# Presentation: 608657

## Magda Peck ScDProfessor and Associate Chair for   Community Health, Department of Pediatrics University of Nebraska Medical CenterDirector, UNMC/UNOmaha MPH Program CEO/Senior Advisor, CityMatCH mpeck@unmc.edu      402.561.7500

## What we all want...

**What we ****all**** want...**

**AMCHP**** 2004 Closing Plenary**** **

**Preventing Prematurity:*****                                    ******a Call to Action***

## Rules of 3 

***Rules of****** ******3***** **

## 3’s of a Kind

**3’s of a Kind**

- Strikes**..**
- ABCs
- Little pigs, blind mice, wise men, bears, wishes...
- Little words...
- Trilogies
- ........

## Shaping Effective Programs and Policies

**Shaping Effective Programs and Policies**

**1. KNOWLEDGE        ****	****BASE**

**3. POLITICAL ****	****WILL**

**2. SOCIAL          STRATEGY**

- From: Richmond and Kotelchuck

## Supplemental Analyses of Recent Trends in Infant Mortality, Kenneth D. Kochanek, M.A., and Joyce A. Martin, M.P.H., February 11, 2004, NCHS/CDC

- Increase of IMR in 2002 to 7.0 (first time since 1958) in neonatal period, most in moderately preterm and LBW (1500-2499g, 32-36 weeks gestation)
- Moderately preterm increased from 8.7% in 1990 to 10.1% in 2002; Very preterm LBW (<32 weeks) increased from 1.92% to 1.96% in same time period
- 1% of moderately preterm born in 2002 did not survive vs. 18% of infants born very preterm

## Racial Disparity of Preterm Births, 2002

- Center for Health Statistics

## “Tonight, we’re going to let the statistics speak for themselves.”

*“**Tonight, we’re going to let the statistics speak for themselves.”*

## Complex Concepts – Mixed Messages

- Which outcome? Mortality vs. Morbidity
- Whose outcome? Mother vs. Infant
- Severity of Outcome: “Moderately” or “Very”
- Timing of Outcome: pre- inter-conceptional, fetal, neonatal, postneonatal

## NCHS Definition of terms (2/11/04)

**Infant mortality rate** – Deaths of infants aged under 1 year per 1,000 or 100,000 live births. The infant mortality rate is the sum of the neonatal and postneonatal mortality rates.
**Neonatal mortality rate** – Deaths of infants aged 0-27 days per 1,000 live births. The neonatal mortality rate is the sum of the early neonatal and late neonatal mortality rates.
**Early neonatal mortality rate** – Deaths of infants aged 0-6 days per 1,000 live births.
**Late neonatal mortality rate** – Deaths of infants aged 7-27 days per 1,000 live births.
**Postneonatal mortality rate** – Deaths to infants aged 28 days-1 year per 1,000 live births.
**Late fetal mortality rate** – Fetal deaths of 28 or more weeks of gestation per 1,000 live births plus fetal deaths.
**Perinatal mortality rate** – Late fetal deaths plus early neonatal deaths per 1,000 live births plus fetal deaths.
**Low birthweight rate** – Births with weight at delivery of less than 2,500 grams per 100 live births.  The low birthweight rate is the sum of the moderately low and very low birthweight rates.
**Moderately low birthweight rate** – Births with weight at delivery of 1,500-2,499 grams per 100 live births.
**Very low birthweight rate** – Births with weight at delivery of less than 1,500 grams per 100 live births.
**Term** – Births at 37-41 weeks of gestation.
**Preterm rate** – Births at less than 37 completed weeks of gestation per 100 live births. The preterm rate is the sum of the moderately and very preterm rates.
**Moderately preterm rate** – Births at 32-36 weeks of gestation per 100 live births.
**Very preterm rate** – Births at less than 32 weeks of gestation per 100 live births.

## PPOR may add clarity...  

**Phase I maps fetal-infant mortality into four ****“Periods of Risk”** —  Maternal Health/ Prematurity, Maternal Care, Newborn Care & Infant Health
- Identifies populations and periods of risk with the **most deaths, highest rates.**
- Uses comparison (reference) group(s) to **estimate *****“excess” *****fetal-infant deaths**

_**Perinatal Periods of Risk**_

**Notes:**
Before conducting any of the analytic phases, it is essential to evaluate the quality of the linked live birth and infant death and fetal death data.  The quality of reporting varies substantially across this country.  

For the first phase, you plug your community’s numbers into corresponding cells of the PPOR matrix and compute the rates – for both the community, target populations and the reference group. This phases determines excess death, the type of excess death, and excess death among which population groups.  This gives you some idea generally about where our future efforts should be applied. It is very important not to stop at phase 1 and further examine the reasons for excess death.

During phase 2 we examine the identified gaps from the phase 1 analysis. This phase examines the reasons for the excess death and potential avenues for prevention.  This examination could include further epidemiologic studies, death reviews and community assessment.

## Uses linked infant birth – death file

- Includes fetal deaths

- Building the **PPOR** “Map”

-  Examines birth weight and time of death *at the same time*

-  Looks specifically at very low birth weight (<1500 g) births

- Measures Feto-infant *mortality*

## PPOR Map of Fetal-Infant Mortality

**PPOR** Map of Fetal-Infant Mortality

**500-1499 g**

**1500+ g**

**Fetal   Death**

**Neonatal**

**Post- neonatal**

**Maternal Health/ Prematurity**

**Maternal  Care**

**Newborn  Care**

**Infant Health**

- Source: www.citymatch.org/ppor

## Map of Fetal-Infant Mortality Rates

**4.1 **(124)

- (69)
**2.3**

- (50)
**1.6**

- (58)
**1.9**

- Overall Fetal-Infant Mortality    Rate
- =** ****9.9**
**(301/30,409 x 1000)**

- Douglas County, NE, All Races, 1999-2002

**500-1499 g**

**1500+ g**

## PPOR Map of Fetal-Infant Mortality       Douglas County, Nebraska. All Races, 1991-2002

**4.1**

**2.4**

**1.6**

**3.7**

**Fetal-Infant Rate=****11.7**

**4.1**

**1.7**

**1.9**

**4.1**

**1.6**

**1.9**

**2.5**

**2.3**

**Fetal-Infant Rate=****10.2**

**Fetal-Infant Rate=**** 9.9**

**1991-1994**

**1995-1998**

**1999-2002**

## Estimated Excess Fetal-Infant Deaths Douglas County, NE, All Races, 1999-2002                               compared to the NATIONAL reference group 

**Maternal Health/ Prematurity**
**Maternal Care**
**Newborn Care**
**Infant Health**

**Total**

**Whites**

**Blacks**

**122**** ****excess** deaths

**53**** ****excess** White deaths

**49** **excess**** ** Black deaths

- (301 Total Fetal-Infant Deaths)

## U.S. PPOR Rates, Overall and by Period of Risk, 1989-1991, 1995-1998 and 1998-2000

**12.5**

**9.9**

**9.3**

**4.8**

**3.9**

**3.7**

- Source: National PPOR Data Tables               www.citymatch.org/ppor

## PPOR Rates in U.S., by Race/Ethnicity and by Period of Risk Components, for Resident Mothers 20+ years age, 13+ years of education in US, 1998-2000

**2.2**

**6.4**

**2.8**

**6.6**

**5.9**

**12.3**

- Source: National PPOR Data Tables               www.citymatch.org/ppor

## From Data to Potential Actions

**Maternal Health/ Prematurity**

**Maternal  Care**

**Newborn  Care**

**Infant Health**

- Preconception Health  Health Behaviors      Perinatal Care

- Prenatal Care  High Risk Referral Obstetric Care

- Perinatal Management   Neonatal Care  Pediatric Surgery

- Sleep Position   Breast Feeding   Injury Prevention

## Data Into Action for Effective Programs and Policies

**Data Into Action for Effective Programs and Policies**

**KNOWLEDGE BASE**

**POLITICAL WILL**

**2.  SOCIAL STRATEGY**

- From: Richmond and Kotelchuck

## Slide 23

## Alabama’s Partnership in Action

- 1. WIC – Farmers Market Nutrition
-     Program
- 2. March of Dimes Prematurity Campaign      Launch
- 3. Perinatal Calendar
- 4. Smoking Cessation

## Jacksonville’s Magnolia Project

**Reducing Infant Mortality:**
**An Interconceptional Care Strategy**
- Thanks to: Carol Brady, MA, Executive Director
- Northeast Florida Healthy Start Coalition

## Impacting Women’s Health Before Pregnancy

**Nearly half** of all pregnancies are unplanned (mistimed or unwanted)
_**All**_** women age 15 - 44** should be considered pre-/interconceptional!
- Identify **opportunities** for addressing         pre and interconceptional issues (family planning, pediatrics, case management).

- Thanks to: Carol Brady, MA, Executive Director
- Northeast Florida Healthy Start Coalition

## Why focus on well-women?

**PPOR**
- Greatest racial disparities occurred in **Maternal Health/Prematurity** and **Maternal Care**
- Disparities **disappeared** in the other categories
- Kitagawa: too many **black babies born too soon** and too small

**FIMR**
- Infections and STDs
- Poor nutrition
- Late/inadequate prenatal care
- Previous poor outcome

- Family planning problems
- General state of        mother’s health
- No Healthy Start      screening

## From Data to Potential Actions

**Maternal Health/ Prematurity**

**Maternal  Care**

**Newborn  Care**

**Infant Health**

**Preconception Health**  Health Behaviors      Perinatal Care

- Prenatal Care  High Risk Referral Obstetric Care

- Perinatal Management   Neonatal Care  Pediatric Surgery

- Sleep Position   Breast Feeding   Injury Prevention

## Infant Mortality Rates, Duval County, 1997-2002 (Preliminary)

## Data Into Action for Effective Programs and Policies

**Data Into Action for Effective Programs and Policies**

**KNOWLEDGE          BASE**

**3. POLITICAL WILL**

**SOCIAL STRATEGY**

- From: Richmond and Kotelchuck

## March of Dimes Prematurity Campaign Goals

- Increase public awareness of the problems of prematurity to at least 60%
- Decrease the rate of preterm birth in the US by at least 15%

## Slide 32

## "Cowardice asks the question, is it safe?  Expediency asks the question, is it politic?       Vanity asks the question, is it popular?  But conscience asks the question, is it right?  

**And there comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because his conscience tells him that it is right...."**
**	****	****-Martin Luther King, Jr. **

## Slide 34

## “There is no use trying,” said Alice; “one can’t believe in impossible things.”

**“****I dare say you haven’t had much practice,” said the Queen.      ‘When I was your age, I always did it for a half an hour a day.      Why, sometimes I’ve believed as many as six impossible things before breakfast.”**
- -Lewis Carroll

**AMCHP**** 2004 Closing Plenary**** **

**Preventing Prematurity:****                                    **_**Our**_** Public Health Priority.**