The Perinatal Periods of Risk Approach (PPOR) From Data to Action to Improve Women and Infants

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The Perinatal Periods of Risk Approach
(PPOR)From Data to Action to Improve Women and
Infants Health
AMCHP 2005
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CityMatCH Mission
Improving the health and well-being of urban
women, children and families by strengthening
public health organizations and leaders in their
communities.
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PPOR is a six step approach used to address
feto-infant mortality
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6 Basic Steps Perinatal Periods of Risk
Approach

• Step 1 Assure Analytic and Community Readiness 
• Step 2 Conduct Analytic Phases of PPOR
• Step 3 Develop Strategic Actions for Targeted
  Prevention
• Step 4 Strengthen Existing and/or Launch New
  Prevention Initiatives
• Step 5 Monitor and Evaluate Approach
• Step 6 Sustain Stakeholder Investment and
  Political Will

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Step 1 Assure Analytic and Community Readiness

Provides a framework for discussing the problem
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You need to be analytically ready to do the PPOR
approach

• Fetal death files (no gest. age restrictions)
• Linked birthinfant death certificate files
• Unlinked infant death certificate files
• Critical number of Events (n60)
• Key data items missing or poor quality

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You need the Community Onboard and Ready

• Champions, Leadership and Adequately Trained
  Staff that
• Understands the feto-infant mortality problem
• Understands the work plan
• Commits to providing resources for the
  investigation
• Commits to providing resources for community
  collaboration
• Gives priority and champions the initiative

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Community ReadinessFrom Concepts to Tools

• Leadership
• Partnership
• Commitment
• Change

RAISING THE ROOF FOR PPOR What Shape Is
Your Tent?
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Step 2 Conduct Analytic Phases of PPOR

• Includes Fetal and Infant Deaths (gt 24 weeks)
• Focuses on VLBW (lt 1,500 grams)
• Generates a Map for targeting strategic actions
• Examines birthweight and gestational age at the
  same time

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Infant Mortality Rate,Urban County, 1990-2001
White rate for 2001 is provisional
Source DHHS
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PPOR Map fetal infant deaths
Age at Death
Fetal Death
Post- neonatal
Neonatal
Birthweight
500-1499 g
1500 g
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It allows a Community to move toward
ACTION!
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PPOR PHASE 1 Map and Gap

• Phase 1 Identifies the populations with overly
  high numbers and rates of mortality.
• Phase 2 Explains why the excess deaths.

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Map of Fetal-Infant Deaths
Urban County, All Races2000-2002
236 Fetal-Infant Deaths 23,282 live births and
fetal deaths 10.2 overall rate
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PPOR Map of Feto- Infant Mortality Urban County,
By Race, 2000-2002(Nnumber of live births and
fetal deaths)
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Its more than rates and numbers, it allows a
community to focus on the Gaps

• ASK Which women/infants have the "best"
  outcomes?
• ASSUME all infants can have similar best
  outcomes
• CHOOSE a comparison group(s) (reference group)
  who already has achieved best outcomes
• COMPARE fetal-infant mortality rates in your
  target group with those of the comparison
  group(s)
• CALCULATE excess deaths ( target comparison
  groups). This is your communitys Opportunity
  Gap.

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National PPOR Initiative External Reference
Group

• Defined by maternal characteristics
• 20 or more years of age
• 13 or more years of education
• Non-Hispanic white women
• mothers who at the time of the babys birth were
  residents of cities or counties with populations
  over 250,000 and no major reporting problems.

Total Fetal-Infant Mortality Rate 5.9
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Excess Fetal-Infant Mortality Rates Overall
population Urban County, 2000-2002 (rounded for
ease of computation)
Urban County Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
4.2 2.1 1.9 2.0 10.2
External Reference Group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
2.2 1.5 1.1 1.0 5.9
__________________________________________________
__________
Excess Mortality Rate Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
By Subtraction 2.0 0.6 0.8 1.0 4.3
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Fetal-Infant Mortality Rates Racial/Ethnic
subgroups of Urban County, 2000-2002 (rounded
for ease of computation)
Racial Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Overall Feto-Infant Mortality
White, non-Hispanic 3.1 2.0 1.9 1.6 8.6
Black, non-Hispanic 8.8 2.4 2.4 4.0 17.6
Hispanic and other races 4.6 2.0 1.3 2.3 10.2
External Reference Group 2.2 1.5 1.1 1.0 5.9
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Excess Fetal-Infant Mortality RatesBased on
EXTERNAL reference group Racial/Ethnic
subpopulations of Urban County, 2000-2002
(based on rounded rates for ease of computation)
Racial /Ethnic Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Feto-Infant Mortality
White, non-Hispanic 0.9 0.5 0.8 0.6 2.8
Black, non-Hispanic 6.6 0.9 1.3 3.0 11.8
Other Races 2.4 0.5 0.2 1.3 4.4
All 2.0 0.6 0.8 1.0 4.4
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CALCULATING EXCESS NUMBER OF DEATHSFROM
Fetal-Infant Mortality Ratesusing External
Comparison Group Urban County, 2000-2002
Racial /Ethnic Group Excess Mortality Rate Live Births and Fetal deaths Multiply Number of Excess Deaths
White Non-Hispanic 2.8 16,045 2.816,045 1,000 45
Black Non-Hispanic 11.8 3,291 11.83,291 1,000 39
Other Race 4.4 3,947 4.43,947 1,000 17
All 4.4 23,282 4.423,282 1,000 101
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Urban County by Race 2000-2002 Excess Number of
Deathsbased on external comparison group
Racial /Ethnic Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Feto-Infant Mortality
White, non-Hispanic 14 8 13 10 45
Black, non-Hispanic 22 3 4 10 39
Other Races 9 2 1 5 17
All 45 13 18 25 101
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Feto-Infant Mortality Rates in the Internal
Comparison Group(Best Outcomes in Urban
County)Urban County, 2000-2002

• Defined by maternal characteristics
• 20 or more years of age
• 13 or more years of education
• Non-Hispanic White women
• Residents of Urban County at time of babys birth

Total Fetal-Infant Mortality Rate 7.4
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Excess (Internal) Fetal-Infant Mortality Rates
Overall population Urban County, 2000-2002
(note rounding error)
Urban County Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
4.2 2.1 1.9 2.0 10.2
Internal Reference Group Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
2.4 2.2 1.8 1.0 7.4
__________________________________________________
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Excess Mortality Rate Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Fetal-Infant Mortality
By Subtraction 1.8 -0.1 0.1 1.0 2.7
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Fetal-Infant Mortality Rates Urban County, by
Race, 2000-2002
Racial Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Overall Feto-Infant Mortality
White, non-Hispanic 3.1 2.0 1.9 1.6 8.6
Black, non-Hispanic 8.8 2.4 2.4 4.0 17.6
Hispanic and other races 4.6 2.0 1.3 2.3 10.1
Internal Reference Group 2.4 2.2 1.8 1.0 7.4
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Urban County by Race 2000-2002 Excess
Fetal-Infant Mortality Ratesbased on internal
comparison group
Racial /Ethnic Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Feto-Infant Mortality
White, non-Hispanic 0.7 -0.2 0.1 0.6 1.2
Black, non-Hispanic 6.4 0.2 0.6 3.0 10.2
Other Races 2.2 -0.2 -0.5 1.3 2.8
All 1.8 -0.1 0.1 1.0 2.7
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Urban County by Race 2000-2002 Excess Number of
Deathsbased on internal comparison group
Racial /Ethnic Groups Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health Feto-Infant Mortality
White, non-Hispanic 10 -3 1 10 18
Black, non-Hispanic 21 1 2 10 34
Other Races 9 -1 -2 5 11
All 41 -3 2 24 63
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PPOR PHASE 2 A framework for targeting further
investigations and actions

• Phase 1 Identifies the populations with overly
  high numbers and rates of mortality.
• Phase 2 Explains why the excess deaths.

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Where and Why the excess deaths?

• Womens Health vs.
• NICU survival
• Causes of Death

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PPOR Fosters integration with other key efforts

• Fetal Infant Mortality Reviews
• Previous assessments
• Previous perinatal studies or surveillance
• PRAMS or other surveys
• Health system assessments
• Asset mapping
• Previous policy and program evaluations

Paint the faces behind the numbers
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PPOR is about impact and results

• Builds data and epi capacity
• Promotes effective data use
• Strengthens essential partnerships
• Fosters integration with other key efforts
• Encourages evidence-based interventions
• Helps leverage resources
• Enables systems change for perinatal health

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6 Basic Steps Perinatal Periods
of Risk Approach

• Step 1 Assure Analytic and Community Readiness 
• Step 2 Conduct Analytic Phases of PPOR
• Step 3 Develop Strategic Actions for Targeted
  Prevention
• Step 4 Strengthen Existing and/or Launch New
  Prevention Initiatives
• Step 5 Monitor and Evaluate Approach
• Step 6 Sustain Stakeholder Investment and
  Political Will

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Headline News Stronger local/state partnership
builds better data capacity to
address health disparities Ohio Successful
integration of PPOR, FIMR, Healthy Start and
March of Dimes yields better prevention of
feto-infant deaths Florida
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Perinatal Periods of Risk For More Information
www.citymatch.org
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By looking at the numbers in a new way, we can
finally understand fetal/infant mortality and its
common causes. Only through understanding can we
take steps to ensure every child gets a chance at
life.