The Perinatal Periods of Risk (PPOR) Approach
For Preventing Infant Mortality in US Urban Communities
The PPOR approach was developed during 2000-2004 by
CityMatCH www.CityMatCH.org and its member health
departments, with support and involvement of the Centers for
Disease Control and Prevention and the March of Dimes. It was
adapted for U.S. cities from an approach used by the World
Health Organization (The Healthy Newborn Lawn J, McCarthy BJ,
and Ross SR.1) PPOR methods are detailed in a suite of articles in
the Maternal and Child Health Journal.2
PPOR brings community stakeholders together to build consensus, support, and partnership
around evidence, or “data” based on vital records. The initial (Phase 1 analysis) data are fetalinfant mortality numbers, rates, and rate differences, which are organized according to four
Perinatal Periods of Risk based on both birth weight and age at death. The periods of risk are
useful because causes of death tend to be similar within each, so when a community finds that
its problems lie in only one or two periods of risk, efforts can be focused on those periods.
A distinctive feature of PPOR is its use of a “reference group,” a population with near-optimal
birth outcomes. This reference group is a real population of mothers selected by the
stakeholders. It provides a realistic benchmark or target toward which the community can
strive, and allows estimation of preventable or excess mortality even when preventability
cannot be determined for each case of death. The reference group can be an internal reference
group (such as white, educated women within the city) or an external group. The key analytic
step is subtraction of the reference population mortality rate from the study population
mortality rate in each period of risk and overall. The periods of risk that contribute most to the
overall excess mortality become the subject of further study.
To determine how to reduce the mortality disparity in the period of risk under study, the
community uses local vital records and other data to examine the causes of death and risk
factors known to contribute to mortality within that period. First, the primary causes of the
excess mortality are determined. Second, the risk factors most likely to be contributing to those
causes are identified. Third, the potential impact of reducing the identified risk factors is
estimated. These three steps, which comprise Phase 2 of PPOR analysis, allow stakeholders to
prioritize action based on the best available evidence.
Urban communities across the U.S. have used PPOR as a way to monitor progress (surveillance),
to guide public health planning, and to help prioritize prevention activities.
1The Healthy Newborn is available for download here:
http://www.care.org/careswork/whatwedo/health/hpub.asp? )
2 MCHJ Volume 16, Number 6/November 2010
http://www.springerlink.com/content/1092-7875/14/6/ on pages 838-874.
Updated 2/15/2012