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The Perinatal Periods of Risk Approach

The Perinatal Periods of Risk Approach. Sanil Thomas MS Biostatistics candidate April 27, 2010. Introduction. Infant mortality rate (IMR) is a critical indicator of nation’s health IMR remains higher in United States than in other industrialized countries

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The Perinatal Periods of Risk Approach

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  1. The Perinatal Periods of Risk Approach Sanil Thomas MS Biostatistics candidate April 27, 2010

  2. Introduction • Infant mortality rate (IMR) is a critical indicator of nation’s health • IMR remains higher in United States than in other industrialized countries • But IMR does not provide sufficient information to understand the factors that contribute to infant mortality

  3. Introduction • Traditional methods don’t include the fetal death counts for the analysis of mortality rates • Fetal-infant mortality is a multi dimensional issue and a detailed analytical approach to fetal- infant mortality is needed to focus community initiatives for improving maternal and infant health.

  4. Objectives • To look at Feto-Infant mortality in a new way • Apply PPOR framework for New York State • To see the distribution of common risk factors by county level

  5. Perinatal Periods of Risk (PPOR) Approach • The Perinatal Periods of Risk Approach was developed by Dr. Brian McCarthy from the W.H.O. Perinatal Collaborative Center at CDC and other W.H.O. colleagues. • Simple method that is based on a strong conceptual prevention • The PPOR Data allow you to look at feto-infant mortality in new ways

  6. PPOR : 6 Basic Steps 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

  7. Analytic Phases of PPOR Phase 1: Identifies populations and periods of risk with the largest excess mortality. Phase 2: Explains why the excess deaths occurred.

  8. PPOR Examines Deaths in TWO dimensions simultaneously: • Age at death • Weight at birth

  9. The First Dimension Of PPOR Analysis: Age at Death 1 Year Conception Birth Fetal 4 wks Infancy 20 wks 28 wks Spontaneous Abortion Early Fetal Late Fetal Neonatal Postneonatal Infant Feto-Infant

  10. Very Low Birthweight (PPOR limit) = less than 1500 grams (3.3 pounds) Low Birthweight = less than 2500 grams (5.5 pounds) Normal Birthweight e.g., a 7.5-pound baby weighs 3,400 grams Second Dimension: Birthweight Birthweight

  11. PPOR “Map” fetal & infant deaths Age at Death Fetal (24+ wks) Neonatal Postneonatal Birthweight 1 2 3 500-1499 g 4 5 6 1500+ g

  12. Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health PPOR “Map” fetal & infant deaths Age at Death Fetal Death Post- neonatal Neonatal Birthweight 500-1499 g 1500+ g

  13. Maternal Health/ Prematurity Preconception Health Health Behaviors Perinatal Care Prenatal Care High Risk Referral Obstetric Care Maternal Care Perinatal Management Neonatal Care Pediatric Surgery Newborn Care Sleep Position Breast Feeding Injury Prevention Infant Health PPOR is about ACTION(each period of risk is associated with a set of possible areas for action)

  14. PPOR: Phase 2 • Poisson log linear modeling • Covariates/Fixed effects • Mother’s race • Mother’s education • Mother’s age • Payor • Random effect - County

  15. PPOR: Phase 2 • Fetal death was not used • 2004-2007 • Predicted death counts were used to obtain smoothed death rates • Modeling done for each county • Relative risk calculated from the beta estimates

  16. Data • New York State Dept. of Health. • Electronic records of births • Linked birth-death cohort • selected fetal deaths • Phase 1 : 2003-2007 • Phase 2 : 2004-2007

  17. Software used • SAS • Excel • ArcGIS

  18. Results

  19. Phase 1 Results

  20. 2.58 Maternal Health/ Prematurity 1.63 Maternal Care 1.12 Newborn Care 1.21 Infant Health Phase 1 Results New York State Death Rates per 1000 live births and fetal deaths

  21. Phase 2 ResultsPoisson Log Linear model estimates

  22. Conclusions • Infant mortality • Higher risk ratio for black mothers relative to white mothers • Higher risk ratio for mothers having education less than high school when compared to mothers having education more than bachelors • Higher risk ratio for mothers of age less than 20 when compared to mothers of age between 20 and 34 • Smoothed rates are higher in St.Lawrence, Erie, Schenectady, Oneida, Broome, Cortland etc • Risk ratio for black mothers relative to white mothers are higher in the counties Orleans, Oswego, Chenango and Cortland

  23. Limitation • Missing data • 12428 records out of 497787 records • 246 deaths • Inconsistent fetal data

  24. Future study • Detailed Phase 2 analysis including fetal deaths • MHP and IH categories – Protocol for Phase 2 studies • Cluster Analysis • Spatial smoothing analysis

  25. Reference • http://www.citymatch.org/ppor_index.php • Cai, J, Hoff GL, Dew PC et al. Perinatal periods of risk: analysis of fetalinfant mortality rates in Kansas City, Missouri. Matern Child Health J.2005;9:199-205 • Cai J, Hoff GL, Archer R et al. Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri. J Public Health Manage Pract. 2007;13:270-277.

  26. Acknowledgments • Dr. Glen D. Johnson, PhD, MS, MA • Dr. Marilyn A. Kacica, M.D.,M.P.H

  27. Questions???

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