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
Dec 24, 2015
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.