1. Using PPOR and FIMR to lead to SCIENCE-BASED ACTION In Omaha, Nebraska November 25th 2008 David Busse, Teresa Hergott, Carol Gilbert

2. Objectives Discuss mission and purpose of local BBC Collaborative PPOR analysis: –Phase 1: EXCESS MORTALITY in Douglas County –Phase 2: Reasons and potential solutions Identify FIMR as an addition to local community strategy Demonstrate taking recommendations to action 2

3. Baby Blossoms Collaborative Eliminate factors that contribute to health disparities though efforts to strengthen the community capacity by: 1) identifying the contributing factors that lead to racial, geographic and economic disparities. 2) reducing overall feto-infant mortality. 3) building on the strengths of our community.

4. 4 BBC Partners Alegent Health Babies R Us Big Picture Productions Blue Cross Blue Shield of Nebraska Charles Drew Health Center/ Omaha Healthy Start Children’s Hospital CityMatCH College of Saint Mary’s Douglas County Coroner’s Office Early Childhood Consortium of the Omaha Area Early Childhood Training Center Essential Pregnancy Service Fred Leroy Health Center Hope Medical Outreach Coalition March of Dimes Nebraska Methodist Physicians Clinic Metro Omaha Medical Society Ministerial Alliance NE Children and Families Foundation NE Health and Human Services System NE Medical Center NE Methodist Health System NE Midwives Association NE SIDS Foundation Office of Minority Health Omaha District Dietetic Association Omaha Police Department Omaha Public Schools Our Healthy Community Partnership Project Harmony Region 6 Mental Health Salem Baptist Church Salvation Army United Health Care University of Creighton Medical Center University of Nebraska at Omaha Urban League of Nebraska Visiting Nurse Association

5. PPOR Analysis Phase 1: IDENTIFIES the populations and periods of risk with the most excess mortality Phase 2: examines REASONS for the excess deaths through further epidemiologic studies, death reviews, program and policy reviews and other community assessments.

6. Map of Feto-Infant Deaths 103 fetal deaths + 167 deaths of live born infants =270 Feto-infant deaths Divided by 33,046 live births and fetal deaths =8.2 overall feto-infant mortality rate Douglas County, All Races 2003-2006 111/ 3.4 Maternal Health/ Prematurity (44 fetal deaths, 67 live births) 59/1.8 Maternal Care (fetal deaths) 39/1.2 Newborn Care (live births) 61/1.8 Infant Health (live births)

7. N=21,190 live births+fetal deaths 2.6 1.71.01.3 Non-Hispanic White Feto-Infant Rate = 6.6 N=4,797 live births+fetal deaths 2.53.82.1 5.8 Non-Hispanic Black Feto-Infant Rate = 14.2 PPOR Map of Feto- Infant Mortality Douglas County, By Race, 2003-2006

8. Map of Feto-Infant Mortality Rates 1993-2006 Douglas County, NE, All Races 4.0 2.31.42.9 10.7 Feto-Infant Rate = 10.7 4.1 1.81.9 4.0 1.41.8 2.5 1.9 Feto-Infant Rate = 10.3 9.1 Feto-Infant Rate = 9.1 1993-1996 1997-2000 2001-2004 3.4 1.21.8 Feto-Infant Rate = 8.2 2003-2006

9. 9 Feto-Infant Mortality Rates for External Comparison Group White non-Hispanic Mothers age 20 or older, with more than a high school education USA 2000-2002 2.2 Maternal Health/ Prematurity (fetal deaths, live births) 1.5 Maternal Care (fetal deaths) 1.1 Newborn Care (live births) 0.9 Infant Health (live births) Total 5.7 Deaths Per thousand Live Births And Fetal Deaths

10. 10 Excess Feto-Infant Mortality Rates Using External Comparison Group Douglas County, NE 2003-2006 3.4 – 2.2 = 1.2 excess 1.8 - 1.5 =0.3 excess 1.2 – 1.1 = 0.1 excess 1.8-0.9 = 0.9 excess Overall 8.2 – 5.7 =2.5 excess

11. 11 Excess Feto-Infant Mortality Translated into estimated numbers of preventable deaths Douglas County, NE 2003-2006 39 Maternal Health/ Prematurity (fetal deaths, live births) 10 Maternal Care (fetal deaths) 3 Newborn Care (live births) 30 Infant Health (live births)

12. 12 N=21,190 live births+fetal deaths 0.4 0.2-.10.4 Non-Hispanic White Feto-Infant Rate =.9 N=4,797 live births+fetal deaths 1.42.90.6 3.6 Non-Hispanic Black Feto-Infant Rate = 8.5 Excess Feto- Infant Mortality Douglas County, By Race, 2003-2006

13. 13 Phase 1 Conclusions Rates have improved in all four periods of risk Highest excess mortality rates are in the Maternal Health/Prematurity Period and Infant Health Periods Black mothers continue to have higher rates than White mothers, especially in those two periods of risk

14. 14 FIMR Process An action-oriented community process that leads to systems change

15. 15 What is unique about FIMR? Utilize a 2-pronged approach –Case Review Team (CRT) –Community Action Team (CAT) Only fetal and infant death review that makes community recommendations Only review process that includes a home visit with Mom

16. 16 Value of Mom’s Story “I am the only one who can tell the story of my life. I say what it means.” Dorothy Allison

17. 17 Baby Blossoms CAT “Creative thinkers” Review initial recommendations Prioritize and implement recommendations Connect to community stakeholders

18. 18 Prioritizing Recommendations All CAT’s face the tough decision of identifying which of the many recommendations will have priority for implementation

19. 19 PPOR Phase 2 Analysis What are the reasons? How can we fix it?

20. 20 Excess Deaths – Infant Health Period Douglas County, NE 2003-2006 vs. National Reference Group DEATHS PER 1,000 LIVE BIRTHS – BY CAUSE Con- genita l Anom -alies Ill- define d Condi -tions Infec- tious Disea ses Acci- dental Injury Peri- natal Condi -tionsSIDSOtherTotal Douglas County 0.2430.0610.0000.030 1.0320.4551.852 Nat'l Ref Grp 0.2630.0690.0370.1000.0310.2180.2320.951 Excess Mortality Rate -.020 -.008 -.037 -.07 -.0010.814 0.223 0.901 Estimated Excess Deaths 0 -2027730

21. 21 Excess SIDS Deaths by Race – Infant Health Period of Risk Douglas County, NE 2003-2006 vs. National Reference Group SIDS Rate Nat'l Ref Grp Expected Deaths Excess Deaths Douglas County White, not Hispanic 0.7100.218510 Douglas County Black, not Hispanic 2.5170.218111 Non-Hispanic White and Non-Hispanic Black infants accounted for 77.8% of the excess SIDS deaths during this period. Non-Hispanic Black infants were 3.5 times as likely to die from SIDS as a Non-Hispanic White infant.

22. 22 18 48 20 15 27 24 0 20 40 60 White Black Native Amer. Asian/Pacif. Hispanic Total Safe Sleep (Percent NOT sleeping on back) Nebraska PRAMS, Douglas County 2004-2006

23. 23 0 10 20 30 40 50 20002001200220032004200520062007 Percent Baby NOT Sleeping on Back (and 95% confidence intervals) Nebraska PRAMS, Douglas County 2004-2006

24. 24 Phase 2 Green box conclusions Green Box– the bulk of the excess mortality is due to “SIDS” ICD-10 R95. Black/African American babies are more likely to die from SIDS than White babies. [We plan to begin to looking at accidental suffocation (W75) and Cause Unknown/Unspecified (R99) as well] PRAMS—Black babies are less likely to be sleeping on backs PRAMS—unsafe sleep position prevalence is decreasing.

25. 25 Priority FIMR Recommendation There will be an increase in community awareness regarding risks associated with bed sharing –Adult co-sleeping with infant –Infant sleeping non back position on soft surface –Autopsy unable to rule out suffocation as cause of death –Poor provider communication regarding suffocation vs. SIDS

26. 26 Taking Recommendations to Action Safe Sleep Initiative

27. Maternal Health/ Prematurity Birthweight Distribution Birthweight- Specific Mortality Phase 2 Analysis: Maternal Health/Prematurity Period

28. 28 Excess Deaths – Maternal Health/Prematurity Douglas County, NE 2003-2006 vs. National Reference Group due primarily (67%) to a higher than normal proportion of very small babies due partly (33%) to lower than normal survival rates of very small babies Specific Mortality 33% Birthweight Distribution 67%

29. 29 Local, population-based data on risk factors for Prematurity (need for pre-conception care) % Among White % Among Black % Among All Unintended Pregnancy386744 Late or no Prenatal Care113118 No insurance prior to preg.143025 Overweight/Obese prior (PRAMS 2004-2006) 334435 Mother < 19 years old2145 Nebraska PRAMS, Douglas County 2004-2006 (all but smoking are statistically significant by race/ethnicity)

30. 30 Local, population-based data on risk factors for Prematurity (need for prenatal care, screening) Nebraska PRAMS, Douglas County 2004-2006 (all but smoking are statistically significant by race/ethnicity) % Among White % Among Black % Among All Previous Preterm4116 Below 200% Poverty Level278443 Smoking prior to pregnancy262722 Stress (4 or more events PRAMS 2004- 2006) 163519 Physical Abuse7139

31. 31 Mental Health and Depression, Prenatal and Post-partum Nebraska PRAMS, Douglas County 2004-2006 0 5 10 15 20 25 White Black Native Amer. Asian/Pac Hispanic All Percent Sought help for depression during pregnancy Felt depressed post-partum--always or often Felt no interest post-partum--always or often

32. 32 Taking Recommendations to Action BBC members were informed and educated on ACOG standards for prenatal risk assessment Tobacco prevention education incorporated into Now and Beyond preconception health education program

33. 33 Smoking and Prematurity (attributable risk example) The odds of having a preterm birth if a woman smokes is 1.5 times the odds of having a preterm birth if she doesn’t (Creasy et al., 2004) The prevalence of smoking during the last three months of pregnancy in Douglas County 2000-2003 was 14% (PRAMS Nebraska 2004-2006). Population Attributable Risk = PARP = PREV*(OR-1)/[PREV*(OR-1) + 1] =6.5% (we could eliminate 6.5% of prematurity by not smoking)

34. 34 Priority FIMR Recommendation Tobacco cessation services and resources will be covered and available for women of child bearing age, their families and involved significant others. –Maternal tobacco use before, during and after pregnancy –Tobacco use of involved significant others in home –Lack of resources/ services for tobacco cessation with pregnant Moms

35. 35 Priority FIMR Recommendation Every pregnant woman should receive early prenatal risk assessment that identifies physical, psychosocial, economic and cultural/ linguistic issues –Previous preterm birth –Pre-existing maternal health conditions –Late entry to prenatal care

36. 36 Priority FIMR Recommendation Mental health services/ resources will be available to women of child bearing age, involved significant other and their families –Multiple life stressors/ social chaos for Mom and family prior to pregnancy –Maternal history of mental illness before pregnancy –Lack of mental health services prior to and after pregnancy

37. 37 Priority FIMR Recommendation Every woman should receive preconception education including birth spacing –Short pregnancy spacing –Previous poor pregnancy outcome with preterm delivery –Unintended pregnancy

38. 38 Supported by the Douglas County Health Department Taking Recommendations to Action

39. 39 What FIMR and PPOR can Accomplish Vital records narrow the focus to problem areas, and justify starting FIMR. Population-based data help find likely causes. FIMR promotes better understand of contributing factors, and discovers information not previously measured. Population-based data support and prioritize FIMR recommendations.

40. 40 FIMR and PPOR both rely on community / stakeholder engagement to... Ensure priority recommendations are translated into science-based action Build on existing resources and strengths in community

41. 41 Thank you.

42. 42 What FIMR and PPOR can Accomplish Use PPOR/vital records to narrow focus to problem areas, and justify starting FIMR. Find Use vital records and PRAMS to find likely causes. Use FIMR to better understand causes. Use data from PPOR and PRAMS to support and prioritize FIMR recommendations Ensure priority recommendations are translated into science-based action Build on existing resources and strengths in community