readiness. Building Community Support Data and Assessment (Analysis) Collect Data and Review Cases (CRT) Strategy, Planning and Implementation Monitoring and Evaluating Monitor Implementation and Evaluate Results (CAT) Community Action Team (CAT) Translates Recommendations into Action

12. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR --- Community Involvement ---  In both PPOR and FIMR programs, community groups ideally oversee the whole process of data collection, analysis, and use of the information.  Bringing in and “nurturing” this group can be time-intensive.  In many cases, community members are busy volunteers, who need to use their time efficiently.

13. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR ----Data and Methods---- 1. FIMR cases can be selected solely from the Period(s) of Risk with the largest “Opportunity Gap”. 2. Probability sampling can be employed to obtain a sample that represents the entire community but oversamples an important population or period of risk.

14. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR ----Data and Methods----  Patterns can emerge when FIMR case review data is organized according to the four Periods of Risk.  The Healthy Start coalition in Jacksonville Florida used a PPOR-style “map” of FIMR data to help redirect funding toward preconception care for high-risk woman.

15. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating and Evaluating Results Fetal (24+gest)NeonatalPostneonatal 500- 1499g 1500g+ MATERNAL HEALTH 85%–Preterm labor or premature rupture of membranes 46%–Sexually transmitted diseases 36%–Maternal age less than 21 years or more than 35 years 36%–No, late or inconsistent prenatal care 32%–Infant infection 29%–Pre-existing medical condition 29%–Substance use (alcohol, tobacco or drugs) 25%–Maternal obesity 25%–History of previous adverse pregnancy outcome 21%–Family planning issues MATERNAL CARE 67%–Sexually transmitted diseases 47%–Lack of patient education 33%–Maternal obesity 33%–No, late or inconsistent prenatal care 33%–Substance use (alcohol, tobacco or drugs) NEWBORN CARE 55%–Pre-existing infant condition 45%–Inadequate prenatal care 34%–Maternal age less than 21 years or more than 35 years 31%–No Healthy Start screening 28%–previous adverse pregnancy outcome 21%–Family planning issues 21%–Lack of support systems 21%–Preterm labor or PROM 21%–Sexually transmitted diseases 21%–Substance use INFANT HEALTH 52%–Sexually transmitted diseases 48%–No, late or inconsistent prenatal care 41%–Need for SIDS education 36%–Maternal age less than 21 years or more than 35 years 25%–Pre-existing infant medical condition 25%–Maternal obesity 23%–Lack of preventive and medical follow up

16. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 How does FIMR fit in with Phase 2 PPOR Analysis? 500-1499 g 1500+ g Fetal Death Neonatal Post- neonatal Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Birthweight Age at Death

17. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Phase 2 Analysis explains why the excess deaths occurred and directs prevention efforts  Identify causal pathways or biologic mechanisms for excess mortality  Estimate prevalence of risk and preventive factors by type of mechanism  Estimate the impact of the risk and preventive factors.

18. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007  Community health and health systems assessment  Fetal Infant Mortality Reviews (FIMR)  Further epidemiologic study PPOR Phase 2 Analysis Three Directions

19. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 Integrating PPOR and FIMR ----Data and Methods----  If FIMR includes all deaths or a representative sample of deaths, it may be possible to make inferences about the population based on FIMR results.  For example, cause specific mortality rates could be based on information from FIMR reviews.

20. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 FIMR in PPOR Phase 2 FIMR provides information on actual cause of death FIMR is not limited to previously proven causes of death

21. CityMatCH PPOR Learning Network, Integrating PPOR and FIMR, June 2007 “Paint the Faces Behind the Numbers”  FIMR may provide stories that help a community understand local infant mortality issues in ways that numbers cannot.