Transcript Slide 1

Using FIMR and PPOR to
Identify Strategies for Infant
Survival in Baltimore
Meena Abraham, M.P.H.
Baltimore City Perinatal Systems Review
MedChi, The Maryland State Medical Society
Partners
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Baltimore City Health Department
Baltimore City Healthy Start, Inc.
MedChi, The Maryland State Medical Society
Funded through the Improved Pregnancy
Outcomes grant from the Center for
Maternal and Child Health, DHMH.
Other—March of Dimes, United Way, Family
League of Baltimore
Baltimore City Population
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Population Size—632,680
Racial Composition
– 67% African American
– 31% White
– 2% Other
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Poverty
– 24% live at or below poverty in Baltimore.
– 9% live at or below poverty in Maryland.
Infant Mortality Rates
Baltimore City, Maryland, and U.S.,
1998 - 2002
deaths per 1,000 live
births
15
13
Baltimore
City
Maryland
11
9
United States
7
Year
20
02
20
01
20
00
19
99
19
98
5
Source: Md Vital Statistics Administration
18
16
14
12
10
8
6
4
2
0
African
American
White
19
98
19
99
20
00
20
01
20
02
deaths per 1,000 live
births
Infant Mortality Rates by Race
Baltimore City, 1998 - 2002
Year
Source: Md Vital Statistics Administration
Initiative in Baltimore
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Background—High rates fetal-infant mortality.
Purpose—To improve services to women at risk
for a poor pregnancy outcome.
Tools for Assessment/Monitoring—FIMR, PPOR
Objectives
– To identify women at risk for fetal-infant
mortality, poor pregnancy outcome.
– To identify strategies for improving services.
Baltimore’s Resources
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Institutions—high-tech care, clinical and
public health expertise.
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Community-based Services
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Maternal & Infant Nursing
HealthCare Access
Baltimore City Healthy Start
Success by 6
Health Commissioner—maternal/infant
health priority.
Phase I PPOR Analysis
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What does our study population look
like?
Which births are excluded?
What is the distribution of birth weight
and mortality in our population?
Are there differences in our population?
Distribution of Fetal and Infant Deaths
African American vs White/Other Rates
Baltimore City, 1997-1999
Maternal Health/
Prematurity
8.6 vs 3.6
Maternal
Care
Newborn
Care
Infant
Health
4.0 vs 1.8
2.3 vs 1.5
3.4 vs 2.1
Total Rate:
18.2 vs 9.1
Distribution of Excess Mortality
African American Compared to White/Other
Maternal
Health/
Prematurity
Maternal Care
14%
9%
54%
Newborn Care
23%
Infant Health
Excess Deaths Among
African Americans = 182
Phase II PPOR Analysis
What are the reasons for the disparity in
birth outcomes?
 Birthweight distribution?
 Birthweight-specific mortality?
 Distribution of risk factors?
Excess Deaths By Birthweight and
Birthweight-specific Mortality
A. Overall Excess Deaths
B. Excess Maternal Hlth/ Prematurity
10%
20%
80%
Birthweight
Birthweight-specific Mortality
90%
PPOR Findings
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Greatest disparity is in maternal health/
prematurity and maternal care
– Infant deaths <1500 g and fetal deaths
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90% of excess mortality is due to
birthweight distribution.
Only 10% to birthweight-specific
mortality – good systems for infant care.
PPOR Multi-variate Analysis
Outcome: VLBW – live births <1500g
Variables: maternal race, infant sex,
age, education, marital status, parity,
timing of entry into prenatal care,
smoking, and medicaid enrollment
PPOR Findings
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African American women have 2.7
times the risk for VLBW.
Maternal age – 30-39 is lowest risk for
whites but highest risk for A.A.
Maternal education – not significant
for whites but 9 to 11 yrs increased
risk among A.A.
Parity – first birth increase risk for A.A.
PPOR Findings
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Prenatal Care – none is high risk for all.
Medicaid – no effect for whites, not
enrolled and enrollment pending are
high risk for A.A.
Hypertension, multiple gestation, and
other complications all precipitate
preterm delivery and increase the risk.
Implications of PPOR Findings
Focus efforts to prevent VLBW births
and fetal deaths:
– African American women 30 years+
– Women having their first pregnancy
– Early enrollment in prenatal care
– Early enrollment of eligible women in
Medicaid
Fetal & Infant Mortality Review
Mission: To improve the delivery of services to
women and their families.
Activities:
 Compile case histories from birth and death
certificates, medical records, other sources.
 Conduct maternal interviews.
 Review cases and develop recommendations
with a multi-disciplinary board.
 Work with partners/stakeholders to
implement recommendations.
Comprehensive Case Review
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165 fetal & 117 infant deaths reported in 1998.
Case histories compiled on 204 pregnancies
resulting in 220 deaths.
Grouped cases by area of need—e.g. substance
use, domestic violence, infections—and
reviewed 3 to 4 cases at each meeting.
Devoted 1 year to case reviews and 1 year to
developing recommendations for each area of
need.
FIMR Data
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Pregnancy History
– 21% first pregnancy
– Among those pregnant before—32% 4+
pregnancies, 12% LBW, 8% VLBW, 43% fetal or
infant loss in the past as well, 49% elective
abortion
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Infections
– 23% STI
– 46% perinatal infection
FIMR Data
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Health Conditions–3% diabetes, 27% hypertension
Complications–14% placental abruptio, 32% PROM
No prenatal care–13%
Multiple gestation pregnancy–10%
Substance use during pregnancy–28% smoking,
10% alcohol, 25% drugs; 39% any
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Domestic violence–9% (not routinely screened)
Key FIMR Findings
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Women have multiple risk factors for
poor pregnancy outcome.
Women are not always aware of their
risks or ways to reduce them.
Providers and pregnant women are
often not aware of available services.
Summary of Four Priority Areas
1.
Care of women following a perinatal
loss to reduce repeat losses
-Bereavement support
-Medical assessment
-Follow-up care
-Care coordination
-Interval between pregnancies
Summary of Four Priority Areas
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Perinatal infection
-Early detection
-Repeated screening
-Provider education
-Community education
Summary of Four Priority Areas
3.
Family planning and preconception/
inter-conception care
-availability of contraceptive services
-planning post-partum contraception
-family planning waiver card
-importance of primary care
-follow-up services
Summary of Four Priority Areas
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Adequate utilization of prenatal care
-early enrollment in Medicaid
-promote the value of prenatal care
-early enrollment in prenatal care
-”user-friendly” services
-continuity of care
Strategies for Infant Survival
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Subcommittees to address priorities
– Legislative and policy
– Institutional and Health Systems
– Provider Education
– Community Education and Outreach
Activities to Improve Services
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Disseminate Report and Findings
– Breakfast Seminar
– Meetings, Conferences, Mailings
– Press Conference
– Presentations to Stakeholders
Activities to Improve Services
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Develop Health Education Materials
– Perinatal Mortality Curriculum
– Risk-reduction Fact Sheets
– Perinatal Infections Curriculum
Activities to Improve Services
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Develop Institutional Protocols
– Bereavement Services
– Medical Assessment
– Inter-conception Care
Activities to Improve Services
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Educate Providers Serving At-Risk Women
– Grand Rounds—Findings/Recommendations
– Training—Preterm Birth Prevention,
Bereavement, Findings/Recommendations
– Training—Perinatal Infections
Coordinated Services Delivery
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Home Visit, Case Management Providers
– Incorporating FIMR, PPOR findings into
strategic planning.
– Restructuring services to target women with
losses, VLBW.
– Establishing referral for post-loss/interconception care to Maternal & Infant
Nursing Program.
Conclusions
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FIMR and PPOR each contribute valuable
information.
PPOR provides the “what.”
FIMR provides the “why.”
Both approaches promote community action.
FIMR and PPOR have been used successfully
in Baltimore to develop strategies for systems
change and improved infant survival.