Using FIMR and PPOR to Identify Strategies for Infant

Survival in Baltimore

Meena Abraham, M.P.H.Baltimore City Perinatal Systems Review

MedChi, The Maryland State Medical Society

Partners

Baltimore City Health Department Baltimore City Healthy Start, Inc. MedChi, The Maryland State Medical

Society Funded through the Improved Pregnancy

Outcomes grant from the Center for Maternal and Child Health, DHMH.

Other—March of Dimes, United Way, Family League of Baltimore

Baltimore City Population

Population Size—632,680Population Size—632,680 Racial CompositionRacial Composition

– 67% African American– 31% White– 2% Other

PovertyPoverty– 24% live at or below poverty in Baltimore.24% live at or below poverty in Baltimore.– 9% live at or below poverty in Maryland.9% live at or below poverty in Maryland.

Infant Mortality RatesBaltimore City, Maryland, and

U.S., 1998 - 2002

5

7

9

11

13

15

Year

death

s per

1,0

00 liv

e

bir

ths

BaltimoreCityMaryland

United States

Source: Md Vital Statistics Administration

Infant Mortality Rates by Race

Baltimore City, 1998 - 2002

02468

1012141618

Year

deat

hs

per

1,0

00 liv

e bir

ths African

AmericanWhite

Source: Md Vital Statistics Administration

Initiative in Baltimore

Background—High rates fetal-infant mortality. Purpose—To improve services to women at

risk for a poor pregnancy outcome. Tools for Assessment/Monitoring—FIMR, PPOR

Objectives– To identify women at risk for fetal-infant

mortality, poor pregnancy outcome. – To identify strategies for improving services.

Baltimore’s Resources

Institutions—high-tech care, clinical and public health expertise.

Community-based Services Maternal & Infant Nursing HealthCare Access Baltimore City Healthy Start Success by 6

Health Commissioner—maternal/infant health priority.

Phase I PPOR Analysis

What does our study population look like?

Which births are excluded? What is the distribution of birth

weight and mortality in our population?

Are there differences in our population?

Distribution of Fetal and Infant Deaths

African American vs White/Other Rates

Maternal Health/ Prematurity

8.6 vs 3.6

MaternalCare

4.0 vs 1.8

Newborn Care

2.3 vs 1.5

Infant Health

3.4 vs 2.1

Total Rate:

18.2 vs 9.1

Baltimore City, 1997-1999

Distribution of Excess Mortality

54%

23%

9%

14%

MaternalHealth/PrematurityMaternal Care

Newborn Care

Infant Health

African American Compared to White/Other

Excess Deaths Among African Americans = 182

Phase II PPOR Analysis

What are the reasons for the disparity in birth outcomes?

Birthweight distribution? Birthweight-specific mortality? Distribution of risk factors?

90%

10%

80%

20%

Birthweight Birthweight-specific Mortality

Excess Deaths By Birthweight and Birthweight-specific

MortalityA. Overall Excess DeathsB. Excess Maternal Hlth/ Prematurity

PPOR Findings

Greatest disparity is in maternal health/ prematurity and maternal care– Infant deaths <1500 g and fetal deaths

90% of excess mortality is due to birthweight distribution.

Only 10% to birthweight-specific mortality – good systems for infant care.

PPOR Multi-variate Analysis

Outcome: VLBW – live births <1500g

Variables: maternal race, infant sex, age, education, marital status, parity, timing of entry into prenatal care, smoking, and medicaid enrollment

PPOR Findings

African American women have 2.7 times the risk for VLBW.

Maternal age – 30-39 is lowest risk for whites but highest risk for A.A.

Maternal education – not significant for whites but 9 to 11 yrs increased risk among A.A.

Parity – first birth increase risk for A.A.

PPOR Findings

Prenatal Care – none is high risk for all.

Medicaid – no effect for whites, not enrolled and enrollment pending are high risk for A.A.

Hypertension, multiple gestation, and other complications all precipitate preterm delivery and increase the risk.

Implications of PPOR Findings

Focus efforts to prevent VLBW births and fetal deaths:– African American women 30 years+– Women having their first pregnancy– Early enrollment in prenatal care– Early enrollment of eligible women

in Medicaid

Fetal & Infant Mortality Review

Mission: To improve the delivery of services to women and their families.

Activities: Compile case histories from birth and death

certificates, medical records, other sources. Conduct maternal interviews. Review cases and develop recommendations

with a multi-disciplinary board. Work with partners/stakeholders to

implement recommendations.

Comprehensive Case Review

165 fetal & 117 infant deaths reported in 1998.

Case histories compiled on 204 pregnancies resulting in 220 deaths.

Grouped cases by area of need—e.g. substance use, domestic violence, infections—and reviewed 3 to 4 cases at each meeting.

Devoted 1 year to case reviews and 1 year to developing recommendations for each area of need.

FIMR Data

Pregnancy HistoryPregnancy History– 21% first pregnancy21% first pregnancy– Among those pregnant before—Among those pregnant before—32% 4+

pregnancies, 12% LBW, 8% VLBW, 43% fetal or infant loss in the past as well, 49% elective abortion

Infections– 23% STI – 46% perinatal infection

FIMR Data

Health Conditions–3% diabetes, 27% hypertension

Complications–14% placental abruptio, 32% PROM

No prenatal care–13% Multiple gestation pregnancy–10% Substance use during pregnancy–28%

smoking, 10% alcohol, 25% drugs; 39% any Domestic violence–9% (not routinely screened)

Key FIMR Findings

Women have multiple risk factors for poor pregnancy outcome.

Women are not always aware of their risks or ways to reduce them.

Providers and pregnant women are often not aware of available services.

Summary of Four Priority Areas

1. Care of women following a perinatal loss to reduce repeat losses-Bereavement support-Medical assessment-Follow-up care-Care coordination-Interval between pregnancies

2. Perinatal infection-Early detection-Repeated screening-Provider education-Community education

Summary of Four Priority Areas

Summary of Four Priority Areas

3. Family planning and preconception/ inter-conception care -availability of contraceptive services-planning post-partum contraception-family planning waiver card-importance of primary care-follow-up services

Summary of Four Priority Areas

4. Adequate utilization of prenatal care -early enrollment in Medicaid-promote the value of prenatal care-early enrollment in prenatal care-”user-friendly” services-continuity of care

Strategies for Infant Survival

Subcommittees to address priorities– Legislative and policy– Institutional and Health Systems– Provider Education– Community Education and Outreach

Activities to Improve Services

Disseminate Report and Findings– Breakfast Seminar– Meetings, Conferences, Mailings– Press Conference– Presentations to Stakeholders

Activities to Improve Services

Develop Health Education Materials– Perinatal Mortality Curriculum– Risk-reduction Fact Sheets– Perinatal Infections Curriculum

Activities to Improve Services

Develop Institutional Protocols– Bereavement Services– Medical Assessment– Inter-conception Care

Activities to Improve Services

Educate Providers Serving At-Risk Women– Grand

Rounds—Findings/Recommendations– Training—Preterm Birth Prevention,

Bereavement, Findings/Recommendations

– Training—Perinatal Infections

Coordinated Services Delivery

Home Visit, Case Management Providers– Incorporating FIMR, PPOR findings into

strategic planning.– Restructuring services to target women

with losses, VLBW.– Establishing referral for post-loss/inter-

conception care to Maternal & Infant Nursing Program.

Conclusions

FIMR and PPOR each contribute valuable information.

PPOR provides the “what.” FIMR provides the “why.” Both approaches promote community action. FIMR and PPOR have been used successfully

in Baltimore to develop strategies for systems change and improved infant survival.