1. LANE COUNTY PUBLIC HEALTH SERVICES Infant Mortality in Lane County Using the Perinatal Periods of Risk Approach To Look at Local Fetal and Infant Mortality

2. LANE COUNTY PUBLIC HEALTH SERVICES Lane County, Oregon Background Rural & urban population of 336,085 (4 th largest county in Oregon) Stretches from summit of Cascade Mountains to Pacific Ocean, 4,601 square miles 60% live in Eugene/Springfield, 10% in small cities, 30% in rural areas 80% of land is forested, half of that is federal land

3. LANE COUNTY PUBLIC HEALTH SERVICES Lane County, Oregon Population 90.6% White 0.8% Black/African American 1.1% American Indian/Alaskan Native 2.0% Asian 0.2% Native Hawaiian/Pacific Islander 1.9% other 4.6% Latino of any race Population is Changing Latino residents are very much “under-counted” Minorities represent 10% of residents (Census) Minority children in K-12 represent 20% of enrollment

4. LANE COUNTY PUBLIC HEALTH SERVICES Lane County, Oregon

5. LANE COUNTY PUBLIC HEALTH SERVICES The Problem Lane County’s overall fetal-infant mortality rate is: ~Higher than the nation ~Higher than the state ~Higher than Multnomah, Clackamas, & Washington Counties (largest counties by population in OR) ~Higher than the Portland metropolitan area

6. LANE COUNTY PUBLIC HEALTH SERVICES “Infant mortality is the most sensitive index we possess of social justice” Julia Lathrop, Children’s Bureau, 1913

7. LANE COUNTY PUBLIC HEALTH SERVICES Why Perinatal Periods of Risk? Perinatal Periods of Risk (PPOR) is credible. The PPOR approach has been used successfully by the Center for Disease Control (CDC) and other World Health Organization (WHO) collaborators to monitor and investigate fetal-infant mortality in developed and developing countries for many years.

8. LANE COUNTY PUBLIC HEALTH SERVICES Why Perinatal Periods of Risk? PPOR is a simple, standardized approach that we can use locally to identify gaps and plan prevention activities We can compare local fetal & infant mortality rates with that of other cities, counties, and states—as prepared by CDC and the March of Dimes

9. LANE COUNTY PUBLIC HEALTH SERVICES PPOR Steps 1. Bring community partners together 2. Map fetal & infant deaths 3. Focus on understanding the overall rate 4. Look for opportunity gaps 5. Target further investigations & prevention activities on gaps 6. Mobilize for sustainable systems change

10. LANE COUNTY PUBLIC HEALTH SERVICES Stages of PPOR

11. LANE COUNTY PUBLIC HEALTH SERVICES Bring Community Partners Together Early Community Partnership Goals Share initial fetal & infant mortality data with the community Share PPOR approach Begin discussion regarding the reasons for Lane County’s high infant mortality Begin discussion on how we can work most effectively together to make a difference

12. LANE COUNTY PUBLIC HEALTH SERVICES Map Fetal & Infant Deaths Lane County Vital Stats Data 1. Fetal death files 2. Linked birth—infant death certificate files * Based on maternal residence at time of fetal death or live birth

13. LANE COUNTY PUBLIC HEALTH SERVICES ( Includes Fetal and Infant Deaths (>24 weeks) Includes Very Low Birthweight (500-1,499 grams) & Higher Birthweight (>1,500 grams) Examines birthweight & AGE AT DEATH at the same time Generates a local “Map” for targeting strategic actions Map of Local Data

14. LANE COUNTY PUBLIC HEALTH SERVICES 1999-2003 PPOR Map Lane County Overall Fetal-Infant Mortality Fetal DeathsInfant Deaths Birth Weight< 24 weeks> 24 weeksNeonatalPost- Neonatal < 500 g135250 500-1,499 g323267 1,500-2,499 g017106 > 2,500 g1262138

15. LANE COUNTY PUBLIC HEALTH SERVICES 1999-2003 PPOR Map Lane County Overall Fetal-Infant Mortality Reference Group Fetal DeathsInfant Deaths Birth Weight < 24 weeks > 24 weeksNeonatalPost- Neonatal < 500 g135250 500-1,499 g 3 23 + 26 + 7 = 56 1,500-2,499 g 0 17 + 26 = 4310 + 21 = 316 + 38 = 44 > 2,500 g 1

16. LANE COUNTY PUBLIC HEALTH SERVICES Focus on understanding the overall rate Lane County’s Overall Fetal-Infant Mortality Rate was 9.5 (1999-2003) Fetal deaths at >24 weeks gestation & >500 grams; Infant deaths at > 500 grams. 18,268 live births plus 66 fetal deaths (18,334) was the denominator for rate computation (1999-2003)

17. LANE COUNTY PUBLIC HEALTH SERVICES Map of Fetal-Infant Deaths = 9.5 overall rate Lane County 1999-2003 56/3.1 Maternal Health/ Prematurity (fetal deaths, live births) 43/2.3 Maternal Care (fetal deaths) 31/1.7 Newborn Care (live births) 44/2.4 Infant Health (live births)

18. LANE COUNTY PUBLIC HEALTH SERVICES Comparison Fetal-Infant Mortality Rates

19. LANE COUNTY PUBLIC HEALTH SERVICES Look for Gaps All population groups, including the local reference group, had excessively high rates of fetal-infant mortality Broad, over-reaching actions that impact all groups are needed Numbers of deaths in rural areas, minority communities, and for moms aged 19 and under were inadequate for statistical analysis

20. LANE COUNTY PUBLIC HEALTH SERVICES 1999 – 2003 Lane County Fetal-Infant Mortality Rate by Group

21. LANE COUNTY PUBLIC HEALTH SERVICES Gaps in Lane County’s Map of Fetal- Infant Mortality National PPOR reference group rate of 5.8 overall was used for comparison Reference group (national and local) determined by maternal characteristics: age > 20 years, education > 13 years, White non-Hispanic Excess rates of mortality and excess numbers of deaths were found in all four PPOR groups: maternal health/prematurity, maternal care, newborn care, and infant health

22. LANE COUNTY PUBLIC HEALTH SERVICES Excess Excess Fetal-Infant Mortality Rates Lane County Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality 1999-20033.12.31.72.49.5 US Reference Group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality 2.21.51.11.05.8 Excess Mortality Rate Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality By Subtraction 0.90.80.61.43.7 ____________________________________________________________

23. LANE COUNTY PUBLIC HEALTH SERVICES EXCESS NUMBER OF DEATHS Lane County 1999-2003 Excess Mortality Rate Live Births and Fetal deaths Multiply Number of Excess Deaths Lane County 9.5 - 5.8 = 3.7 18,334 3.7*18,334 1,000 = 68

24. LANE COUNTY PUBLIC HEALTH SERVICES Lane County 1999-2003 Excess Fetal- Infant Deaths Based on US Reference Group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Overall Fetal-Infant Excess Deaths Lane County 1715112668

25. LANE COUNTY PUBLIC HEALTH SERVICES Target Further Investigations & Actions Investigations: Why the excess deaths? Additional population-based data assessment & analysis Individual fetal-infant case findings & analysis Actions: Based on PPOR group excess deaths Infant health—safe sleep, breast feeding, injury prevention Maternal health/prematurity—preconception health, health behaviors, perinatal care

26. LANE COUNTY PUBLIC HEALTH SERVICES Analyze Additional Population-Based Data PRAMS (Pregnancy Risk Assessment Monitoring System) Census data Alcohol and Drug data Mental Health data Health care availability studies

27. LANE COUNTY PUBLIC HEALTH SERVICES PRAMS County level data shows disturbing levels of alcohol and tobacco use. One of four women admitted drinking more than 5 drinks at one sitting in the months immediately before (and therefore during the first months of) pregnancy; this was significantly higher than the state average Tobacco use before and after pregnancy was also higher than the state average

28. LANE COUNTY PUBLIC HEALTH SERVICES PRAMS Alcohol and tobacco use have been shown to be markers for illicit drug use Lane County’s higher than expected levels of binge drinking and tobacco use indicate a high potential for co- occurring drug use

29. LANE COUNTY PUBLIC HEALTH SERVICES Vital Statistics Lane County’s fetal & infant death data was studied to identify: ~most frequent age range at time of death ~most frequent causes of death

30. LANE COUNTY PUBLIC HEALTH SERVICES Vital Statistics Age Range: Data indicated that Lane County’s mortality rate for the postneonatal age range (29 days to 1 year) was statistically (significantly) higher than for Oregon as a whole

31. LANE COUNTY PUBLIC HEALTH SERVICES Vital Statistics Cause of Death: Ill-defined causes of death (including SIDS and suffocation) accounted for 35.9% of postneonatal deaths and other external causes (accidents & injuries) accounted for 24.5% of postneonatal deaths— potentially preventable deaths (60.4%)

32. LANE COUNTY PUBLIC HEALTH SERVICES Census & Other Data In 2005, Lane County had 3,487 births Of the women who gave birth: ~34% were < 185% federal poverty level ~43% were first time parents ~35% were unmarried ~14% had < high school education

33. LANE COUNTY PUBLIC HEALTH SERVICES Census and Other Data Over the past ten years, communities in Lane County have had large job losses in the timber industry and have struggled to establish an alternative economic base

34. LANE COUNTY PUBLIC HEALTH SERVICES Analyze individual case study data through Fetal Infant Mortality Review (FIMR) process Infant death as a sentinel event Multidisciplinary review team-health, social service, medical examiner De-identified medical & social information Maternal Interview

35. LANE COUNTY PUBLIC HEALTH SERVICES FIMR Review information from individual cases of fetal & infant death in order to: –Identify factors associated with those deaths –Determine if those factors represent community-wide service system problems that require change –If so, to develop recommendations for change –Assist in the implementation of change

36. LANE COUNTY PUBLIC HEALTH SERVICES Mobilize for Sustainable Change Large Community Group—Lane County Fetal- Infant Mortality Initiative meets quarterly Workgroups on Data, Maternal health (preconception), and Infant Health meet monthly Evidence based strategies are being examined to address identified areas of concern Funding opportunities are being explored Additional community mobilization continues through presentations, earned advertising

37. LANE COUNTY PUBLIC HEALTH SERVICES Next Steps Update PPOR analysis with 2000-2004 data and yearly thereafter Examine trends over time Receive training in PRAMS data extraction, update complete PRAMS data Continued resource development to sustain PPOR efforts & implement a FIMR

38. LANE COUNTY PUBLIC HEALTH SERVICES Lessons Learned Initial efforts to inform and engage community were hampered by our lack of confidence about our ability to analyze & tackle the problem ~Enthusiasm & determination helped mitigate our lack of experience and confidence ~DaTA Institute provided much needed learning opportunities and support ~Support of Health & Human Services management was essential

39. LANE COUNTY PUBLIC HEALTH SERVICES Lessons Learned Efforts were also hampered by the lack of dedicated FTE to the project—all of us just added more to our work load ~After first year, HHS loaned 0.15 FTE to coordinate meetings, take minutes, contact community members ~Budget for upcoming year (though not yet fully funded) includes staffing to keep efforts moving forward and to begin a FIMR

40. LANE COUNTY PUBLIC HEALTH SERVICES Lessons Learned Efforts at fund raising were hampered by funder’s preference for non-governmental projects ~We keep writing grant proposals, have received acceptance of one & assurances for another ~We can now leverage the grant we have ~Presentations to local civic, business, & fraternal organizations increase awareness and help with fund raising

41. LANE COUNTY PUBLIC HEALTH SERVICES Infant Mortality is— “A sentinel event that serves as a measure of a community’s social and economic well-being as well as its health.” Buckley, K. A., et al., Fetal and Infant Mortality Review Manual: A Guide for Communities, 1998.

42. LANE COUNTY PUBLIC HEALTH SERVICES County Contacts Dr. Sarah Hendrickson, Public Health Officer, PPOR Team Member, sarah.hendrickson@co.lane.or.us, 541.682.3956 Karen Gillette, Public Health Manager, PPOR Team Member, karen.gillette@co.lane.or.us, 541.682.3950 Pamela Stuver, Public Health Nursing Supervisor & PPOR Team Leader, pamela.stuver@co.lane.or.us, 541.682.4670 Douglas Daniell, Management Analyst and PPOR Data Team Member, douglas.danielle@co.lane.or.us, 541.682.2047 C.A. Baskerville, Sr. Program Services Coordinator, PPOR Team Member, cindy.baskerville@co.lane.or.us, 541.682.3031 Sandy Moses, Health Educator, PPOR Team Member, sandy.moses@co.lane.or.us, 541.682.3652