lane county public health services infant mortality in lane county using the perinatal periods of...

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


Lane County, OregonBackground• Rural & urban population of 336,085 (4th 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


Lane County, OregonPopulation• 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


Lane County, Oregon


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


“Infant mortality is the most sensitive index we possess of social justice”

Julia Lathrop, Children’s Bureau, 1913


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.


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


PPOR Steps1. 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


Stages of PPOR


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


Map Fetal & Infant Deaths

Lane County Vital Stats Data1. Fetal death files2. Linked birth—infant death certificate files

*Based on maternal residence at

time of fetal death or live birth


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


1999-2003 PPOR Map Lane County Overall Fetal-

Infant MortalityFetal Deaths Infant Deaths

Birth Weight < 24 weeks > 24 weeks Neonatal Post-Neonatal

< 500 g 13 5 25 0

500-1,499 g 3 23 26 7

1,500-2,499 g 0 17 10 6

> 2,500 g 1 26 21 38


1999-2003 PPOR Map Lane County Overall Fetal-Infant

MortalityReference Group

Fetal Deaths Infant Deaths

Birth Weight < 24 weeks > 24 weeks Neonatal Post-Neonatal

< 500 g 13 5 25 0

500-1,499 g 3 23 + 26 + 7 = 56

1,500-2,499 g 0 17 + 26 = 43 10 + 21 = 31 6 + 38 = 44

> 2,500 g 1


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)


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)

44/2.4Infant Health

(live births)


Comparison Fetal-Infant Mortality Rates

7.4

6.4

6.7

7.4

7.9

9.3

9.5

0 2 4 6 8 10

Portland Metro

Washington Co.

Clackamas Co.

Multnomah Co.

OR

USA

Lane Co.


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


1999 – 2003 Lane County Fetal-Infant Mortality Rate

by Group

9.5

8.4

10.0

10.6

8.4

9.3

9.3

9.7

0 2 4 6 8 10 12

total county

reference group*

non-reference group

< 13 years education

> 13 years education

urban

> age 20

1st trimester care

Deaths per 1,000 births


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


ExcessExcess Fetal-Infant Mortality Rates

Lane County Maternal Health/

Prematurity

Maternal Care

Newborn Care

Infant

Health

Fetal-Infant Mortality

1999-2003 3.1 2.3 1.7 2.4 9.5

US Reference

Group

Maternal Health/

Prematurity

Maternal Care

Newborn Care

Infant

Health


2.2 1.5 1.1 1.0 5.8

Excess Mortality

Rate

Maternal Health/

Prematurity

Maternal Care

Newborn Care

Infant

Health


By Subtraction 0.9 0.8 0.6 1.4 3.7

____________________________________________________________


EXCESS NUMBER OF DEATHSLane County 1999-2003

Excess Mortality Rate

Live Births

and Fetal deaths

Multiply Number

of Excess Deaths

Lane County9.5 - 5.8

= 3.718,334

3.7*18,3341,000

= 68


Lane County 1999-2003 Excess Fetal-Infant Deaths

Based on US Reference Group

Maternal Health/

Prematurity

Maternal Care

Newborn Care

Infant Health

OverallFetal-Infant

Excess Deaths

Lane County 17 15 11 26 68


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


Analyze AdditionalPopulation-Based Data

• PRAMS (Pregnancy Risk Assessment Monitoring System)

• Census data

• Alcohol and Drug data

• Mental Health data

• Health care availability studies


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


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


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


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


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%)


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


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

Jurisdiction

Ore

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Lan

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ty

Cob

urg

Cot

tage

Gro

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Cre

swel

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Eu

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e

Flo

renc

e

Jun

ctio

n C

ity

Oak

rid

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Spr

ingf

ield

Ven

eta

Wes

tfir

% in Poverty 7.9 9.0 7.7 15.6 15.3 8.7 10.0 6.3 12.2 14.8 11.4 8.9


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


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


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


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


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


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


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


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.


County Contacts• Dr. Sarah Hendrickson, Public Health Officer,

PPOR Team Member, [email protected], 541.682.3956

• Karen Gillette, Public Health Manager, PPOR Team Member, [email protected], 541.682.3950

• Pamela Stuver, Public Health Nursing Supervisor & PPOR Team Leader, [email protected], 541.682.4670

• Douglas Daniell, Management Analyst and PPOR Data Team Member, [email protected], 541.682.2047

• C.A. Baskerville, Sr. Program Services Coordinator, PPOR Team Member, [email protected], 541.682.3031

• Sandy Moses, Health Educator, PPOR Team Member, [email protected], 541.682.3652

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