PR Stein

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Ellen J. Stein, MD, MPH, FACOG Disparities in Perinatal Outcomes using PPOR: Results for the Bay Area Data Collaborative

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Additional Authors: Al Abramowitz, MS Janet Brown, MSc Anand Chabra, MD, MPH And Special Thanks To: Jerry A. Sierra BADC Collaborative CA Department of Health Services MCAH Branch Epi and Eval Section

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From 1990 to 2001 the birth rate in San Francisco County dropped significantly for all races and ethnicities except Whites

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uses the Perinatal Periods of Risk (PPOR) model for fetal-infant mortality rates birth rates are too low for PPOR analysis of racial/ethnic disparities African-American births have dropped to 699 per year San Francisco County:

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Source: UCSF FHOP Perinatal Databook (Compiled, A Abramowitz) Trends in SF Resident Births by Ethnicity Age 15-44, 1990 to 2001 Total Births 1990: 10,125 Total Births 2001: 8,233

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Changes in Birth Rates SF Residents Age 15-44, 1990 to 2001 Source: UCSF FHOP Perinatal Databook (Compiled, A Abramowitz) Births per 1,000 Female Residents

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Nine Bay Area Counties

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The San Francisco Bay Area Region consists of 9 counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano and Sonoma The Bay Area Data Collaborative (BADC) represents these counties

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The Bay Area region had 287,044 births and 2,210 fetal-infant deaths from 1999 to 2001

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Distribution of African-American Population in the Bay Area Bay Area regional birth data have the statistical power to analyze racial/ethnic disparities

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Fetal-infant mortality (FIM) rates for the Bay Area Data Collaborative are close to the regional mean

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Rates per 1,000 Source: CA Birth Cohort File, 1999-2001 County and Bay Area Data Collaborative (BADC)* Fetal-Infant Mortality (FIM) Rates, 1999-2001 *

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BADC Region and County Fetal-Infant Mortality Rates and 95% Confidence Intervals, 2001

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Bay Area regional racial/ethnic health disparities reflect the county disparities

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Racial/Ethnic Disparities: PPOR Rates Bay Area Data Collaborative (BADC) Region 16.2 6.2 7.6 7.7 6.9 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 Black White Hispanic Asian/PI All Races Fetal-Infant Mortality Rates per 1,000 fetal deaths + births, 1999-2001 (n=355) (n=664) (n=666) (n=464) (n=2210 )  Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma Source: CA Birth Cohort File, 1999-2001

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The Power of Collaboration

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Using PPOR to Demonstrate Racial/Ethnic Disparities for Evidence Based Health Interventions

Different Than Conventional Analysis: 

Combines Fetal And Infant Deaths In A Fetal-Infant Mortality Rate Includes Fetal Deaths 24+ Weeks Includes Fetal And Infant Deaths with birth weight >499 Grams Perinatal Periods of Risk Different Than Conventional Analysis

Parameters: 

AGE AT DEATH  BIRTH WEIGHT  Parameters Fetal-Infant Mortality Perinatal Periods of Risk

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Perinatal Periods of Risk 4 “Periods of Risk” represent potential gaps in maternal and child health systems that lead to fetal-infant mortality

Maternal Health/PrematurityRisk Factors Include:: 

Maternal Health/Prematurity Risk Factors Include: Infection Stress and Work General state of health prior to pregnancy Injuries and abuse Family planning Nutrition Tobacco/alcohol/drug use Previous pregnancy outcomes

Maternal CareRisk Factors Include:: 

Maternal Care Risk Factors Include: Late/inadequate prenatal care Infection Tobacco/alcohol/drug use Inadequate problem recognition Early labor Nutrition Poor weight gain Obesity

Newborn CareRisk Factors Include:: 

Newborn Care Risk Factors Include: Access to obstetric expertise Access to neonatal intensive care Emergency situations Infection Access to pediatric expertise Access to newborn care

Infant HealthRisk Factors Include:: 

Infant Health Risk Factors Include: Birth defects and developmental anomalies Lack of recognition of signs & symptoms of illness Infection Injuries Inadequate well-child care or follow-up SIDS

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Preconceptional Risk Factors Also Include: Infection Stress and Work General state of health prior to pregnancy Injuries and abuse Family planning Nutrition Tobacco/alcohol/drug use Previous pregnancy outcomes

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Newborn Care Deaths (Rate) Maternal Care Deaths (Rate) Infant Health Deaths (Rate) 500-1499 grams 1500+ grams Maternal Health/Prematurity Deaths (Rate) Total Deaths ————— = Births + Fetal Deaths Total Fetal Infant Mortality (FIM) Rate per 1,000 Perinatal Periods of Risk Analytic Model Age at Death Birth Weight

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BADC Distribution and (Rates) FIM, 1999-2001 Newborn Care 306 (1.1) Maternal Care 608 (2.1) Infant Health 350 (1.2) 500-1499 grams 1500+ grams Source: CA Birth Cohort File, 1999-2001 Prematurity/Maternal Health 946 (3.3) 2,210 total deaths ————— = 288,170 births + fetal deaths Total FIM Rate=7.7 per 1,000

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500-1499 grams 1500+ grams BADC Black Distribution and Rates FIM, 1999-2001 Newborn Care 25 (1.1) Prematurity/Maternal Health 178 (8.1) Maternal Care 90 (4.1) Infant Health 62 (2.8) 355 total deaths —————————— = 28,160 births + fetal deaths Total FIM Rate=16.2 Source: CA Birth Cohort File, 1999-2001

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Newborn Care 281 (1.1) Maternal Care 518 (1.9) Infant Health 288 (1.1) 500-1499 grams 1500+ grams Source: CA Birth Cohort File, 1999-2001 Prematurity/Maternal Health 768 (2.9) 1,855 total deaths ————— = 266,310 births + fetal deaths Total FIM Rate=7.0 per 1,000 BADC, All Other, Distribution and Rates FIM, 1999-2001

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BADC Black, All Other FIM Disparities, 1999-2001 Newborn Care Black: 1.1 All Other: 1.1 OR = 1.08 (95% CI .72 - 1.63) Maternal Care Black: 4.1 All Other: 1.9 OR = 2.12 (95%CI 1.69 – 2.65) Infant Health Black: 2.8 All Other: 1.1 OR = 2.63 (95% CI 1.99-3.40) Prematurity/Maternal Health Black: 8.1 All Other: 2.9 OR = 2.84 (95% CI 2.41- 3.34) Black: 16.2, All Other: 7.0 Total OR = 2.35 (95% CI 2.10 – 2.64)

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How to Calculate Excess Deaths TAKE A COMPARISON GROUP

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Opportunity gaps Perinatal Periods of Risk Uses a “comparison group” model to calculate excess deaths in the four risk periods against a standard reference group. Shows the specific period of risk with the best opportunity to improve mortality rates.

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White women Married Over 20 years of age 13+ years of education US Standard Reference Group

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U.S. Whites, 13+ yrs. Education, 12 U.S. Cities Fetal Infant Mortality Rates 1998-2000 Source: NCHS Perinatal Mortality Data Files, 1998-2000 Newborn Care 1.0 Maternal Care 1.5 Infant Health 1.2 500-1499 grams 1500+ grams Total FIM Rate= 5.9 per 1,000 Total Deaths ————— = Births + Fetal Deaths Maternal Health/Prematurity 2.2

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Against U.S. White Comparison Group, 1998-2000 Newborn Care 43 (7%) Maternal Care 213 (32%) Infant Health 34 (5%) 500-1499 grams 1500+ grams Prematurity/Maternal Health 367 (56%) Total Excess Deaths= 658 (100%) All Races Excess Deaths BADC Region, 1999-2001 Source: CA Birth Cohort File, 1999-2001

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Newborn Care 3 (1%) Maternal Care 57 (25%) Infant Health 36 (16%) Prematurity/Maternal Health 130 (58%) Total Excess Deaths=226 Black Excess Deaths BADC Region, 1999-2001 Against U.S. White Comparison Group, 1998-2000

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Excess African American fetal-infant deaths are 1/3 of the excess mortality for the Bay Area Data Collaborative African American births are 7.5% of the total births for the Bay Area Data Collaborative

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Source: CA Birth Cohort File, 1999-2002 Preconceptional Risk Factors Continue the Black Fetal-Infant Mortality Trend 1999-2002 PPOR Rate per 1,000

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Preconceptional care is our opportunity to reduce African American fetal and infant deaths