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Collaborating Center in Reproductive Health

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  1. Collaborating Center in Reproductive Health PRETERM INFANT VS PRETERM BIRTH It is time to enlarge the Image Woodruff Health Sciences Center Emory University National Centers on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention (CDC) Georgia Department of Public Health Alfred W. Brann, Jr., MD, Director Woodruff Health Sciences Center Emory University Brian McCarthy, MD, Principal Investigator Woodruff Health Sciences Center Emory University

  2. AFRO Kenya Madagascar Tanzania Uganda EMRO Afghanistan Egypt Jordan Sudan ERO Armenia Kazakhstan Moldova Republic of Georgia Russia Bosnia Czech Republic Poland Romania Yugoslavia Cypress Greece Turkey PAHO Guatemala Honduras Mexico Cuba Grenada Argentina Columbia Ecuador United States - Georgia - Mississippi SEARO India Indonesia South Korea WPRO China Philippines UNRWA For Palestinian Refugees Gaza West Bank Global Collaborating CenterCountries Receiving ISRH Support

  3. Objectives • Objective 1 – List the largest contributor to infant mortality in Georgia and throughout the world. • Objective 2 – Describe a new indicator for the status of health of a community. • Objective 3 – What percent of Georgia’s feto-infant mortality is related to the health status of women during their reproductive years or during pregnancy? • Objective 4 – Describe an approach to a quantified recurrent public health risk.

  4. Infant Mortality and Per Capita GNP

  5. Georgia’s Six Perinatal Regions Hospital Perinatal Center

  6. Number of Feto-Infant Deaths Data Rich, Information Poor Total Deaths 3936

  7. Georgia Perinatal Surveillance • Total cohort accountability begins with the reporting of all products of conception.

  8. Georgia Perinatal Surveillance • Feto-infant mortality (FIMR) is used as the measure of mortality rather than infant mortality.

  9. Georgia Perinatal Surveillance • Five hundred grams (500gm) or twenty week gestation is used as the starting point for counting feto-infant deaths.

  10. Georgia Perinatal Surveillance • Birth weight and age of death are used to classify each death two-dimensionally in order to identify pockets of excess feto-infant deaths, along with the most effective strategies for reducing these excess deaths.

  11. Why Two-Dimensional Perinatal Surveillance DATA……. INFORMATION…… INTERVENTION…...

  12. Number of Feto-Infant Deaths Data Rich, Information Poor Age at Death Total Deaths 3936 Birth Weight

  13. Birth weight and Age at Death Late Fetal Death (28+ wks) Early Neonatal Death (<7 days) Late Neonatal Death (7-27days) Post Neonatal Death (28+ days) 1 2 3 4 VVLBW (500 - 999gms) 5 6 7 8 VLBW (999-1499 gms) 9 10 11 12 IBW (1499-2499 gms) 13 14 15 16 NBW (2500+ gms)

  14. Interventions for Reducing Mortality Women’s and Maternal Health Maternal and Fetal Care Neonatal Care Infant Care

  15. Birth weight and Age at Death Late Fetal Death (28+ wks) Early Neonatal Death (<7 days) Late Neonatal Death (7-27days) Post Neonatal Death (28+ days) W & M Health 1 W & M Health 2 W & M Health 3 W & M Health 4 VVLBW (0-999gms) W & M Health 5 W & M Health 6 W & M Health 7 W & M Health 8 VLBW (999-1499 gms) M & F Care 9 Newborn Care 10 Newborn Care 11 Infant Care 12 IBW (1499-2499 gms) M & F Care 13 Newborn Care 14 Infant Care 15 Infant Care 16 NBW (2500+ gms)

  16. Summary of Perinatal Health Care Interventions • Reproductive Awareness • Preconception Care • Child Spacing • Nutrition • Micronutrients • STDs • Substance Abuse • Domestic Violence Women’s & Maternal Health Interventions: Infant Care Interventions: • Pregnancy Identification • Prenatal Surveillance & Care • Anticipatory Guidance • Intrapartum Monitoring • “ART” for complications • Surgical Services • High Risk Maternal • Follow-up Maternal & Fetal Care Interventions: Newborn Care Interventions: • Parenting Skill Education • Child Health Supervision • Breastfeeding/nutrition • Immunization • Growth/Development Monitoring • Anticipatory Guidance • A.R.I. • D.D. • Injury Control • “ART” for the At-Risk-Infant • Community Services • Clean Delivery • Resuscitation • Thermal Control • Breast Feeding • “ART” for the At-Risk-Infant • “Baby Friendly” Concept • Parenting Skill Education

  17. Planning for Change • 1. Measure and Compare • 2. Standard against which to compare

  18. The “Opportunity Gap”- The potential for reduction in excessive mortality based on a comparison between rates already achieved by one sub-population in a defined geographical area with those experienced by the remaining population.

  19. Georgia Perinatal Surveillance • Sociodemographic (SD) groups are used to identify disparities as follows: Group 1: ≥ 20 years of age, ≥13 years of education Group 2: ≥ 20 years of age, <13 years of education Group 3: < 20 years of age, <13 years of education

  20. Analysis of Sociodemographic Risks Deaths per 1,000 live births Death Rate Excess Rate Education Sub-group Age White Group 1 >20 >13 years 5.7 .7 White Group 2 >20 <13 years 9.0 4.1 White Group 3 ≤19 <13 years 13.3 8.3 Black Group 1 >20 >13 years 14.0 9.0 Black Group 2 >20 <13 years 19.0 14.0 Black Group 3 ≤19 <13 years 19.6 14.6

  21. Total Feto-Infant Deaths 3936 Excessive Feto-Infant Deaths 2314

  22. W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health W & M Health M & F Care Newborn Care Newborn Care Infant Care M & F Care Newborn Care Infant Care Infant Care Calculating “The Opportunity Gap” = Excess Mortality Excess Mortality = BWPR - BWPR TARGET POPULATION STANDARD Birth weight Proportionate Rate (BWPR) Number of deaths in a given weight group Total Number of births in all weight groups BWPR = x 1000 OR Maternal Health # of Deaths (# in cells) x 1000 (# in entire table)

  23. Feto-Infant Mortality Rate White Group I, Atlanta Region 2.1 0.8 0.9 1.2 Total = 5.0

  24. Analysis of Sociodemographic Risks Deaths per 1,000 live births Death Rate Excess Rate Education Sub-group Age White Group 1 >20 >13 years 5.7 .7 White Group 2 >20 <13 years 9.0 4.1 White Group 3 ≤19 <13 years 13.3 8.3 Black Group 1 >20 >13 years 14.0 9.0 Black Group 2 >20 <13 years 19.0 14.0 Black Group 3 ≤19 <13 years 19.6 14.6

  25. Excessive Mortality Rate by Sociodemographic Group Georgia, 1991-1993 0.3 3.6 1.6 Total=0.7 Total=4.0 Total=8.3 0.1 0.5 0.9 0.1 0.4 0.4 0.2 1.5 3.4 White Group 1 White Group 2 White Group 3 7.2 8.7 8.3 Total=9.0 Total=14.0 Total=14.5 0.5 1.2 1.1 0.5 1.7 1.4 0.8 2.8 3.3 Black Group 1 Black Group 2 Black Group 3

  26. Georgia’s Six Perinatal Regions Hospital Perinatal Center

  27. Excessive Mortality Rate by Region Georgia, 1991-1993 3.2 7.4 4.2 Total=5.6 Total=8.2 Total=11.4 0.3 1.2 1.0 0.7 1.0 0.5 1.4 1.8 2.5 Atlanta Augusta Macon 4.3 4.1 4.6 Total=7.3 Total=8.3 Total=8.6 0.9 0.8 1.1 0.6 0.3 1.0 1.5 2.6 2.4 Columbus Savannah Albany

  28. What do Current Data Show? • Excess fetal and infant death rates occur in all six perinatal regions, with the highest death rate in the Macon region followed by Albany, Savannah, Augusta, Columbus and Atlanta. • The “standard woman” has excess fetal and infant mortality when compared to the same woman who lives in Connecticut.

  29. Georgia’s Six Perinatal Regions Hospital Perinatal Center

  30. Areas of Concentration to Reduce Infant Mortality Area Potential for Improvement LOW HIGH WOMEN’S & MATERNAL HEALTH 60% Maternal Fetal Care 10% Neonatal Intensive Care 9% POSTNATAL CARE 21%

  31. How was this accomplished • Six Regional PERINATAL Centers • Maternal-Fetal Medicine with increasing frequency of maternal transfers • Optimum intrapartum management of preterm labor. • Neonatal-Perinatal Medicine attending high risk deliveries • Six Neonatal Transport Services. • Q.I. Collaboratives to reduce elective deliveries before 39 weeks gestation

  32. From 1981-1983 thru 20021-2003: FIMR (combined) declined : 24.6 to 10.5 per 1000 births Excess FIMR: Blacks 11.8 WH 56% Whites 3.6 WH 34% Analysis of Feto-Infant Mortality Using the BABIES - Framework: Georgia 1981-83 through 2001-03 Anne L Dunlop1,2 Brian J McCarthy1,3 Gordon R Freymann1,4 Colin K Smith5 George W Bugg6 Alfred W Brann6 Int J Health Res, September 2010; 3(3): 153

  33. From 1994-1996 thru 2003-2005 : • Georgia’s VLBW rate remained unchanged; • Significant decrease in rates of twins and 1st VLBW; • Significant increase in recurrent VLBW - 4.8-16% of all VLBW; • For 1st and recurrent VLBW: the black-white disparity widened Very low birth weight births in Georgia, 1994–2005: trends and racial disparities Anne L. Dunlop Hamisu M. Salihu Gordon R. Freymann Colin K. Smith Alfred W. Brann Maternal Child Health Journal: (2011)15:890-898.

  34. Areas of Concentration to Reduce Infant Mortality Area Potential for Improvement LOW HIGH WOMEN’S & MATERNAL HEALTH 60% Maternal Fetal Care 10% Neonatal Intensive Care 9% POSTNATAL CARE 21%

  35. Summary of Perinatal Health Care Interventions • Reproductive Awareness • Preconception Care • Child Spacing • Nutrition • Micronutrients • STDs • Substance Abuse • Domestic Violence Women’s & Maternal Health Interventions: Infant Care Interventions: • Pregnancy Identification • Prenatal Surveillance & Care • Anticipatory Guidance • Intrapartum Monitoring • “ART” for complications • Surgical Services • High Risk Maternal • Follow-up Maternal & Fetal Care Interventions: Newborn Care Interventions: • Parenting Skill Education • Child Health Supervision • Breastfeeding/nutrition • Immunization • Growth/Development Monitoring • Anticipatory Guidance • A.R.I. • D.D. • Injury Control • “ART” for the At-Risk-Infant • Community Services • Clean Delivery • Resuscitation • Thermal Control • Breast Feeding • “ART” for the At-Risk-Infant • “Baby Friendly” Concept • Parenting Skill Education

  36. The Interpregnancy Care Program Interpregnancy Primary Care and Social Support for African-American Women at risk for recurrent very-low-birth weight delivery: A Pilot Evaluation Accepted for Publication - July, 2007 in Maternal and Child Health Journal

  37. Background • Georgia’s infant mortality declined by 50% from 1975 to 1996, primarily due to improved survival of low birth weight (LBW; < 2500 gm) infants; • The largest contributor to Georgia’s infant mortality rate is the birth of LBW and VLBW (< 1500 gm) infants: % of Births% of Infant Deaths < 2500 g 11% 70% < 1500 g 2% (~2500 births) 50%

  38. Number of Live Births less than 1500 gm. by Census Tract 1994-1998 Georgia and Public Health Districts

  39. Background • African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality (1). • Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.

  40. Background • No obstetrical or prenatal assessment or intervention has been successful in predicting or preventing a woman’s first preterm/LBW delivery (5); • The single best predictor of a preterm/VLBW delivery: • a) a recurrent preterm/VLBW birth (6) white 8% black 13% • b) recurrent births < 35 weeks (7): 1 - 16%, 2 - 41%, 3 - 67%

  41. Central Nervous System Morbidity • There has been no change in the prevalence of cerebral palsy in children whose birth weight was less than 1500 gm. • Infants less than 1000 gm. (from the Neonatal Research Network- NICHD) survive with significant handicapping conditions, including: • Cerebral Palsy 17% • Mental Retardation 50% • Blindness / Hearing Loss 10% • Learning Disabilities 50% • The average cost of the INITIAL HOSPITALIZATION of a VLBW is $49,000. • The average cost for supporting an infant who survives with CEREBRAL PALSY is $500,000 over their lifetime. 1 2 3 4

  42. Background • Experience and a growing body of evidence link the delivery of a VLBW infant to aspects of a woman's health status, including (1): • Unrecognized and poorly-controlled medical problems; • Reproductive tract infections (including BV and STI’s); • Substance abuse disorders; • Periodontal disease; • Psychosocial factors including psychological stress and domestic violence.

  43. Background • Short interpregnancy intervals increase the risk of preterm/LBW delivery (2, 3), • the critical interval varies by race (4): • 9 months for African-American women; • 3 months for white women.

  44. Background • Pregnancy is too late to initiate prenatal care if the mother has had a previous VLBW infant or any other adverse pregnancy outcome from whatever cause.

  45. Interconception Care • Primary health care from delivery of one child until conception of the next.

  46. Interconception Care • Reproductive Health Plan • Child Spacing: 18-24 months • Treatment of Chronic Medical Conditions • Nutritional Assessment and STDs • Domestic Violence / Postp. Depression • Modify Adverse Lifestyle Practices • Health Seeking Behaviors • RESOURCE MOTHER