Revealing Disparities in
Pregnancy Outcomes Using
PPOR and FIMMRR
Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD,
MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA
Center for Maternal and Child Health
State University of New York Upstate Medical University
Department of Obstetrics and Gynecology
Supported by a grant from the Community Health Foundation of Western and Central New York.
The Community Health Foundation is a non-profit private foundation with a mission to
improve the health and health care of the people of Western and Central New York.
February 2010
Objective
To examine the relationship of
poor socioeconomic condition, as
reflected by Medicaid status, to
poor outcomes of pregnancy.
The Central New York Region consists of a 13 county area spanning
from St. Lawrence County in the North to Broome and Tioga
counties in the South and includes 21 birth hospitals.
Statewide Perinatal Data System (SPDS)
Population-based birth registry that captures
information on all live births in New York State. It
consists of the New York State Electronic Birth
Certificate (EBC) and additional voluntary questions,
e.g., such as the content of prenatal care, intentions of
pregnancy, and perinatal depression, that are expected
to be used for quality improvement purposes. The
SPDS contains data on: maternal demographics;
obstetrical history; prenatal care; labor and delivery
information; and birth outcomes.
SPDS: Pay Source Coding
Medicaid – select this choice if the mother’s care was paid for by Medicaid, PCAP,
MOMS, Child Health Plus A, Medicaid Managed Care, or Family Health Plus (39.8%)
Private Insurance – select this item if the mother’s care was paid for by private
insurance including indemnity insurance and/or managed care insurance (51.2%)
Self-pay – select this item if the mother had no health insurance (1.1%)
Indian Health Service (0.1%)
CHAMPUS/TRICARE (Military and dependents) (5.0%)
Other government (e.g. Child Health Plus B, Veteran’s Administration) (1.0%)
Other (1.8%)
Unknown (0.1%)
Medicaid group also applies to Medicaid as secondary payor. (5.5%)
Fetal-Infant Mortality/Morbidity
Review/Registry (FIMMRR)
Clinically oriented, community based registry to capture
detailed data on mortalities/ morbidities for the 21 birth
hospitals in the Central New York Region.
By evaluating data from chart reviews of all fetal and
infant mortalities (≥ 300 grams) as well as major
morbidities, patterns have been identified which have
informed recommendations for improvements (both
social and medical).
FIMMRR: Maternal Risk Factors
____ Major pre-pregnancy medical problems: ________________
____ Poor OB History:
____ History of infertility
____ 2 Prior losses before 20 weeks
____ Prior loss after 20 weeks
____ History of preterm delivery
(<37 Wks)
____ History of previous SGA/IUGR birth
____ Poor nutrition, BMI______
(circle) Obese, underweight
____ Poor Care Seeker (circle)
Second Trimester, Third Trimester, No Prenatal Care
____ Poor compliance with prenatal visits (missed >2)
____ Substance abuse (circle)
Tobacco, alcohol, marijuana, prescription drugs, other
____ Poor social setting (in present pregnancy):
____ < 12th Grade education completed and no GED
____ Partner uninvolved
____ History of parenting problems
____ Other
____ Transportation problems
____ Occupational problems
____ Family planning problems
____ Economic issues:
____ Unemployed/ partner unemployed
____ Medicaid Insurance
____ Needs public assistance (housing, healthcare, etc.)
____ WIC referral
____ Other
____
____
____
____
____
____
Adolescent pregnancy (≤ 16 y.o.)
Advanced maternal age (≥ 35 y.o.)
Housing problems
Mental illness (past or present)
Maternal stress:
Emotional stress (at work or home)
____ Physical stress (at work or home)
____ Loss of partner (circle)
Divorce, Separation, Death, Military Deployment, Other
____ Death of family member
____ Pt or partner incarcerated/Legal problems
____ Other
____ Family violence
____ Cultural problems:
____ Recent immigrant (Non-Western origin)
____ Language barrier (written or verbal)
____ Cultural/Religious belief system limits or
prohibits medical interventions
____ Other
____ Less than 6 months since last birth
____ Current pregnancy result of Assisted
Reproductive Technology
____ Other
FIMMRR: Causes of Fetal Death /
Prenatal/Intrapartal Factors
Contributing to Infant Death
_____ Abruptio Placenta/Placental Infarct
_____ Antiphospholipid/SLE Syndrome
_____ Blood Factor Sensitization
_____ Chorioamnionitis (bacterial)
_____ Chronic hypertension/Pre-eclampsia
_____ Cocaine Abuse
_____ Diabetes: Class ___, Type ___
_____ Fetal Anomaly/Chromosomal Abnormality
_____ Feto-Maternal Hemorrhage
_____ Perinatal TORCH Infection __________
_____ Intrapartal asphyxia
_____ Intrauterine Growth Restriction
_____ Maternal Trauma – Type ____________
_____ Non-Immune Hydrops
_____ Termination of Pregnancy,
Indication__________________
_____ Twin-Twin Transfusion Syndrome
_____ Other ________________
FIMMRR: Causes of Infant Death
Circle single dominant cause, check all others noted:
_____Congenital Anomaly/Chromosomal Abnormality
_____Metabolic Disorder
_____Sepsis – Bacterial
_____Perinatal Viral Infection
_____Perinatal asphyxia
_____Hyaline Membrane Disease
_____Blood Factor Sensitization
_____CNS hemorrhage
_____SIDS
_____Trauma – accident
_____Termination of Pregnancy, Indication
_____Overwhelming Immaturity
_____Unexplained
_____Physical Abuse/Neglect
_____Other _____________________
If SIDS, check-off appropriate items:
_____Co-sleeping
_____ Smoking Household
_____ Substance Abuse in Household
_____ Use of Any Impairing Substance
_____ Unsafe Sleep Environment
_____ Exclusive Breastfeeding
_____ Any Breastfeeding
_____Unsafe Sleep Environment
_____Smoking Household
_____Substance Abuse in Household
_____Prone Sleeping
_____Other _______________
FIMMRR: Causes of Death-ICD10
_____Congenital malformations, deformations and chromosomal abnormalities
_____Disorders related to short gestation, low birth weight, not elsewhere classified
_____Sudden infant death syndrome
_____Newborn affected by maternal complications of pregnancy
_____Newborn affected by complications of placenta, cord and membranes
_____Accidents (unintentional injuries)
_____Respiratory distress of newborn
_____Bacterial sepsis of newborn
_____Neonatal hemorrhage
_____Intrauterine hypoxia and birth asphyxia
_____All other causes
Data Notes
Statewide Perinatal Data System (SPDS)


primary source for population characteristics
secondary source for identification of neonatal
and post neonatal deaths
Fetal Infant Morbidity/Mortality Review/Registry
(FIMMRR)


only source for detailed data on fetal deaths
primary source for detailed data on neonatal and post
neonatal deaths
Population Characteristics
Central New York Region 2006-2007
≥ 300 grams
Total
Non-Medicaid
Insured
Medicaid
Insured
Live Births + Fetal Deaths
38962
21277
17685
Live Births
38739
21166
17573
Maternal Age (<17 y)
1.2%
0.3%
2.2%
< .001
Maternal Race (non-white)
14.7%
9.4%
21.0%
< .001
Maternal Education (< 12 y)
16.0%
4.3%
30.2%
< .001
Marital Status (not married)
42.5%
17.8%
72.2%
<.001
p value
Population Characteristics
Central New York Region 2006-2007
Non-Medicaid Medicaid
p value
Insured
Insured
≥ 300 grams
Total
Live Births + Fetal Deaths
38962
21277
17685
Live Births
38739
21166
17573
Early Prenatal Care
75.3%
84.4%
64.3%
< .001
Adequate Prenatal Care
82.5%
88.4%
75.4%
< .001
Smoking During
Pregnancy
21.8%
10.3%
35.6%
< .001
Illegal Drug Use
2.1%
0.5%
4.1%
< .001
Obese (prepregnancy BMI>30)
27.1%
25.8%
28.7%
< .001
Breastfeeding
67.6%
76.8%
56.6%
< .001
Birth Outcomes
Despite increased risk factors for the
Medicaid insured women, most birth
outcomes in the Central New York
Region are not significantly different
between Medicaid and Non-Medicaid
insured women.
Gestational Age
Central New York Region 2006-2007
Non-Medicaid Medicaid
Insured
Insured
≥ 300 grams
Total
Live Births + Fetal Deaths
38962
21277
17685
Live Births
38739
21166
17573
Preterm
9.7%
9.8%
9.5%
NS
<24 weeks
0.2%
0.2%
0.2%
NS
24-27 weeks
0.5%
0.4%
0.5%
NS
28-31 weeks
1.0%
1.0%
0.9%
NS
32-36 weeks
8.0%
8.1%
7.9%
NS
37+ weeks
90.3%
90.2%
90.4%
NS
p value
Birthweight/Intrauterine Growth
Central New York Region 2006-2007
≥ 300 grams
Total
Non-Medicaid
Insured
Medicaid
Insured
Live Births + Fetal Deaths
38962
21277
17685
Live Births
38739
21166
17573
LBW (<2500 grams)
7.7%
7.3%
8.2%
< .001
VLBW (<1500 grams)
1.4%
1.5%
1.4%
NS
ELBW (< 1000 grams)
0.6%
0.7%
0.7%
NS
Small for Gestational Age
10.6%
7.0%
13.4%
< .001
Large for Gestational Age
9.1%
10.8%
8.2%
< .001
p value
Morbidity
Rates of LBW and especially Small for
Gestational Age are significantly higher
in Medicaid Insured births.
Mortality
Using the Fetal-Infant Morbidity/Mortality
Review/Registry (FIMMRR), we also explored
the Fetal/Infant death rates among Medicaid and
Non-Medicaid insured women.
Standard Calculation of Death Rates
(all ≥ 300 grams)
Overall
number of total deaths/total live births + fetal deaths
Fetal
number of intrauterine deaths/total live births + fetal deaths
Neonatal
number of deaths ≤ 28 days of life/total live births
Post-Neonatal
number of deaths 29 -365 days of life/total live births
Infant
Neonatal + Post-Neonatal
Central New York Region 2006-2007
Total Live Births + Fetal Deaths = 38962
14
*
Total
Non-Medicaid Insured
Medicaid Insured
rate/1000
12
10
*
8
6
4
*
2
0
Overall
Fetal
Neonatal
PostNeonatal
* p< .001 Non-Medicaid Insured vs Medicaid Insured
Infant
Central New York Region 2006-2007
Total Live Births + Fetal Deaths = 38962
Overall
Fetal
Neonatal
Post
Neonatal
Infant
Total
11.4
5.7
4.3
1.4
5.7
Non-Medicaid
9.4
5.2
3.7
0.5
4.2
Medicaid
13.7
6.3
5.0
2.5
7.5
≥ 300 grams
Findings
The significant difference in mortality is concentrated
within the Infant Deaths, most strikingly the PostNeonatal Deaths.
The lack of a significant difference in mortality for both
Fetal and Neonatal Deaths, suggests a potential
protective effect by Medicaid.
Further analysis, using the Perinatal Periods of Risk
approach, provided a different prospective.
Total
Central New York Region 2006-2007
Live Births + Fetal Deaths = 38962
Overall Fetal-Infant Mortality Rate 11.3 per 1, 000 Live Births & Fetal Deaths
Age at Death
Fetal Death
Post- neonatal
Birthweight
Maternal Health/
Prematurity 6.9
300-1499 g
1500+ g
Neonatal
Maternal
Care
Newborn
Care
Infant
Health
1.9
1.4
1.1
Non-Medicaid Insured
Central New York Region 2006-2007
Live Births + Fetal Deaths = 21277
Overall Fetal-Infant Mortality Rate 9.4 per 1, 000 Live Births & Fetal Deaths
Age at Death
Fetal Death
Post- neonatal
Birthweight
Maternal Health/
Prematurity 6.1
300-1499 g
1500+ g
Neonatal
Maternal
Care
Newborn
Care
Infant
Health
2.0
0.9
0.4
Medicaid Insured
Central New York Region 2006-2007
Live Births + Fetal Deaths = 17685
Overall Fetal-Infant Mortality Rate 13.7 per 1, 000 Live Births & Fetal Deaths
Age at Death
Fetal Death
Post- neonatal
Birthweight
Maternal Health/
Prematurity 8.0
300-1499 g
1500+ g
Neonatal
Maternal
Care
Newborn
Care
Infant
Health
1.8
1.9
2.0
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Non-Medicaid Medicaid
Insured
Insured
≥ 300 grams
Total
Live Births + Fetal Deaths
38962
21277
17685
Live Births
38739
21166
17573
Overall Fetal-Infant Mortality Rate
11.3
9.4
13.7
S
Maternal Health/Prematurity
6.9
6.1
8.0
S
Maternal Care
1.9
2.0
1.8
NS
Newborn Care
1.4
0.9
1.9
NS
Infant Health
1.1
0.4
2.0
S
sig
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Reference Non-Reference
sig
Group
Group
≥ 300 grams
Total
Live Births + Fetal Deaths
38962
26806
12156
Live Births
38739
26667
12072
Overall Fetal-Infant Mortality Rate
11.3
9.6
15.2
S
Maternal Health/Prematurity
6.9
5.9
9.3
S
Maternal Care
1.9
1.8
2.1
NS
Newborn Care
1.4
1.2
1.7
NS
Infant Health
1.1
0.7
2.2
S
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Non-Medicaid Medicaid Reference
Insured
Insured
Group
≥ 300 grams
Total
Live Births + Fetal Deaths
38962
21277
17685
26806
Live Births
38739
21166
17573
26667
Overall Fetal-Infant Mortality Rate
11.3
9.4
13.7
9.6
Maternal Health/Prematurity
6.9
6.1
8.0
5.9
Maternal Care
1.9
2.0
1.8
1.8
Newborn Care
1.4
0.9
1.9
1.2
Infant Health
1.1
0.4
2.0
0.7
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Excess Mortality Rates
in comparison with Reference Group
Total
Non-Medicaid
Insured
Medicaid
Insured
Overall Fetal-Infant Mortality Rate
1.70
-0.20
4.1
Maternal Health/Prematurity
1.00
0.20
2.10
Maternal Care
0.10
0.20
0.00
Newborn Care
0.20
-0.30
0.70
Infant Health
0.40
-0.30
1.30
≥ 300 grams
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Excess Mortality Numbers
in comparison with Reference Group
Total
Non-Medicaid
Insured
Medicaid
Insured
Overall Fetal-Infant Mortality Rate
66
-4
73
Maternal Health/Prematurity
39
4
37
Maternal Care
4
4
0
Newborn Care
8
-6
12
Infant Health
16
-6
23
≥ 300 grams
Perinatal Periods of Risk (PPOR)
Central New York Region 2006-2007
Comparison to Reference Group supports our
previous Findings.
It is also useful to examine the distribution of
various causes of death in each PPOR category.
Fetal-Infant Morbidity/Mortality Review & Registry
Central New York Region 2006-2007
Dominant Cause of Death: rate/1000 live births + fetal deaths
≥ 300 grams
Abruptio/Placental Infarct
Other Placental Problems
Cord Accident/Prolapse
Congenital Anomaly/
Chromosomal Abnormality
Prematurity
Overwhelming Immaturity
Other
Sepsis
SIDS/SUID
Trauma
Unexplained
Maternal Health/Prematurity
Maternal Care
Non-Medicaid
6.1
0.66
0.47
0.29
1.34
Medicaid
8.0
1.41
0.56
0.45
1.02
Non-Medicaid
2.0
0.23
0.33
0.38
0.33
Medicaid
1.8
0.45
0.39
0.11
0.06
0.52
2.05
0.15
0.19
0
0
0.43
0.96
2.25
0.34
0.34
0.11
0.06
0.50
0
0
0.14
0
0
0
0.57
0.17
0
0.11
0.06
0
0
0.45
Fetal-Infant Morbidity/Mortality Review & Registry
Central New York Region 2006-2007
Dominant Cause of Death: rate/1000 live births + fetal deaths
≥ 300 grams
Abruptio/Placental Infarct
Other Placental Problems
Cord Accident/Prolapse
Congenital Anomaly/
Chromosomal Abnormality
Prematurity
Overwhelming Immaturity
Other
Sepsis
SIDS/SUID
Trauma
Unexplained
Newborn Care
Infant Health
Non-Medicaid
0.9
0
0.22
0
0.54
Medicaid
1.9
0
0.06
0.06
1.34
Non-Medicaid
0.4
0
0
0
0.13
Medicaid
2.0
0
0
0
0.46
0
0
0.09
0.05
0
0
0
0
0
0.06
0.17
0.11
0.11
0
0
0
0
0.04
0.18
0.04
0
0
0
0.29
0.11
0.74
0.4
0
Cause of Death Conclusions
These findings support our earlier Findings that
pre-pregnancy and early pregnancy factors, along
with post neonatal factors play the largest role in
the disparity between death rates among Medicaid
and Non-Medicaid insured women.
A protective effect of Medicaid Status is
suggested regarding Fetal and Neonatal deaths.
Sharing the Results
CNY Regional Perinatal Forum
CNY Regional Perinatal Program/Affiliate Hospitals
Onondaga County Health Department/Syracuse Healthy Start
SUNY Upstate Medical University
Departmental Grand Rounds (OB-GYN/Pediatrics)
Masters in Public Health courses
Resultant Targeted Interventions

Improve preconceptional/interconceptional care
 Facilitate access to early/quality prenatal care
 Implement stronger smoking cessation programs
 Improve maternal post partum supports and
counseling about importance of Safe Sleep
Environment
Contact Information:
Center for Maternal & Child Health
www.upstate.edu/cmatch/
315-464-5706

Richard H. Aubry, MD, MPH
 Pamela Parker, BA
 Kristen Luke-Houseman, RN, BA
aubryr@upstate.edu
parkerp@upstate.edu
lukehouk@upstate.edu
Preliminary Data. Not for release without permission.