jamie s. kim, mph co-authors: carol gilbert, ms and laurin kasehagen, ma, phd june 5, 2012
DESCRIPTION
Perinatal Periods of Risk (PPOR) approach to better understand fetal-infant mortality: A State-level analysis in Kansas 2005-2009. Jamie S. Kim, MPH Co-Authors: Carol Gilbert, MS and Laurin Kasehagen, MA, PhD June 5, 2012. Acknowledgement. - PowerPoint PPT PresentationTRANSCRIPT
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Our Vision – Healthy Kansans living in safe and sustainable environments.1
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Perinatal Periods of Risk (PPOR) approach to better understand
fetal-infant mortality: A State-level analysis in Kansas 2005-2009
Jamie S. Kim, MPH
Co-Authors: Carol Gilbert, MS and Laurin Kasehagen, MA, PhD
June 5, 2012
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Acknowledgement CityMatCH: Carol Gilbert and Dr. Laurin Kasehagen
http://www.citymatch.org/ Kansas Department of Health and Environment:
http://www.kdheks.gov/ Bureau of Epidemiology and Public Health Informatics - Greg
Crawford, Carol Moyer, Dr. Farah Ahmed and Joy Crevoiserat Bureau of Family Health staff (especially Linda Williams, Dr. Debbie
Richardson, Joseph Kotsch, Jamey Kendall, Marc Shiff and Dave Thomason)
Center for Performance Management - Brenda Nickel Center for Health Equity - Aiko Allen
Kansas Blue Ribbon Panel on Infant Mortality and Connie Satzler (and her staff): http://kansasinfantmortality.org/
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Infant Mortality in Kansas
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Our Vision – Healthy Kansans living in safe and sustainable environments.
The Problem
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
2
4
6
8
10
Infant Mortality Rate TrendsKansas and U.S., 2000-2009
Rate
per
1,0
00 li
ve b
irths
Source: Bureau of Epidemiology and Public Health Informatics, KDHE; National Center for Health Statistics
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Our Vision – Healthy Kansans living in safe and sustainable environments.
The Problem
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
2
4
6
8
10
Infant Mortality Rate TrendsKansas and U.S., 2000-2010
Rate
per
1,0
00 li
ve b
irths
U.S. 2010 preliminary dataSource: Bureau of Epidemiology and Public Health Informatics, KDHE; National Center for Health Statistics
Desired Direction = Below Line
HP2020 = 6.0
HP2010 = 4.5
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Our Vision – Healthy Kansans living in safe and sustainable environments.
The Problem
*BNH= non-Hispanic black; **WNH=non-Hispanic whiteSource: Bureau of Epidemiology and Public Health Informatics, KDHE
2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
5
10
15
20
25
Infant Mortality Rate Trends by Non-Hispanic Black and Non-Hispanic White
Kansas, 2000-2009
Rate
per
1,0
00 li
ve b
irths
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Our Vision – Healthy Kansans living in safe and sustainable environments.
The Problem
*BNH= non-Hispanic black; **WNH=non-Hispanic whiteSource: Bureau of Epidemiology and Public Health Informatics, KDHE
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
5
10
15
20
25
Infant Mortality Rate Trends by Non-Hispanic Black, Non-Hispanic White and Hispanic
Kansas, 2000-2010
Rate
per
1,0
00 li
ve b
irths
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Our Vision – Healthy Kansans living in safe and sustainable environments.
What We’re Doing
The Kansas Blue Ribbon Panel on Infant Mortality http://kansasinfantmortality.org/index.asp Releases updated recommendations (Apr 2011)
and actionable logic model (Oct 2011)
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Our Vision – Healthy Kansans living in safe and sustainable environments.
What We’re Doing KDHE Center for Health Equity (i.e., office of
minority health) and SIDS Network of Kansas coordinate multi-year statewide health promotion campaign on infant mortality. Healthy Baby Begins With You Tour KS/Tonya Lewis
Lee (April 2011): Wichita, Topeka, Kansas City 506 media events and estimated 6,112,313
audience reach (Sept, Oct, Nov - national campaign months for Infant Mortality, SIDS, Prematurity)
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Our Vision – Healthy Kansans living in safe and sustainable environments.
What We’re Doing
SIDS Network of Kansas expands Safe Sleep Education outreach.
Sedgwick County FIMR releases first FIMA data report. (July 2011)
Preconception Peer Educator Training (PPE) Wichita, Topeka, Kansas City (Sept 2012)
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Our Vision – Healthy Kansans living in safe and sustainable environments.
What We’re Doing Healthy Communities Wyandotte (HCW)
releases recommendations (Oct 2011) March of Dimes provides grants to Saline,
Sedgwick, Shawnee and Geary counties to establish community collaboratives that will address birth disparities through prenatal care and community health partnerships.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
What We’re Doing State/County collaboration to facilitate use of
PPOR Kansas Leadership Center National FIMR Conference – Geary, Reno,
Saline, Sedgwick, Shawnee and Wyandotte FIMR in Kansas: Long-Term
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Purpose A recommendation from the Kansas Blue
Ribbon Panel on Infant Mortality
Describes the Perinatal Periods of Risk (PPOR) approach to analyze resident fetal and infant death data in Kansas for the period 2005-2009.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Purpose Gain greater insight into the underlying factors
contributing to Kansas’ fetal and infant deaths. Data to Action: Results offer important
information that can be used to develop community-based prevention strategies related to racial/ethnic disparities in infant mortality rate (IMR).
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Methods Perinatal Periods of Risk (PPOR) approach
Phase 1: identifies populations and periods of risk with excess mortality
Phase 2: explains excess mortality and identifies important risk factors
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Our Vision – Healthy Kansans living in safe and sustainable environments.
The Perinatal Periods of RiskAge at Death
Fetal Death>=24 weeks
Neonatal0-27 days
Post-neonatal
28-364 days
500-1499 grams Maternal Health/Prematurity
1500+ grams Maternal Care
Newborn Care
Infant Health
Birth weight
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Our Vision – Healthy Kansans living in safe and sustainable environments.
PPOR Intervention Model
Maternal Health/Prematurity
Maternal Care
NewbornCare
Infant Health
Preconceptional HealthHealth Behaviors
Perinatal Care, etc.
Prenatal CareHigh Risk Referral
Obstetric Care, etc.
Perinatal ManagementNeonatal Care
Pediatric Surgery, etc.
Safe Sleep PositionBreast Feeding
Injury Prevention, etc.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Data Sources Bureau of Epidemiology and Public Health
Informatics, Kansas Department of Health and Environment Fetal death certificate data Live birth certificate data Linked birth-death cohort data
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Study Population Fetal deaths 2005-2009
24 weeks or greater gestational age 500 grams or larger
Live births 2005-2009 500 grams or larger
Linked birth and death data 2005-2009 500 grams or larger
Residents of Kansas at time of birth
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Reference Group External: USA 2000-2002 Reference Group
Defined by maternal characteristics 20 or more years of age 13 or more years of education Non-Hispanic white women Residents of the US at the time of baby’s birth
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Maternal Health/Prematurity
Maternal Care
Newborn Care Infant Health
TotalFetal-Infant Mortality
2.2 1.5 1.1 0.9 5.7
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Phase 1
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Overall PPOR Map of Fetal-Infant Deaths
Kansas, 2005-2009Age at Death
Fetal Death Neonatal Post-
neonatal Total
Birth weight
500-1499 grams 290 279 71 640
1500+ grams 424 302 467 1193714 581 538 1833
Fetal Deaths Live BirthsDenominator 714 + 205,338 = 206,052
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Fetal-Infant Mortality RateKansas, 2005-2009
Age at Death
Fetal Death Neonatal Post-
neonatalOverall
Rate
Birth weight
500-1499 grams 3.1
1500+ grams 2.1 1.5 2.3
Period rates add up to overall rate 9.0
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Calculating Excess RatesKansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Fetal-Infant Mortality
Kansas 3.1 2.1 1.5 2.3 9.0Minus
USA Reference Group* 2.2 1.5 1.1 0.9 5.7
Equals
Excess Mortality Rates 0.9 0.6 0.4 1.4 3.3
*USA 2000-2002 Reference Group
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess MortalityKansas, 2005-2009
Excess Fetal-Infant Mortality Rate=3.3
0.9
0.6 0.4 1.4 3.3
Excess Mortality 27.3%
18.2% 12.1% 42.4% 100.0%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Kansas Excess MortalityKansas, 2005-2009
MH/P27.3%
MC18.2%
NC12.1%
IH42.4%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Non-Hispanic White Kansas, 2005-2009
Age at DeathFetal
Death Neonatal Post-neonatal Total
Birth weight
500-1499 grams 190 176 35 401
1500+ grams 270 222 301 793460 398 336 1194
Fetal Deaths Live BirthsDenominator 460 + 147,560 = 148,020
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Fetal-Infant Mortality Rate Non-Hispanic White Kansas, 2005-2009
Age at Death
Fetal Death Neonatal Post-
neonatalOverall
Rate
Birth weight
500-1499 grams 2.7
1500+ grams 1.8 1.5 2.0
Period rates add up to overall rate 8.0
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Calculating Excess Rates Non-Hispanic White (WNH)
Kansas, 2005-2009Maternal Health/
PrematurityMaternal
CareNewborn
CareInfant Health
Fetal-Infant Mortality
WNH 2.7 1.8 1.5 2.0 8.0Minus
USA Reference Group* 2.2 1.5 1.1 0.9 5.7
Equals
Excess Mortality Rates 0.5 0.3 0.4 1.1 2.3
*USA 2000-2002 Reference Group
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess MortalityNon-Hispanic White Kansas, 2005-2009
Excess Fetal-Infant Mortality Rate=2.3
0.5
0.3 0.4 1.1 2.3
Excess Mortality 21.7%
13.0% 17.4% 47.8% 100.0%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Non-Hispanic White Excess MortalityKansas, 2005-2009
MH/P21.7%
MC13.0%
NC17.4%
IH47.8%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Non-Hispanic BlackKansas, 2005-2009
Age at DeathFetal
Death Neonatal Post-neonatal Total
Birth weight
500-1499 grams 40 38 20 98
1500+ grams 54 24 55 13394 62 75 231
Fetal Deaths
Live Births
Denominator = 94 + 14,004 14,098
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Fetal-Infant Mortality RateNon-Hispanic BlackKansas, 2005-2009
Age at Death
Fetal Death Neonatal Post-
neonatalOverall
Rate
Birth weight
500-1499 grams 7.0
1500+ grams 3.8 1.7 3.9
Period rates add up to overall rate 16.4
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Calculating Excess Rates Non-Hispanic Black (BNH)
Kansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Fetal-Infant Mortality
BNH 7.0 3.8 1.7 3.9 16.4Minus
USA Reference Group* 2.2 1.5 1.1 0.9 5.7
Equals
Excess Mortality Rates 4.8 2.3 0.6 3.0 10.7
*USA 2000-2002 Reference Group
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess MortalityNon-Hispanic Black Kansas, 2005-2009
Excess Fetal-Infant Mortality Rate=10.7
4.8
2.3 0.6 3.0 10.7
Excess Mortality 44.9%
21.5% 5.6% 28.0% 100.0%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Non-Hispanic Black Excess Mortality
Kansas, 2005-2009
MH/P44.9%
MC21.5%
NC5.6%
IH28.0%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
HispanicKansas, 2005-2009
Age at DeathFetal
Death Neonatal Post-neonatal Total
Birth weight
500-1499 grams 42 49 13 104
1500+ grams 80 43 87 210122 92 100 314
Fetal Deaths
Live Births
Denominator = 122 + 32,832 32,954
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Fetal-Infant Mortality RateHispanic
Kansas, 2005-2009
Age at Death
Fetal Death Neonatal Post-
neonatalOverall
Rate
Birth weight
500-1499 grams 3.2
1500+ grams 2.4 1.3 2.6
Period rates add up to overall rate 9.5
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Calculating Excess RatesHispanic
Kansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Fetal-Infant Mortality
Hispanic 3.2 2.4 1.3 2.6 9.5Minus
USA Reference Group* 2.2 1.5 1.1 0.9 5.7
Equals
Excess Mortality Rates 1.0 0.9 0.2 1.7 3.8
*USA 2000-2002 Reference Group
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess MortalityHispanic
Kansas, 2005-2009
Excess Fetal-Infant Mortality Rate=3.8
1.0
0.9 0.2 1.7 3.8
Excess Mortality 26.3%
23.7% 5.3% 44.7% 100.0%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Hispanic Excess MortalityKansas, 2005-2009
MH/P26.3%
MC23.7%
NC5.3%
IH44.7%
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Phase I: Summary
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Period-Specific and Fetal Infant Mortality Rates by Race and Hispanic Origin of
Mother in Kansas, 2005-2009
Maternal Health/
PrematurityMaternal
CareNewborn
CareInfant Health
Fetal-Infant Mortality
Kansas 3.1 2.1 1.5 2.3 9.0
White NH* 2.7 1.8 1.5 2.0 8.0Black NH* 7.0 3.8 1.7 3.9 16.4
Hispanic 3.2 2.4 1.3 2.6 9.5
*NH = non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess Fetal-Infant Mortality RatesKansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Excess Fetal-Infant Mortality
Kansas 0.9 0.6 0.4 1.4 3.3
White NH* 0.5 0.3 0.4 1.1 2.3
Black NH* 4.8 2.3 0.6 3.0 10.7
Hispanic 1.0 0.9 0.2 1.7 3.8
*NH = non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Calculating excess number of deaths from fetal-infant mortality rates
Kansas, 2005-2009Formula:Estimated number of excess deaths = Rate*Denominator/1000
Race/Ethnic Group
Overall Excess Mortality Rate
Live Births and
Fetal Deaths
MultiplyNumber of
Excess Deaths
Kansas 3.3 206,052 680White NH* 2.3 148,020 340Black NH* 10.7 14,098 151Hispanic 3.8 32,954 125*NH=Non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Estimated Excess Number of DeathsKansas, 2005-2009
Maternal Health/
PrematurityMaternal
CareNewborn
CareInfant Health
Excess Fetal-Infant
Mortality
Kansas 185 124 82 288 680White NH* 74 44 59 163 340
Black NH* 68 32 8 42 151
Hispanic 33 30 7 56 125
*NH = non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Phase 2
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Part A: Infant Health Risk Period
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess Fetal-Infant Mortality RatesKansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Excess Fetal-Infant Mortality
Kansas 0.9 0.6 0.4 1.4 3.3
White NH* 0.5 0.3 0.4 1.1 2.3
Black NH* 4.8 2.3 0.6 3.0 10.7
Hispanic 1.0 0.9 0.2 1.7 3.8
*NH = non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Part A: Infant Health Risk PeriodUnderlying cause of death
Birth defects (Q00-Q99) Infections (A00-B99, G009, J180 and J189) Injuries (V01-Y89) Perinatal conditions (P00-P96) Sudden Infant Death Syndrome (SIDS) (R95) Other ill-defined and unspecified causes of mortality
(R99), and other causes.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Part A: Infant Health Risk Period
Mortality Rates and Excess Mortality Rates in the Infant Health Risk Period by Underlying Cause of Death by Race and
Hispanic Origin of Mother in Kansas, 2005-2009
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Part B: Maternal Health/ Prematurity Risk Period
Kitagawa Analysis
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Excess Fetal-Infant Mortality RatesKansas, 2005-2009
Maternal Health/Prematurity
Maternal Care
Newborn Care
Infant Health
Excess Fetal-Infant Mortality
Kansas 0.9 0.6 0.4 1.4 3.3
White NH* 0.5 0.3 0.4 1.1 2.3
Black NH* 4.8 2.3 0.6 3.0 10.7
Hispanic 1.0 0.9 0.2 1.7 3.8
*NH = non-Hispanic
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Components of the Excess Fetal Infant Mortality Rates (FIMR) in non-Hispanic Black
Kansas, 2005-2009
BirthweightDistribution
91%
Birthweight Specific Mortality
9%
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Conclusions
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Our Vision – Healthy Kansans living in safe and sustainable environments.
PPOR Intervention Model
Maternal Health/Prematurity
Maternal Care
NewbornCare
Infant Health
Preconceptional HealthHealth Behaviors
Perinatal Care, etc.
Prenatal CareHigh Risk Referral
Obstetric Care, etc.
Perinatal ManagementNeonatal Care
Pediatric Surgery, etc.
Safe Sleep PositionBreast Feeding
Injury Prevention, etc.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Conclusions Opportunities for intervention to reduce
excess fetal-infant death vary according to the mother’s race/ethnicity.
Excess mortality in the Maternal Health/Prematurity risk period due primarily to high rates of VLBW births call for targeted interventions for improving preconception health of non-Hispanic black mothers in particular.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Conclusions This could involve improving the overall health
of women in general. Or, a more targeted approach could focus on women of reproductive age with chronic diseases, previous poor outcomes, or poorly managed chronic diseases and ensuring better well-woman care and receipt of prenatal care (maternal health/prematurity issues).
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Conclusions Excess mortality in the Infant Health risk
period suggests the need for targeted interventions to better provide and monitor infant care, especially of non-Hispanic black and Hispanic infants, in the post-neonatal period. This may include promotion of breastfeeding and safe sleep practices, and prevention of life-threatening injuries.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Conclusions The excess fetal infant deaths among non-
Hispanic blacks and Hispanics in the Maternal Care risk period highlights the importance of improving access to and utilization of prenatal care services and referrals for high-risk pregnancies.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Conclusions To significantly impact Kansas overall IMR,
community-specific, tailored prevention efforts on prematurity, safe sleep, and injury prevention may be necessary.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
RecommendationsInfant Health Risk Period
Next step in PPOR Phase 2 analysis Examine the risk factors for SIDS
Smoking during and after pregnancy Infant sleep position Bedding
PRAMS Fetal Infant Mortality Review (FIMR) and Child
Death Review teams
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Recommendations
64
Maternal Health/Prematurity Risk Period Next step in PPOR Phase 2 analysis
Study disparities in the prevalence of factors that are known to be associated with VLBW births
Maternal obesity Asthma Infections Hypertension
Vital records and Medicaid files PRAMS
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Recommendations PRAMS
Understand maternal behaviors and experiences before, during, and shortly after pregnancy
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Public Health Implication Complex factors necessitate a multi-pronged
approach to reduce Kansas’ overall IMR and collaborative efforts of community members, public health, and the medical community.
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Our Vision – Healthy Kansans living in safe and sustainable environments.
References Kansas Blue Ribbon Panel on Infant Mortality.
Infant Mortality in Kansas. April 2011 Bureau of Epidemiology and Public Health
Informatics, Kansas Department of Health and Environment. Infant Mortality Kansas, 2010, Provisional Findings
Handouts from Prematurity Briefing 2011. March of Dimes, 2011 Prematurity Conference. Sue Lyddon Hall, MD, Prediatrix Medical Group, Stormont-Vail HealthCare
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Our Vision – Healthy Kansans living in safe and sustainable environments.
References Handouts from CityMatCH PPOR Workshop
“Perinatal Periods of Risk: Using Data and Community Involvement to Prevent Infant Mortality.” 2009 MCH Epidemiology Pre-Conference Data Skills Trainings.
Perinatal Periods of Risk (PPOR) materials from CityMatCH website. http://www.citymatch.org/ppor_index.php
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References William M. Sappenfield, et al. Perinatal
Periods of Risk: Analytic Preparation and Phase 1 Analytic Methods for Investigating Feto-Infant Mortality. Matern Child Health J (2010) 14:838-850
William M. Sappenfield, et al. Perinatal Periods of Risk: Phase 2 Analytic Methods for Further Investigating Feto-Infant Mortality. Matern Child Health J (2010) 14:851-863
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Our Vision – Healthy Kansans living in safe and sustainable environments.
References SUNNY FUTURES Healthy Start Consortium.
Data Subcommittee. Infant Mortality and Morbidity in Houston, Texas: 1999-2003. A report from the Neighborhood Centers Inc.
Jinwen Cai, Gerald L. Hoff, Rex Archer, Larry D. Jones, Paula S. Livingston, and V. James Guillory. Perinatal Periods of Risk Analysis of Infant Mortality in Jackson County, Missouri. J Public Health Management Practice, 2007, 13(3),270-277
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Our Vision – Healthy Kansans living in safe and sustainable environments.
References W.H.O. Perinatal Periods of Risk Approach: The
U.S. Urban Experience. http://webmedia.unmc.edu/Community/CityMatch/PPOR/howto/PPORGeneralDescription.pdf
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Thank you!
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Our Vision – Healthy Kansans living in safe and sustainable environments.
Jamie S. Kim, MPHMCH Epidemiologist
Bureau of Family Health/Bureau of Epidemiology and Public Health Informatics
Kansas Department of Health and [email protected]
785-296-6467
http://www.kdheks.gov/bfh/index.html
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Our Vision – Healthy Kansans living in safe and sustainable environments.74