Download Feto-infant mortality

World Health Organization
Collaborating Center in Reproductive Health
Promoting Healthy Birth Outcomes
October 27-28, 2009
Emory University
Woodruff Health Sciences Center
The National Centers for Disease Control and Prevention (CDC)
Georgia Department of Human Resources
Division of Public Health
Alfred W. Brann, Jr., MD, Director
Woodruff Health Sciences Center
Emory University
Brian McCarthy, MD, Principal Investigator
The National Centers for Disease Control
and Prevention
WHO Collaborating Center
Countries Receiving HSR Support
AFRO
•
Kenya
•
Madagascar
•
Tanzania
•
Uganda
EMRO
•
Afghanistan
•
Egypt
•
Jordan
•
Sudan
ERO
•
Armenia
•
Kazakstan
•
Moldova
•
Republic of Georgia
•
Russia
•
Bosnia
•
Czech Republic
•
Poland
•
Romania
•
Yugoslavia
•
Cypress
•
Greece
•
Turkey
PAHO
•
Guatemala
•
Honduras
•
Mexico
•
Cuba
•
Grenada
•
Argentina
•
Columbia
•
Ecuador
•
United States - Georgia
- Mississippi
SEARO
•
India
•
Indonesia
•
South Korea
WPRO
•
China
•
Philippines
UNRWA For Palestinian Refugees
•
Gaza
•
West Bank
Health Services Research
The systematic study of whether current
medical and other relevant knowledge has
been brought to bear to improve the health
of a community under a set of existing
conditions.
Expertise required*Clinical Practice
*Epidemiology
*Behavioral Science
*Public Policy
*P.H. Program Management
*Cultural and Social
Aspects of Health
*Country or state-specific
Knowledge
Infant Mortality and Per Capita GNP
Objectives
• Objective 1 – List the largest contributor to infant
mortality.
• Objective 2 – Describe a new indicator for the status of
health of a community.
• Objective 3 – Describe an approach to a quantified
recurrent public health risk.
• Objective 4 – Describe four critical questions that are
critical for reproductive-aged women.
Georgia Perinatal Surveillance
• Total cohort accountability begins
with the reporting of all products of
conception.
Georgia Perinatal Surveillance
• Feto-infant mortality (FIMR) is used
as the measure of mortality rather
than infant mortality.
Georgia Perinatal Surveillance
• Five hundred grams (500gm) or
twenty week gestation is used as
the starting point for counting fetoinfant deaths.
Georgia Perinatal Surveillance
• Birth weight and age of death are
used to classify each death twodimensionally in order to identify
pockets of excess feto-infant deaths,
along with the most effective
strategies for reducing these excess
deaths.
Georgia Perinatal Surveillance
• Sociodemographic (SD) groups are used to
identify disparities as follows:
Group 1: ≥ 20 years of age, ≥13 years of
education
Group 2: ≥ 20 years of age, <13 years of
education
Group 3: < 20 years of age, <13 years of
education
Georgia Perinatal Surveillance
• The opportunity gap is based on a
comparison between the “standard” fetoinfant mortality in Georgia (the lowest rate
achieved by one SD group in a defined
geographical area) with the rates
experienced by the remaining SD groups.
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
Number of Feto-Infant Deaths
Data Rich, Information Poor
Total
Deaths
3936
Number of Feto-Infant Deaths
Data Rich, Information Poor
Age at Death
Birth
Weight
Total
Deaths
3936
Birthweight and Age at Death
Late
Fetal
Death
(28+ wks)
VVLBW
(500 - 999gms)
VLBW
(999-1499 gms)
IBW
(1499-2499 gms)
NBW
(2500+ gms)
Early
Neontal
Death
(<7 days)
Late
Neonatal
Death
(7-27days)
Post
Neonatal
Death
(28+ days)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Interventions for Reducing Mortality
Women’s and Maternal Health
Maternal and Fetal Care
Neonatal Care
Infant Care
Birthweight and Age at Death
Late
Fetal
Death
(28+ wks)
Early
Neontal
Death
(<7 days)
Late
Neonatal
Death
(7-27days)
Post
Neonatal
Death
(28+ days)
W&M
Health
1
W&M
Health
2
W&M
Health
3
W&M
Health
4
VLBW
(999-1499 gms)
W&M
Health
5
W&M
Health
6
W&M
Health
7
W&M
Health
8
IBW
(1499-2499 gms)
M&F
Care
9
Newborn
Care
10
Newborn
Care
11
Infant
Care
12
NBW
(2500+ gms)
M&F
Care
13
Newborn
Care
14
Infant
Care
15
Infant
Care
16
VVLBW
(0-999gms)
Summary of Perinatal Health Care Interventions
Women’s & Maternal Health
Interventions:
• Reproductive Awareness
• Preconception Care
• Child Spacing
• Nutrition
• Micronutrients
• STDs
• Substance Abuse
• Domestic Violence
•
Maternal & Fetal Care
Interventions:
• Pregnancy Identification
• Prenatal Surveillance & Care
• Anticipatory Guidance
• Intrapartum Monitoring
• “ART” for complications
• Surgical Services
• High Risk Maternal
Followup
Newborn Care
Interventions:
• Clean Delivery
• Resuscitation
• Thermal Control
• Breast Feeding
• “ART” for the At-Risk-Infant
• “Baby Friendly” Concept
• Parenting Skill Education
Infant Care
Interventions:
• Parenting Skill Education
• Child Health Supervision
Breastfeeding/nutrition
Immunization
Growth/Development Monitoring
Anticipatory Guidance
A.R.I.
D.D.
Injury Control
“ART” for the At-Risk-Infant
•Community Services
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
Excessive Mortality Rate by Region
Georgia, 1991-1993
0.7
3.2
4.2
7.4
Total=5.6
Total=8.2
Total=11.4
0.3
1.4
Atlanta
0.6
1.0
1.2
1.8
Augusta
0.5
1.0
2.5
Macon
4.3
4.6
4.1
Total=7.3
Total=8.3
Total=8.6
0.9
0.8
1.5
Columbus
0.3
2.6
Savannah
1.1
1.0
2.4
Albany
What do Current Data Show?
• Excess fetal and infant death rates occur in all six
perinatal regions, with the highest death rate
in the Macon region followed by Albany,
Savannah, Augusta, Columbus and Atlanta.
• The “standard woman” has excess fetal and infant
mortality when compared to the same woman who
lives in Connecticut.
The “Opportunity Gap”-
The
potential for reduction in excessive mortality
based on a comparison between rates
already achieved by one sub-population in a
defined geographical area with those
experienced by the remaining population.
Analysis of Sociodemographic Risks
Deaths per 1,000 live births
Sub-group
Age
Education
Death
Rate
Excess
Rate
White Group 1
>20
>13 years
5.7
.7
White Group 2
>20
<13 years
9.0
4.1
White Group 3
≤19
<13 years
13.3
8.3
Black Group 1
>20
>13 years
14.0
9.0
Black Group 2
>20
<13 years
19.0
14.0
Black Group 3
≤19
<13 years
19.6
14.6
Calculating
“The Opportunity Gap” = Excess Mortality
Excess Mortality = BWPR
TARGET
POPULATION
- BWPR
STANDARD
Birthweight Proportionate Rate (BWPR)
BWPR =
Number of deaths in a given weight group
Total Number of births in all weight groups
x 1000
OR
Maternal
Health
# of
Deaths
(# in cells)
W&MW&MW&MW&M
Health Health Health Health
x 1000
W&MW&MW&MW&M
Health Health Health Health
M & FNewborn
NewbornInfant
Care Care Care Care
M & FNewbornInfant Infant
Care Care Care Care
(# in entire table)
Analysis of Sociodemographic Risks
Deaths per 1,000 live births
Sub-group
Age
Education
Death
Rate
Excess
Rate
White Group 1
>20
>13 years
5.7
.7
White Group 2
>20
<13 years
9.0
4.1
White Group 3
≤19
<13 years
13.3
8.3
Black Group 1
>20
>13 years
14.0
9.0
Black Group 2
>20
<13 years
19.0
14.0
Black Group 3
≤19
<13 years
19.6
14.6
Total
Feto-Infant
Deaths
3936
Excessive
Feto-Infant
Deaths
2314
Calculating
“The Opportunity Gap” = Excess Mortality
Excess Mortality = BWPR
TARGET
POPULATION
- BWPR
STANDARD
Birthweight Proportionate Rate (BWPR)
BWPR =
Number of deaths in a given weight group
Total Number of births in all weight groups
x 1000
OR
Maternal
Health
# of
Deaths
(# in cells)
W&MW&MW&MW&M
Health Health Health Health
x 1000
W&MW&MW&MW&M
Health Health Health Health
M & FNewborn
NewbornInfant
Care Care Care Care
M & FNewbornInfant Infant
Care Care Care Care
(# in entire table)
Feto-Infant Mortality Rate
White Group I, Atlanta Region
2.1
0.9
0.8
1.2
Total = 5.0
Excessive Mortality Rate by Sociodemographic Group
Georgia, 1991-1993
0.1
0.3
1.6
3.6
Total=0.7
Total=4.0
Total=8.3
0.1
0.2
0.4
0.5
1.5
0.4
0.9
3.4
White Group 1
White Group 2
White Group 3
7.2
8.3
8.7
Total=9.0
Total=14.0
Total=14.5
0.5
1.2
0.5
0.8
Black Group 1
1.7
1.1
2.8
Black Group 2
1.4
3.3
Black Group 3
Interventions for Reducing Mortality
Women’s and Maternal Health
Maternal and Fetal Care
Neonatal Care
Infant Care
Georgia’s Six Perinatal Regions
Hospital
Perinatal Center
Areas of Concentration
to Reduce Infant Mortality
Area
Potential for Improvement
LOW
WOMEN’S & MATERNAL HEALTH
Maternal Fetal Care
Neonatal Intensive Care
POSTNATAL CARE
HIGH
60%
10%
9%
21%
Figure 1: Percent of Births According to Sociodemographic group
for Georgia, 1981-83, 1991-93, 2001-03
40%
Percent of birthing population
35%
30%
Time Period:
25%
1981 - 1983
1991 - 1993
2001 - 2003
20%
15%
10%
5%
0%
Age 20+, Educ.
13+ yrs.
Age 20+, Educ.
<13 yrs.
Age <20, Educ.
<13 yrs.
Age 20+, Educ.
13+ yrs.
Age 20+, Educ.
<13 yrs.
Age <20, Educ.
<13 yrs.
White NH Grp 1
White NH Grp 2
White NH Grp 3
Black NH Grp 1
Black NH Grp 2
Black NH Grp 3
Sociodemographic Group
Figure 2: Comparison of Sociodemographic Group Specific Feto-Infant (20+ Weeks)
Moratlity Rates for Georgia, 1981-83, 1991-93, 2001-03
50
45
40
FIMR per 1000
35
30
1981-83
1991-93
2001-03
25
20
39.1
35.7
15
10
5
28.4
26.2
18.1
11.9
7.7
24.6
22.1
18.8
12.8
28.7
26.0
9.8
18.0
12.3
17.9
11.5
16.7
10.5
5.1
0
Age 20+, Educ. Age 20+, Educ. Age <20, Educ. Age 20+, Educ. Age 20+, Educ. Age <20, Educ.
13+ yrs.
<13 yrs.
<13 yrs.
13+ yrs.
<13 yrs.
<13 yrs.
White NH Grp 1 White NH Grp 2 White NH Grp 3 Black NH Grp 1 Black NH Grp 2 Black NH Grp 3
Sociodemographic Group
Total
Figure 4: Sociodemographic Group Specific LBWR/TB
for Georgia 1981-83, 1991-93, 2001-03
18.0%
16.0%
14.0%
% LBWR/TB
12.0%
1981-83
1991-93
2001-03
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
White NH
Grp 1
White NH White NH
Grp 2
Grp 3
Black NH
Grp 1
Sociodemographic Group
Black NH
Grp 2
Black NH
Grp 3
Figure 4: SES Group Specific Birthweight Specific Mortality Rates
1000
800.8
639.9
BWSMR per 1000 TB
425.2
218.9
135.2
100
112.0
< 1000
50.2
31.0
26.4
1000-1499
1500-2499
2500+
Linear (< 1000)
10
7.0
4.6
3.7
1
1981-83
1991-93
Time Period
2001-03
Summary of Perinatal Health Care Interventions
Women’s & Maternal Health
Interventions:
• Reproductive Awareness
• Preconception Care
• Child Spacing
• Nutrition
• Micronutrients
• STDs
• Substance Abuse
• Domestic Violence
•
Maternal & Fetal Care
Interventions:
• Pregnancy Identification
• Prenatal Surveillance & Care
• Anticipatory Guidance
• Intrapartum Monitoring
• “ART” for complications
• Surgical Services
• High Risk Maternal
Followup
Newborn Care
Interventions:
• Clean Delivery
• Resuscitation
• Thermal Control
• Breast Feeding
• “ART” for the At-Risk-Infant
• “Baby Friendly” Concept
• Parenting Skill Education
Infant Care
Interventions:
• Parenting Skill Education
• Child Health Supervision
Breastfeeding/nutrition
Immunization
Growth/Development Monitoring
Anticipatory Guidance
A.R.I.
D.D.
Injury Control
“ART” for the At-Risk-Infant
•Community Services
Background
•
Georgia’s infant mortality declined by 50% from 1975 to
1996, primarily due to improved survival of low birth
weight (LBW; < 2500 gm) infants;
•
The largest contributor to Georgia’s infant mortality rate
is the birth of LBW and VLBW (< 1500 gm) infants:
% of Births
% of Infant Deaths
< 2500 g
11%
70%
< 1500 g
2% (~2500 births) 50%
Background
• African-American women in Georgia have twice
the rate of LBW and 3-4 times the rate of VLBW
delivery compared to Caucasian women,
resulting in twice the rate of infant mortality (1).
• Survival of VLBW infants has significantly
improved in the last 25 years, but the prevalence
of cerebral palsy has not changed.
Background
•
No obstetrical or prenatal assessment or intervention
has been successful in predicting or preventing a
woman’s first preterm/LBW delivery (4);
•
The single best predictor of a preterm/VLBW delivery
is a history of a previous preterm/VLBW delivery (5).
• White women
– 8%
• African-American women
– 13%
Background
•
Experience and a growing body of evidence link
the delivery of a VLBW infant to aspects of a
woman's health status, including (1):
– Unrecognized and poorly-controlled medical
problems;
– Reproductive tract infections (including BV and
STI’s);
– Substance abuse disorders;
– Periodontal disease;
– Psychosocial factors including psychological stress
and domestic violence.
Background
• Short interpregnancy intervals increase
the risk of preterm/LBW delivery (2, 3),
• the critical interval varies by race (4):
– 9 months for African-American women;
– 3 months for white women.
Background
• Pregnancy is too late to initiate
prenatal care if the mother has had
a previous VLBW infant.
Interpregnancy Care
• Primary health care from delivery of
one child until conception of the next.
The Interpregnancy Care Program
Interpregnancy Primary Care and Social Support
for African-American Women at risk for recurrent
very-low-birthweight delivery:
A Pilot Evaluation
Accepted for Publication - July, 2007 in
Maternal and Child Health Journal