Post on 28-Jul-2020
Indianapolis’ PPOR Story
Enhancing Infant Survival and Maternal and Family Well-Being Through Partnerships and Collaboration
National Healthy Start Association ♦ 12th Annual Spring Conference
Yvonne Beasley, MN, RN
Healthy Babies/Healthy Moms Coalition 1986
• Dialogue regarding poor birth outcomes in Marion County
National Healthy Start Association ♦ 12th Annual Spring Conference
Marion County IMR 1984-1989
4.54.512.115.2--Other
------Hispanic
21.620.824.218.32425.2Black non-Hispanic
8.99.19.37.011.39.9White non-Hispanic
12.112.213.314.214.413.7Overall
198919881987198619851984
Source: Epidemiology
Department, DR1255
*Some rates unavailable
National Healthy Start Association ♦ 12th Annual Spring Conference National Healthy Start Association ♦ 12th Annual Spring Conference
National Healthy Start Association ♦ 12th Annual Spring Conference
Community Based Approach 1989
• Business, political, and community leaders unite to form a public and private partnership, develop a work plan, and mobilize the community’s resources to reduce the infant mortality rate.
National Healthy Start Association ♦ 12th Annual Spring Conference
National Healthy Start Association ♦ 12th Annual Spring Conference
Indianapolis Campaign for Healthy Babies
1989: Indianapolis Campaign for Healthy Babies (ICHB) formed, and was active through 1992
• New Health Centers
• Expansion of existing health centers
• Care Coordination Services initiated for pregnant women
• WIC services expanded
National Healthy Start Association ♦ 12th Annual Spring Conference
Sustaining IHBC Efforts
• 1993 Health and Hospital Corporation of Marion County assumed responsibility for the Campaign under “Healthy Babies Initiatives”
• New services initiated: Prenatal Outreach, Prenatal Substance Abuse, Male Responsibility, and community awareness
National Healthy Start Association ♦ 12th Annual Spring Conference
Incentive Program for Pregnant Women
1995
• MCHD initiated Bed, Britches, Etcetera B.A.B.E. in partnership with St. Vincent Hospital, and St. Francis Hospital
• Women were given coupons for entering prenatal care and attending follow-up prenatal visits, WIC appointments, well child visits,etc.
National Healthy Start Association ♦ 12th Annual Spring Conference
Fetal and Infant Mortality Review
•1995 – Marion County Health Department establishes the Indianapolis Healthy Babies Consortium to begin efforts to administer a Fetal and Infant Mortality Review (FIMR) Project
•1999 – Healthy Babies of the New Millennium, the final volume in a series of reports prepared by the FIMR project
National Healthy Start Association ♦ 12th Annual Spring Conference National Healthy Start Association ♦ 12th Annual Spring Conference
MCHD Infrastructure
• Indianapolis Healthy Start 1997 – present
• 1999 Executive Report Healthy Babies in the New Millennium
• 2002 Indianapolis Healthy Babies Consortium reconvenes
• 2003 Epidemiology Department established
• 2003-Consumer Connection Consortium established
• 2004 FIMR Program reestablished
National Healthy Start Association ♦ 12th Annual Spring Conference
Rebuilding Community Infrastructure
2004
• PPOR Team identified-Technical Assistance provided through CityMatCH
• FIMR – PPOR Workshop
• FIMR Chart Review Team Launched
• Healthy Start Community Assessment of MCH high risk population and identification of catchment area.
National Healthy Start Association ♦ 12th Annual Spring Conference
National Healthy Start Association ♦ 12th Annual Spring Conference National Healthy Start Association ♦ 12th Annual Spring Conference
PPOR Team Members
•Originally started with only three members: currently 13 members:
•Marion County Public Health Department – 7 members•Populations Health Bureau Director, Maternal & Child Health Director, Healthy Start, FIMR, and Epidemiology
•Indiana State Department of Health – 2 members•MCH Nurse Consultant, Epidemiology
•Indiana Perinatal Network – 2 Members•Indiana Access, SIDS Alliance
•Wishard Health Services – 1 member•OB / GYN Primary Care Clinic
•Healthy Families – 1 member
National Healthy Start Association ♦ 12th Annual Spring Conference
PPOR Team Activities•Attended three PPOR “How to Do” Workshops
•Phoenix, AZ – December 2003•Washington, DC – March 2004•Portland, OR – September 2004
•Participate in monthly PPOR seminar calls
•Presented to Indianapolis Healthy Babies Consortium – July 2004
•Presented preliminary PPOR data•Recruited team members•Collected community surveys and community readiness tents
•Held three team meetings•Met bi-monthly – November, February and April•Review data until July 2005•Develop logic model and interventions by December 2005
Indianapolis PPOR Map
PPOR Excess Deaths *
Compared to Internal and External Reference Groups**1999-2003 Birth Cohort Data***
Marion County, IN
*Excluded are infants who weighed <500 grams at birth and fetal deaths that occurred before the 24th week or were <500 grams.
**Internal Reference Group: White, non-Hispanic women, age >=20 yrs., married, non-smoking, who have an education >=13 years, received
prenatal care in the 1st trimester and reside in Marion County, IN.
External Reference Group: White non-Hispanic women, age >=20 yrs., who have an education >=13 years.
***Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, IN
Maternal Overall
All Marion County Health Maternal Newborn Infant Excess
Prematurity Care Care Health Deaths
Marion County (273 deaths) (148 deaths) (100 deaths) (163 deaths) (684 deaths)
Excess compared to Internal Group 137 77 19 97 331
Excess compared to External Group 117 40 20 92 268
National Healthy Start Association ♦ 12th Annual Spring Conference
Infant Health
•1999, 2000, 2003 Indiana was #1 in the Nation for:
•Injury-related fatalities for infants
•Unintentional injury-related fatalities for infants
•Leading cause of injury related fatalities was suffocation
•Leading cause of intentional injury-related fatalities was physical abuse/beatings
National Healthy Start Association ♦ 12th Annual Spring Conference
Study Population
• All births and fetal deaths that occurred in Marion County to Marion County resident mothers from 2001-2005, and all deaths that occurred in Marion County among those infants before the infants turned 1 year of age.
• Infants <500gms or <24wks were included in a separate category called PPOR Ineligible.
• Reference population was infants born to non-Hispanic white mothers over 20 years of age with more than a high school education (12+ years)
National Healthy Start Association ♦ 12th Annual Spring Conference
Ineligible group
418 Deaths
Excess Deaths=174 (97, 250)
Deaths per 1000 pregnancies=5.92 (5.37, 6.52)
Excess Death Rate=2.46
Maternal Health Prematurity
270 Deaths
Excess Deaths=125 (65, 185)
Deaths per 1000 pregnancies=3.82 (3.39, 4.31)
Excess Death Rate=1.77
Maternal Care Newborn Care Infant Health
146 Deaths 97 Deaths 143 Deaths
Excess Deaths=38 (-12, 89) Excess Deaths=27 (-15, 68) Excess Deaths=97 (59, 136)
Deaths per 1000 pregnancies=2.07 (1.75, 2.44) Deaths per 1000 pregnancies=1.37 (1.12, 1.68) Deaths per 1000 pregnancies=2.02 (1.71, 2.39)
Excess Death Rate=0.55 Excess Death Rate=0.37 Excess Death Rate=1.38
PPOR Mapping ResultsReference Group
17,075 Pregnancies and 148 Deaths
Deaths per 1000 pregnancies = 8.67
Overall
70,662 Pregnancies and 1,074 Deaths
Excess Deaths=462 (342, 581)
Deaths per 1000 pregnancies=15.20 (14.32, 16.14)
Excess Death Rate=6.53
Risk Factors for VLBW
• In a multivariate analysis, the following were statistically significantly associated with delivering a VLBW infant in Marion County:
• Black race (OR=1.58, 95% CI: (1.37, 1.82)) versus white race
• Multiples versus singletons
• <12 years education (OR=1.15, 95% CI: (1.07, 1.24) versus 12+ years education
National Healthy Start Association ♦ 12th Annual Spring Conference
Risk Factors for VLBW
• In a multivariate analysis, the following were statistically significantly associated with delivering a VLBW infant in Marion County Continued:
• Adequate+ PNC (OR=2.19, 95% CI: (1.77, 2.70)) versus adequate PNC
• Smoking (OR=1.27, 95% CI: (1.18, 1.38)) versus non-smoking
National Healthy Start Association ♦ 12th Annual Spring Conference
Causes of Postneonatal
Death
• Top 3 Causes of Death for PPOR Infant Health Category in Marion County
1. Unspecified threats to breathing
2. Hanging, strangulation, and suffocation
3. SIDS
National Healthy Start Association ♦ 12th Annual Spring Conference
Investigation into SUID Deaths
• Diagnosis ICD codes (ICD-9/ICD-10)
• SIDS (798.0/R95)
• Accidental suffocation and strangulation (E913/W75-W77, W81-W84)
• Intent unknown suffocation (E983/Y20)
• Neglect, abandonment, and other maltreatment syndromes (E967, E968.4/Y06-Y07)
• Unknown cause (799.9/R99)
Source: Rahmanifar, A (2008).Trends in sudden and unexpected deaths in Indiana 1990-2006: Evidence of recent
change in classification and reporting. http://www.in.gov\isdh\
Patterns of SUID DeathsComparison of Indiana and Marion County by SIDS vs. Other SUID
Rates, 1990-2007
Calculated as SIDS and Other SUID deaths/live births*100,000
0
50
100
150
200
250
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
SID
S/S
UID
Morta
lity
Rate
per 1
00,0
00
Indiana SIDS Rate Marion County SIDS Rate
Indiana Other SUID Rate Marion County Other SUID Rate
Source: Rahmanifar, A (2008).Trends in sudden and unexpected deaths in Indiana 1990-2006: Evidence of recent
change in classification and reporting. http://www.in.gov\isdh\,
Maternal
Health/
Prematurity
1. Pre & Inter-
Conception Care
2. Health Behaviors
3. Prenatal Care
Infant
Health
1. Safety Issues
2. Breast -Feeding3. Family &
Parenting Issues
-Public education campaigns-Reproductive Health plans-Mentoring programs-Better control ofChronic Diseases& Obesity-Expand Medicaid for FP & IC Care, Mental health and Substance Abuse Programs-PNC Coordination
-Safe Sleep & Home Safety education
-Breastfeeding
-Long term CC services
-Substance Abuse
Screening & Treatment
Focus Areas Action Areas
Actions
Strategic Actions to Improve Birth
Outcomes in Marion County
FP-Family Planning, IC-Interconception Care, PNC Prenatal Care Coordination, CC-Care Coordination
Based on Perinatal Periods of Risk (PPOR) data for Marion County 2001-2005
Marion County FIMR
• Investigated all SIDS and Other SUID deaths from cases reviewed from 2004-2009
• Cases SIDS/SUID statistics
• A total of 54 cases reviewed
• 33 maternal interviews conducted
• 89% of deaths were postneonatal
• 87% of deaths were accidental suffocation and strangulation
• 13% of deaths were classified as SIDS
National Healthy Start Association ♦ 12th Annual Spring Conference
Marion County FIMR
• Of the SIDS and Other SUID Deaths
• 85% of the mothers were single
• 48% of the infants were bed-sharing
• 41% were sleeping on an adult bed/pillow
• 19% were found on a couch or chair
• 39% of infants were found on their abdomen
• 72% of deaths occurred to families on Medicaid
• 55% of the mothers used tobacco
National Healthy Start Association ♦ 12th Annual Spring Conference
Addressing the Need for Safe Sleep Education
• 48% of the case histories did not include documented safe sleep education
• 2% claim they did not receive education at all
• In a majority of cases infants were found with items in their sleeping area
• 30% with infant blankets
• 20% with adult pillows
• 30% with adult blankets
• Almost 30% no documented information in death scene investigation
National Healthy Start Association ♦ 12th Annual Spring Conference
Why is sleeping on the back safer for baby?
SAFE: Back Sleeping PositionWindpipe lies on top of the stomach tube in this position. Anything vomited must work against gravity to go into the lungs.
UNSAFE: Stomach Sleeping PositionStomach tube lies on top of the windpipe so that anything vomited will pool at the opening of the windpipe and make it easier to go into the lungs.
Windpipe
Stomach Tube
Stomach Tube
Windpipe
Used with written permission from the National Institutes of Health. Adapted from Continuing Education Program on SIDS Risk Reduction: Curriculum for Nurses. National Institutes of Health. 2006. p.26. Revised for parent education.
Who Needs the Message?
• African American families living in poverty
• 96% of deaths occurred in families that lived in communities where more than 15% of the population lived under the Federal Poverty Line
• For a family of 4 = annual income of $22,050
• Specialized messages and education opportunities for women receiving Medicaid
• Reinforce education among single parent households
• Education for parents who use tobacco
National Healthy Start Association ♦ 12th Annual Spring Conference
How PPOR Became Part of Indianapolis Healthy Start (IHS)
• Focused Core Service Interventions
• Case Management, Outreach and Health Education
• Key Messages: Preconception care, Health behaviors, Safe sleep & injury prevention, Breastfeeding, Access to prenatal care
• Data Collection
• Local Health Systems Action Plan (LHSAP)
• Resources allocated for collaboration
National Healthy Start Association ♦ 12th Annual Spring Conference
LHSAP– Maternal Health/Prematurity
• Sponsor Indiana Perinatal Network provider education to increase screening of ATOD
• Public education campaigns – Baby R U Ready, folic acid
National Healthy Start Association ♦ 12th Annual Spring Conference
LHSAP– Maternal Health/Prematurity
Continued
• Increase access to care
• Group prenatal care
• Indiana Medicaid Presumptive Eligibility
� Indiana Perinatal Network
� Reversal of the decision to not adopt presumptive eligibility for Indiana Pregnant women
� Began July 1, 2009
National Healthy Start Association ♦ 12th Annual Spring Conference
Baby’s Early Development
Week of Pregnancy
Missed Period
1st Prenatal Care Appt
Adapted from: Damus, K. (2010). History, Highlights and Hope: Shattering the U.S. Infant Mortality Glass Ceiling, Emerging issues in Maternal Child Health Webinar. https://cc.readytalk.com/cc/schedule/display.do?udc=o7kewuje4j81
LHSAP–Infant Health
• Efforts to promote Sudden Unexpected Infant Death Investigation (SUIDI) training, reporting, and education
• State Child Fatality Review Teams lead by Dr. Toni Laskey
• Safe Sleep Education – collaboration between Indianapolis Healthy Start and hospitals provides $1500 stipends for staff and patient education
•DVD’s purchased to show safe sleep education
• Implementation of safe sleep sacks at discharge
National Healthy Start Association ♦ 12th Annual Spring Conference
SUID Death Investigation
National Healthy Start Association ♦ 12th Annual Spring Conference
LHSAP–Infant Health
Continued
• Bedtime Basics for Babies campaign – First Candle Collaboration
• Safe Sleep Media Campaign
• Participation in Breastfeeding Coalitions
• Conduct Child Safety Checklists –Safe Housing
National Healthy Start Association ♦ 12th Annual Spring Conference
Infant Mortality Media Campaign
Marion County InfantMortality
Infant Mortality Marion County 1993-2009
0
5
10
15
20
25
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Cases/1
00,0
00
Over allWhite Non-LatinoBlack Non-LatinoLatino
National Healthy Start Association ♦ 12th Annual Spring Conference
Stakeholder Involvement Assisted By:
• Tailored Messages
• Front line staff
• Hospital Staff
• Community
• CRT and CAT Accomplishments (Action)
• Increase in Perceived Value of Data
National Healthy Start Association ♦ 12th Annual Spring Conference
National Healthy Start Association ♦ 12th Annual Spring Conference
What Helped to Keep Stakeholders involved
• 2004 – 2006 ISDH GAP Grant: FIMR Nurse Abstractor and Epidemiologist
• 2004 PPOR TA from City MatCH
• 2005 – 2007 ISDH GAP Grant: Preconception Health Nurse
• 2006 Purchase of BASINET
• September 1, 2007 – August 31, 2010 Bilingual Bicultural Healthy Start Demonstration Grant-Office of Minority Health
National Healthy Start Association ♦ 12th Annual Spring Conference
What Helped to Keep Stakeholders Involved?
• Repetition of Information
• Indianapolis Healthy Babies Consortium
• FIMR Case Review Team
• FIMR Community Action Team
• Local Conferences
National Healthy Start Association ♦ 12th Annual Spring Conference
Challenges
• Keeping Partners Informed and Focused
• New Partners/Staff Turnover
• New Data
• Data Interpretation
• Three Epidemiologists
• Develop a data-driven community
National Healthy Start Association ♦ 12th Annual Spring Conference
PPOR Directs Action
• Helps Determine Who Needs the Information
• Safe Sleep example (Dissemination of data to front line staff)
• Resource Allocation
National Healthy Start Association ♦ 12th Annual Spring Conference
Conclusion
• PPOR provides the Big Picture for community efforts
• Catalyst for the development of a more data-oriented community
National Healthy Start Association ♦ 12th Annual Spring Conference
ConclusionContinued
• The use of PPOR Investigations allows for a comprehensive look into fetal and infant mortality
• Looks deeper into the causes behind the problem and provides guidance to develop solutions
• Directly aids in systems change
• Allows for the targeting of specialized messages to those in the community that need them
• Aids in resource allocation
National Healthy Start Association ♦ 12th Annual Spring Conference
Final Thought
“The problem of infant mortality is one of the great social and economic problems of our day. A nation may waste its forest, its water power, its mines and to some degree even its land, but if it is to hold its own…its children must be conserved at any cost. On the physical, intellectual and moral strength of the children of today, the future depends.”
Julia Lathrop, MD, first Director,
Federal Children’s Bureau, 1913
National Healthy Start Association ♦ 12th Annual Spring Conference