Maternal and Child Health Journal

, Volume 14, Issue 6, pp 838–850 | Cite as

Perinatal Periods of Risk: Analytic Preparation and Phase 1 Analytic Methods for Investigating Feto-Infant Mortality

  • William M. SappenfieldEmail author
  • Magda G. Peck
  • Carol S. Gilbert
  • Vera R. Haynatzka
  • Thomas BryantIII


The Perinatal Periods of Risk (PPOR) methods provide the necessary framework and tools for large urban communities to investigate feto-infant mortality problems. Adapted from the Periods of Risk model developed by Dr. Brian McCarthy, the six-stage PPOR approach includes epidemiologic methods to be used in conjunction with community planning processes. Stage 2 of the PPOR approach has three major analytic parts: Analytic Preparation, which involves acquiring, preparing, and assessing vital records files; Phase 1 Analysis, which identifies local opportunity gaps; and Phase 2 Analyses, which investigate the opportunity gaps to determine likely causes of feto-infant mortality and to suggest appropriate actions. This article describes the first two analytic parts of PPOR, including methods, innovative aspects, rationale, limitations, and a community example. In Analytic Preparation, study files are acquired and prepared and data quality is assessed. In Phase 1 Analysis, feto-infant mortality is estimated for four distinct perinatal risk periods defined by both birthweight and age at death. These mutually exclusive risk periods are labeled Maternal Health and Prematurity, Maternal Care, Newborn Care, and Infant Health to suggest primary areas of prevention. Disparities within the study community are identified by comparing geographic areas, subpopulations, and time periods. Excess mortality numbers and rates are estimated by comparing the study population to an optimal reference population. This excess mortality is described as the opportunity gap because it indicates where communities have the potential to make improvement.


Perinatal periods of risk (PPOR) Feto-infant mortality Health disparities methodology 



Thanks to Dr. Brian McCarthy for developing and sharing his original methods and encouraging us to modify the approach for use in U.S. cities. Thanks to the Perinatal Periods of Risk City Teams, Pat Simpson and Jennifer Skala for their help in developing and adapting the methods for use in urban communities. Special thanks to Dr. Milton Kotelchuck and Dr. Laurin Kasehagen for their advice in writing these articles for publication. This work was supported in part by the following Cooperative Agreements: Merging Research and Practice for Urban Child Health—TS-283-14/16 (under CDC Cooperative Agreement U50/CCU300860); Building Urban MCH Capacity—TS 0922 (under CDC Cooperative Agreement U50/CCU300860); Toward Greater Science Use in Urban Health Agencies—TS-1337 (under CDC Cooperative Agreement U50/CCU300860); and the Maternal, Infant, and Reproductive Health: Science-Based Capacity Building for Major Urban Public Health Agencies (5 U65 DP724969-05) between CityMatCH at the University of Nebraska Medical Center and the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, with supplemental support from the National Center for Birth Defects and Developmental Disabilities, and the Health Resources and Services Administration, Maternal and Child Health Bureau. Additional support was provided by the National March of Dimes Birth Defects Foundation, and the University of Nebraska Medical Center, Department of Pediatrics.


  1. 1.
    Mathews, T. J., & MacDorman, M. F. (2004). Infant mortality statistics from the period linked birth/infant death data set. National Vital Statistics Reports, 2007(55), 1–32.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. (2005). Racial/ethnic disparities in infant mortality—United States, 1995–2002. MMWR, 54, 553–556.Google Scholar
  3. 3.
    Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal Child Health Journal, 7, 13–30.CrossRefGoogle Scholar
  4. 4.
    Wise, P. H. (2003). The anatomy of a disparity in infant mortality. Annual Reviews of Public Health, 24, 341–362.CrossRefGoogle Scholar
  5. 5.
    Pestronk, R. M., & Franks, M. L. (2003). A partnership to reduce African American infant mortality in Genesee County, Michigan. Public Health Report, 118, 324–335.Google Scholar
  6. 6.
    Cottrell, B. H., & Shannahan, M. (2004). Maternal bacterial vaginosis, fetal/infant mortality in eight Florida counties, 1999 to 2000. Public Health Nursing, 2004(21), 395–403.CrossRefGoogle Scholar
  7. 7.
    Burns, P. G. (2005). Reducing infant mortality rates using the perinatal periods of risk model. Public Health Nursing, 22, 2–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Besculides, M., & Laraque, F. (2005). Racial and ethnic disparities in perinatal mortality: Applying the perinatal periods of risk model to identify areas of intervention. Journal of the National Medical Association, 97, 1128–1132.PubMedGoogle Scholar
  9. 9.
    Cai, J., et al. (2005). Perinatal periods of risk: An analysis of fetal-infant mortality rates in Kansas City, Missouri. Maternal and Child Health Journal, 9, 199–205.CrossRefPubMedGoogle Scholar
  10. 10.
    Cai, J., et al. (2007). Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri. Journal of Public Health Management and Practice, 13, 270–277.PubMedGoogle Scholar
  11. 11.
    WHO, CDC, CARE. (2009). WHO Collaborating Center in Reproductive Health (CDC), CCHI Care, CDC Health Inititiative, and The Health Unit—CARE. Lawn, J., McCarthy, B., & Ross, S. R. The healthy newborn: a reference manual for program managers. Accessed December 16, 2009.
  12. 12.
    Heaman, M., et al. (2002). Preventable feto-infant mortality application of a conceptual framework for perinatal health surveillance to Manitoba perinatal outcomes. Canadian Journal of Public Health, 93(Suppl 2), S27–S32.Google Scholar
  13. 13.
    Peck, M. G., Sappenfield, W. M., & Skala, J. (in press). Perinatal periods of risk: A community approach for using data to improve women and infants’ health. Maternal and Child Health Journal.Google Scholar
  14. 14.
    Sappenfield, W. M., Peck, M. G., Haynatzka, V. R., Gilbert, C. S., & Bryant, T. (in press). Phase 2 analytic methods for further investigating feto-infant mortality. Maternal and Child Health Journal.Google Scholar
  15. 15.
    CityMatCH. (2008). Training opportunities: perinatal periods of risk. . Accessed July 5, 2008.
  16. 16.
    Kogan, M. D., et al. (1998). The changing pattern of prenatal care utilization in the United States, 1981–1995, using different prenatal care indices. The Journal of the American Medical Association, 279, 16233–16238.CrossRefGoogle Scholar
  17. 17.
    Alexander, G. R., et al. (2008). Infant mortality assessment manual. Accessed July 5, 2008.
  18. 18.
    Alexander, G. R., Kogan, M. D., & Himes, J. H. (1999). 1994–1996 U.S. singleton birth weight percentiles for gestational age by race, Hispanic origin and gender. Maternal and Child Health Journal, 3, 225–231.CrossRefPubMedGoogle Scholar
  19. 19.
    National Center for Health Statistics. (1995). Division of vital statistics. Instruction manual part 12: Computer edits for natality data, effective 1993, Hyattsville, MD.Google Scholar
  20. 20.
    Taffel, S., Johnson, D., & Heuser, R. (1982). A method of imputing length of gestation on birth certificates. Vital and Health Statistics, Series 2, 93, 1–11.Google Scholar
  21. 21.
    Sappenfield, B., & Haynatzka, V. (2001). Periods of risk practice collaborative: Frequently asked data and analytic questions. Accessed July 5, 2008.
  22. 22.
    Centers for Disease Control and Prevention. (2007). Unregistered deaths among extremely low birthweight infants—Ohio, 2006. MMWR, 56, 1101–1103.Google Scholar
  23. 23.
    DiGiuseppe, D. L., et al. (2002). Reliability of birth certificate data: a multi-hospital comparison to medical records information. Maternal and Child Health Journal, 6, 169–179.CrossRefPubMedGoogle Scholar
  24. 24.
    Martin, J. A., & Hoyert, D. L. (2002). The national fetal death file. Seminars in Perinatology, 26, 3–11.CrossRefPubMedGoogle Scholar
  25. 25.
    Kung, H. C., Hoyert, D. L., Xu, J. Q., & Murphy, S. L. (2008). Deaths: Final data for 2005. National Vital Statistics Reports, 56(10), 117.Google Scholar
  26. 26.
    Beitsch, L. M., Mahan, C. S., & Cupoli, J. M. (1992). Healthy start strengthening public and private partnership. Florida Medical Association Journal, 79, 567–568.Google Scholar
  27. 27.
    Florida Department of Health. (2008). Florida’s healthy start. Accessed July 6, 2008.
  28. 28.
    Coalition of Northeast Florida, Inc. (2008). Northeast Florida healthy start coalition. Accessed July 6, 2008.
  29. 29.
    CityMatCH. (2008).Table 7A: The feto-infant mortality excess number and rate, and the excess number and rates for the four perinatal periods of risk components. Accessed July 5, 2008.
  30. 30.
    Alexander, G. R., et al. (2003). U.S. birth weight/gestational age-specific neonatal mortality: 1995–1997 Rates for Whites, Hispanics and Blacks. Pediatrics, 111, e61–e66.CrossRefPubMedGoogle Scholar
  31. 31.
    Northam, S., & Knapp, T. R. (2006). The reliability and validity of birth certificates. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 3–12.CrossRefPubMedGoogle Scholar
  32. 32.
    Zollinger, T. W., Przybylski, M. J., & Gamache, R. E. (2006). Reliability of Indiana birth certificate data compared to medical records. Annals of Epidemiology, 16, 1–10.CrossRefPubMedGoogle Scholar
  33. 33.
    Martin, J. A., & Menacker, F. (2007). Expanded health data from the new birth certificate, 2004. National Vital Statistics Reports, 55(12), 1–22.Google Scholar

Copyright information

© US Government 2010

Authors and Affiliations

  • William M. Sappenfield
    • 1
    • 2
    • 3
    Email author
  • Magda G. Peck
    • 2
  • Carol S. Gilbert
    • 2
  • Vera R. Haynatzka
    • 2
  • Thomas BryantIII
    • 4
  1. 1.Division of Reproductive HealthCenters for Disease Control and PreventionAtlantaUSA
  2. 2.CityMatCH, Department of PediatricsUniversity of Nebraska Medical CenterOmahaUSA
  3. 3.Division of Family Health ServicesFlorida Department of HealthTallahasseeUSA
  4. 4.Duval County Health Department, Institute for Public Health Informatics and ResearchJacksonvilleUSA

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