Using Perinatal Periods of Risk (PPOR) and Geographic Information System (GIS) to assess feto-infant mortality rates and to identify strategic areas for

Using Perinatal Periods of Risk (PPOR) and Geographic Information System (GIS) to assess feto-infant mortality rates and to identify strategic areas for community-based intervention in Louisville Sarojini Kanotra, PhD, MPH, CHESTroutman, Adewale, MD, MA, MPHSheila Andersen, JD, MA, BSNNazenin Assef, MS

About Louisville16th largest city in the United States

ObjectivesAssess feto-infant mortality rates in Louisville Metro using Perinatal Periods of Risk approachIdentify the strategic areas in perinatal health for community-based intervention using GIS mappingTranslate data into information for policy and program planning

Demographics of Louisville Metro Population by Race

Infant Mortality Rate, 2002HP2010 Goal=4.5

Infant Mortality Rate In Louisville Metro by Race, 2002

Fetal-Infant Mortality Rates, All Races2000-2002255 total deaths 29707total live births1997-1999

265 total deaths

29,049 total births

Excluded from the analysis: fetal deaths under 24 weeks and live births under 500 grams

Fetal-Infant Mortality Rates, Whites2000-2002140 total deaths 21,523 total live births1997-1999159 total deaths 21,452 total live births

Fetal-Infant Mortality Rates, African Americans2000-2002102 total deaths 7303 total live births1997-1999100 total deaths 7055 total live births

Excess Mortality (Rates) as Compared to an Internal Reference, All Races, 2000-2002Internal reference included women 20 years or older, non-Hispanic White, had 13 or more years of education

Feto-Infant Mortality Rates by Race, 2000-2002WhiteAfrican American

Maternal Health/ Prematurity Excess

Chart3

0.37117183

0.077337095

Fetal Mortality

Fetal Mortality: Birthweight Distribution and Birthweight-Specific Mortality

Please, do not enter any data on this worksheet.

Table 3: Birthweight Distribution & Birthweight-Specific MortalityTable 4: Birthweight Distribution & Birthweight-Specific Mortality

Population Group 1 =Target PopulationPopulation Group 2 = Reference Population

Column (1):Number of live births + Number of fetal deaths from Table 1 & 2 from Data Entry Worksheet.

Column (2):Number of fetal deaths from Table 1 & 2 from Data Entry Worksheet.

Column (3):Calculated--Birthweight distribution= Column (1)/ Total Births.

Column (4):Calculated--Birthweight-specific Feto-Infant Mortality Rates = Column (2)/ Column (1) *1000.


Column (1)Column (2)Calculated (3)Calculated (4)Column (1)Column (2)Calculated (3)Calculated (4)

Number ofNumber ofFetalNumber ofNumber ofFetal

Live BirthsFetalBirthweightMortalityLive BirthsFetalBirthweightMortality

Birthweight& Fetal DeathsDeathsDistributionRates& Fetal DeathsDeathsDistributionRates

500-7495620.8%35.75110.3%19.6

750-9995850.8%86.24130.2%73.2

1,000-1,2495930.8%50.86740.3%59.7

1,250-1,4995450.7%92.67040.4%57.1

1,500-1,99919442.7%20.624221.3%8.3

2,000-2,49957747.9%6.968963.6%8.7

2,500-6,4996266986.3%1.4181302794.0%1.5

Total726432100.0%4.41929047100.0%2.4

Warning: Small Numbers.Warning: Small Numbers. Please, look at the footnote for explanations.

Please, look at the footnote for explanations.Warning: Small Numbers. Please, look at the footnote for explanations.

Footnote: The birthweight-specific rates based on less than 5 deaths are extrtemely unstable.

The summary values (the row Total of the tables bellow) are more reliable.

Table 5: Excess Mortality - Effects of the Birthweight Distribution and of the Birthweight-Specific Mortality

Column (1):Calculated--The effect of the birthweight distribution on the overall excess rates. Equal to the excess mortality due to

different prevalence in the corresponding birthweight category under the assumption of average

birthweight-specific mortality rates.

Column (2):Calculated--The effect of birthweight-specific mortality on the overall excess rates. Equal to the excess birthweight-specific mortality

for the corresponding birthweight category under the assumption of average prevalence in that category.

Column (3):Calculated--combined effect by birthweight category = Column(1)+Column(2).

Column (4):Calculated--The effect of the birthweight distribution on excess rates - percentages.

Column (5):Calculated--The effect of birthweight-specific mortality on excess rates - percentages.

Column (6):Combined effect by birthweight category - percentages.

Actual Contribution to the Difference in Excess Mortality RatesPercentage Contribution to the Difference in Excess Mortality Rates

Column (1)Column (2)Calculated (3)Calculated (4)Column (5)Column (6)

Feto-InfantFeto-Infant

BirthweightMortalityBirthweightMortality

BirthweightDistributionRatesTotalDistributionRatesTotal

500-7490.10.10.27.1%4.2%11.4%

750-9990.50.10.523.7%3.3%27.1%

1,000-1,2490.3-0.10.213.1%-2.6%10.4%

1,250-1,4990.30.20.514.5%10.0%24.4%

1,500-1,9990.20.20.410.4%12.3%22.7%

2,000-2,4990.3-0.10.217.4%-5.2%12.2%

2,500-6,499-0.1-0.0-0.2-5.7%-2.4%-8.2%

Total1.60.42.080.4%19.6%100.0%BirthweightMortality80.37%19.63%

MH / Prem.1.10.31.458.4%14.9%73.3%BirthweightMortality58.35%14.93%

Warning: The difference between rates is less than 2 per 1,000. Percentages may be unstable.

Contribution of the Birthweight Distribution and Birthweight-Specific Mortality to:

A. Total Excess (All Birthweight Categories)B. Maternal Health/Prematurity Excess

Components of the Overall Excess RatesComponents of the Overall Excess Rates

Fetal Mortality

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Population Group 1 =Target Population

Population Group 2 = Reference Population

Birthweight Distribution

Infant Mortality

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Birthweight-Specific Mortality Rates (per 1,000 births)

Feto-Infant Mortality

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Birthweight

Mortality

Contribution to the Difference in Excess Mortality Rates

Data Entry WorkSheet

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Infant Mortality: Birthweight Distribution and Birthweight-Specific Mortality

Please, read before proceeding!

There are two choices for computing the infant mortality rates for the target and reference populations:

A) Traditional option - using as a denominator all live births of 500 or more grams.

B) PPOR approach option - using as a denominator all live births of 500 or more grams plus the fetal deaths

of 500 or more grams plus the fetal deaths of 500 or more grams/ 24 or more gestation.

Please, select the option you prefer by pressing the first button for A) and the second for B).

Warning: The second option tends to diminish differences between birthweight-specific rates at the lower birthweight

categories and hence emphasize the effect of different birthweight distributions.

Please, do not enter any data bellow.



Column (1):A. Number of live births from Table 1 & 2 from Data Entry Worksheet

OR

B. Number of live births plus fetal deaths from Table 1 & 2 from Data Entry Worksheet.

Column (2):Number of infant deaths from Table 1 & 2 from Data Entry Worksheet.





Number ofNumber ofInfantNumber ofNumber ofInfant

Live Births+InfantBirthweightMortalityLive Births+InfantBirthweightMortality

BirthweightFetal DeathsDeathsDistributionRatesFetal DeathsDeathsDistributionRates

500-74953120.3%226.4756680.2%1.1

750-99972100.4%138.9889030.2%0.3

1,000-1,2496210.4%16.11044540.3%0.4

1,250-1,4996230.4%48.41262460.3%0.5

1,500-1,99927541.6%14.54894781.2%0.2

2,000-2,49975964.5%7.914002923.6%0.0

2,500-6,499154263692.3%2.336968652994.2%0.0

Total1670972100.0%4.3392536660100.0%0.0

Warning: Small Numbers.Warning: Small Numbers.

Please, look at the footnote for explanations.Please, look at the footnote for explanations.















InfantInfant



500-7490.10.60.73.3%13.4%16.7%

750-9990.10.50.63.3%10.6%13.9%

1,000-1,2490.00.10.10.2%1.2%1.4%

1,250-1,4990.00.20.20.3%3.9%4.1%

1,500-1,9990.00.20.20.7%4.8%5.5%

2,000-2,4990.00.30.40.9%7.5%8.4%

2,500-6,499-0.02.22.1-0.5%50.5%50.0%



Relationship Between Birthweight Distribution and Birthweight-Specific Mortality Components of the Excess Rates for:



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Birthweight

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Feto-Infant Mortality: Birthweight Distribution and Birthweight-Specific Mortality

Please, do not enter any data on this worksheet.



Column (1):Number of live births + Number of fetal deaths from Table 1 & 2 from Data Entry Worksheet.

Column (2):Number of infant + fetal deaths from Table 1 & 2 from Data Entry Worksheet.





Number ofNumber ofFeto-InfantNumber ofNumber ofFeto-Infant

Live BirthsFeto-InfantBirthweightMortalityLive BirthsFeto-InfantBirthweightMortality

Birthweight& Fetal DeathsDeathsDistributionRates& Fetal DeathsDeathsDistributionRates

500-74956140.8%250.05190.3%176.5

750-99958150.8%258.64160.2%146.3

1,000-1,2495940.8%67.86780.3%119.4

1,250-1,4995480.7%148.170100.4%142.9

1,500-1,99919482.7%41.2242101.3%41.3

2,000-2,499577107.9%17.368983.6%11.6

2,500-6,49962664586.3%7.2181305694.0%3.1

Total7264104100.0%14.319290107100.0%5.5

Warning: Small Numbers.

Please, look at the footnote for explanations.















Feto-InfantFeto-Infant



500-7491.10.41.512.3%4.3%16.7%

750-9991.20.61.813.5%6.5%20.0%

1,000-1,2490.4-0.30.15.0%-3.4%1.5%

1,250-1,4990.60.00.66.3%0.3%6.6%

1,500-1,9990.6-0.00.66.7%-0.0%6.6%

2,000-2,4990.60.31.07.2%3.8%11.0%

2,500-6,499-0.43.73.3-4.5%42.1%37.5%



Relationship Between Birthweight Distribution and Birthweight-Specific Mortality Components of the Excess Rates for:



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Kitagawa Table for 8 Birthweight Groups

Formula from Fleiss's Statistical Methods for Rates and Proportions, p. 238.

see also Kitagawa, E.M. (1955). Components of difference between two rates.

J. Am. Stat. Assoc., 50, 1168-1194.

Step 1: Please, fill in the following table:

Table 1: Target Population

Number ofNumber ofNumber of

LiveInfantFetal Deaths

BirthweightBirthsDeaths24+ wks

0-49929115The data from the first row will not be used in the calculations.

500-74954122

750-99953105

1,000-1,2495613

1,250-1,4994935

1,500-1,99919044

2,000-2,49957364

2,500+6257369

Unknown850

Total72698837

Percent of Live Births with Unknown Birthweight:0.1%

Percent of Infant Deaths with Unknown Birthweight:5.7%

Percent of Fetal Deaths with Unknown Birthweight:0.0%

Step 2: Please, choose a reference group:

A.Enter a reference population of your choice in Table 2 bellow.

OR

B.Click on the button to use the national reference group

of white-non hispanic, 20+ years old, 13+ years of education women 98-00.

Table 2: Reference Population

Number ofNumber ofNumber of

LiveInfantFetal Deaths

BirthweightBirthsDeaths24+ wks

0-4993097The data from the first row will not be used in the calculations.

500-7495081

750-9993833

1,000-1,2496344

1,250-1,4996664

1,500-1,99924082

2,000-2,49968326

2,500+181032927

Unknown1411

Total192877055

Percent of Live Births with Unknown Birthweight:0.1%

Percent of Infant Deaths with Unknown Birthweight:1.4%

Percent of Fetal Deaths with Unknown Birthweight:1.8%

National Reference

Dissemination of the ResultsNew Health Department DirectorHealth Status Assessment CommitteeHealthy Start Advocates Meetings attended by the Medical Examiner and State RepresentativeMarch of Dimes Prematurity SummitChild Fatality Review Meetings(State & Local)Community Partnership for Protection of ChildrenLocal Birthing HospitalSpecial meeting organized for State Legislators serving the Healthy Start area

Outcomes of Data DisseminationDevelopment of a PPOR TeamReduction of persisting disparities in infant mortality is part of the strategic plan of the departmentReceived local monies to start a Center for Elimination of Racial Disparities Collaboration with the State in starting Fetal Infant Mortality Review (FIMR) in LouisvilleWomens Health Task Force Committee

Other InitiativesMayors Healthy Hometown MovementMAPP process Translation of Data into Policy GrantSafe-Sleeping CampaignCrib for Kids CampaignState applying for the PRAMS grant

Accomplishments of Healthy Start ProgramReduction in poor pregnancy outcomes such as low birth weight births Increase in the number of women initiating prenatal care in the first trimesterIncrease in the number of women receiving preventive care services after deliveryZero infant mortality to Healthy Start participants

Where are we now?Assess feto-infant mortality rates in Louisville Metro using Perinatal Periods of Risk approachIdentify the strategic areas in perinatal health for community-based intervention using GIS mappingTranslate data into information for policy and program planning

Give DATA a Voice

IMR has gone up from 5.9 in 2001 to 8.85 in 200245 less deaths if the outcome was similar to the internal reference78 more deaths in AA as compared to WBirth outcomes mirror the trends seen in infant mortalityNeighborhood Place is it is a partnership of agencies and community residents who have come together to deliver services in a new way.

Documents

Using Perinatal Periods of Risk (PPOR) and Geographic Information System (GIS) to assess feto-infant mortality rates and to identify strategic areas for