Abstract
Introduction
The Perinatal Periods of Risk approach (PPOR) is designed for use by communities to assess and address the causes of high fetal-infant mortality rates using vital records data. The approach is widely used by local health departments and their community and academic partners to inform and motivate systems changes. PPOR was developed and tested in communities based on data years from 1995 to 2002. Unfortunately, a national reference group has not been published since then, primarily due to fetal death data quality limitations.
Methods
This paper assesses data quality and creates a set of unbiased national reference groups using 2014–2016 national vital records data. Phase 1 and Phase 2 analytic methods were used to divide excess mortality into six components and create percentile plots to summarize the distribution of 100 large US counties for each component.
Results
Eight states with poor fetal death data quality were omitted from the reference groups to reduce bias due to missing maternal demographic information. There are large Black-White disparities among reference groups with the same age and education restrictions, and these vary by component. PPOR results vary by region, maternal demographics, and county. The magnitude of excess mortality components varies widely across US counties.
Discussion
New national reference groups will allow more communities to do PPOR. Percentile plots of 100 large US counties provide an additional benchmark for new communities using PPOR and help emphasize problem areas and potential solutions.
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Data Availability
Counts and rates are included in Online Appendices designed to be accessible to PPOR users. Additional tables are available from the corresponding author.
Code Availability
SAS Code is available on request from the corresponding author.
References
Alexander, G. R., Wingate, M. S., Bader, D., & Kogan, M. D. (2008). The increasing racial disparity in infant mortality rates: Composition and contributors to recent US trends. American Journal of Obstetrics and Gynecology, 198(1), 51.e51–51.e59.
Assari, S. (2020). Protective effects of maternal education against low birth weight deliveries: Blacks’ diminished returns. Research in Health Science, 5(4), 1–17. https://doi.org/10.22158/rhs.v5n4p1
Besculides, M., & Laraque, F. (2005). Racial and ethnic disparities in perinatal mortality: Applying the perinatal periods of risk model to identify areas for intervention. Journal of the National Medical Association, 97(8), 1128–1132.
Braveman, P. G., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports (Washington, D.C.: 1974), 129, 19–31.
Brisendine, A. E., Rice, W. S., Goldfarb, S. S., & Wingate, M. S. (2020). The weathering hypothesis and stillbirth: Racial disparities across the life span. Ethnicity & Health, 25(3), 354–366. https://doi.org/10.1080/13557858.2017.1420145
Catalano, A., Bennett, A., Busacker, A., Carr, A., Goodman, D., Kroelinger, C., Okoroh, E., Brantley, M., & Barfield, W. (2017). Implementing CDC’s Level of Care Assessment Tool (LOCATe): A national collaboration to improve maternal and child health. Journal of Women’s Health, 26(12), 1265–1269. https://doi.org/10.1089/jwh.2017.6771
CityMatCH. (2012). Celebrating the 15th anniversary of PPOR’s conception. CityLights. Retrieved from https://www.citymatch.org/wp-content/uploads/2012/01/CityLights201212.pdf
Collins, J. W., Jr., & Butler, A. G. (1997). Racial differences in the prevalence of small-for-dates infants among college-educated women. Epidemiology (Cambridge, MA), 8(3), 315.
Ekeke, P., Mendez, D. D., Yanowitz, T. D., & Catov, J. M. (2020). Racial differences in the biochemical effects of stress in pregnancy. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph17196941
Fishman, S. H., Hummer, R. A., Sierra, G., Hargrove, T., Powers, D. A., & Rogers, R. G. (2020). Race/ethnicity, maternal educational attainment, and infant mortality in the United States. Biodemography and Social Biology, 66(1), 1–26. https://doi.org/10.1080/19485565.2020.1793659
Gregory, E. C., & Driscoll, A. (2014). User guide to the 2014 fetal death public use file. National Center for Health Statistics, Centers for Disease Control and Prevention. Retrieved from https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/fetaldeath/2014FetalUserGuide.pdf
Hodgkinson, S., Beers, L., Southammakosane, C., & Lewin, A. (2014). Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics, 133(1), 114–122. https://doi.org/10.1542/peds.2013-0927
Khoshnood, B., Wall, S., & Lee, K. S. (2005). Risk of low birth weight associated with advanced maternal age among four ethnic groups in the United States. Maternal and Child Health Journal, 9(1), 3–9. https://doi.org/10.1007/s10995-005-2446-4
Kim, E. W., Teague-Ross, T. J., Greenfield, W. W., Williams, K., Kuo, D., & Hall, R. W. (2013). Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. Journal of Perinatology, 33(9), 725–730. https://doi.org/10.1038/jp.2013.37
Kirmeyer, S., & MacDorman, M. (2006). User guide to the 2006 fetal death public use file. National Center for Health Statistics. Retrieved from https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/fetaldeath/2006FetalUserGuide.pdf
Kitagawa, E. M. (1955). Components of a difference between two rates. Journal of the American Statistical Association, 50(272), 1168–1194.
Kowaleski, J. L. (1997). State definitions and reporting requirements for live births, fetal deaths, and induced termination of pregnancy. 1997 edition (ISBN 0-8406-0534-X). Retrieved from Hyattsville
Müller-Nordhorn, J., Schneider, A., Grittner, U., Neumann, K., Keil, T., Willich, S. N., & Binting, S. (2020). International time trends in sudden unexpected infant death, 1969–2012. BMC Pediatrics, 20, 377.
Peck, M. G., Sappenfield, W. M., & Skala, J. (2010). Perinatal periods of risk: A community approach for using data to improve women and infants’ health. Maternal and Child Health Journal, 14(6), 864–874. https://doi.org/10.1007/s10995-010-0626-3
Prince, C. B., Young, M. B., Sappenfield, W., & Parrish, J. W. (2016). Investigating the decline of fetal and infant mortality rates in Alaska during 2010 and 2011. Maternal and Child Health Journal, 20(4), 754–759. https://doi.org/10.1007/s10995-015-1906-8
Roth, J., Hendrickson, J., Schilling, M., & Stowell, D. W. (1998). The risk of teen mothers having low birth weight babies: Implications of recent medical research for school health personnel. Journal of School Health, 68(7), 271–275. https://doi.org/10.1111/j.1746-1561.1998.tb00581.x
Sappenfield, W. M., Peck, M. G., Gilbert, C. S., Haynatzka, V. R., & Bryant, T., 3rd. (2010a). Perinatal periods of risk: Analytic preparation and phase 1 analytic methods for investigating feto-infant mortality. Maternal and Child Health Journal, 14(6), 838–850. https://doi.org/10.1007/s10995-010-0625-4
Sappenfield, W. M., Peck, M. G., Gilbert, C. S., Haynatzka, V. R., & Bryant, T., 3rd. (2010b). Perinatal periods of risk: Phase 2 analytic methods for further investigating feto-infant mortality. Maternal and Child Health Journal, 14(6), 851–863. https://doi.org/10.1007/s10995-010-0624-5
Schummers, L., Hacker, M. R., Williams, P. L., Hutcheon, J. A., Vanderweele, T. J., McElrath, T. F., & Hernandez-Diaz, S. (2019). Variation in relationships between maternal age at first birth and pregnancy outcomes by maternal race: A population-based cohort study in the United States. BMJ Open, 9(12), e033697. https://doi.org/10.1136/bmjopen-2019-033697
Shapiro-Mendoza, C. K., Camperlengo, L., Ludvigsen, R., Cottengim, C., Anderson, R. N., Andrew, T., Covington, T., Hauck, F. R., Kemp, J., & MacDorman, M. (2014). Classification system for the Sudden Unexpected Infant Death Case Registry and its application. Pediatrics, 134(1), e210. https://doi.org/10.1542/peds.2014-0180
Sims, J., & Coley, R. L. (2019). Variations in links between educational success and health: Implications for enduring health disparities. Cultural Diversity & Ethnic Minority Psychology, 25(1), 32–43. https://doi.org/10.1037/cdp0000239
Singh, G. K., & Yu, S. M. (2019). Infant mortality in the United States, 1915–2017: Large social inequalities have persisted for over a century. International Journal of Maternal and Child Health (MCH) and AIDS (IJMA), 8(1), 19–31. https://doi.org/10.21106/ijma.271
Vilda, D., Hardeman, R., Dyer, L., Theall, K. P., & Wallace, M. (2021). Structural racism, racial inequities and urban–rural differences in infant mortality in the US. Journal of Epidemiology and Community Health. https://doi.org/10.1136/jech-2020-214260
Wallace, M., Crear-Perry, J., Richardson, L., Tarver, M., & Theall, K. (2017). Separate and unequal: Structural racism and infant mortality in the US. Health & Place, 45, 140–144. https://doi.org/10.1016/j.healthplace.2017.03.012
Weinberg, D., Stevens, G., Finkenauer, C., Brunekreef, B., Smit, H. A., & Wijga, A. H. (2019). The pathways from parental and neighbourhood socioeconomic status to adolescent educational attainment: An examination of the role of cognitive ability, teacher assessment, and educational expectations. PLoS ONE, 14(5), e0216803. https://doi.org/10.1371/journal.pone.0216803
Woodall, A. M., & Driscoll, D.A. (2020). Racial and ethnic differences in mortality rate of infants born to teen mothers: United States, 2017–2018. NCHS Data Brief (371), 1–8.
Xaverius, P., Salas, J., Kiel, D., & Woolfolk, C. (2014). Very low birth weight and Perinatal Periods of Risk: Disparities in St. Louis. BioMed Research International, 2014, 547234. https://doi.org/10.1155/2014/547234
Funding
The work of Carol Gilbert and Pamela Xaverius was partially funded by a research grant from the US Health Resources and Services Administration (Grant No. HRSA-MCHB R40MC31761-01-00).
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The ideas for paper content and methods (assessing and reducing bias, using six PPOR outcomes, and percentile charts) were those of CSG, who did all the analysis for this paper. Both WMS and PKX reviewed, helped to develop, and approved the ideas for this paper. In addition, PKX organized, helped to write, and was PI on the MCHB grant. WMS, the main developer and articulator of the PPOR analytic methods, closely followed the analysis steps for this paper and gave feedback throughout the process. MKT contributed enormously to organization of the paper, including refining its scope.
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IRB exemption was obtained through the University of Nebraska Medical Center (# 667-18-EP). Analyses were completed using SAS 9.4.
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Gilbert, C.S., Xaverius, P.K., Tibbits, M.K. et al. Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses. Matern Child Health J 26, 2396–2406 (2022). https://doi.org/10.1007/s10995-022-03561-9
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DOI: https://doi.org/10.1007/s10995-022-03561-9