Integrated approaches to improve birth outcomes: Perinatal periods of risk, infant mortality review, and the Los Angeles Mommy and Baby project

This article provides an example of how PerinatalPeriods of Risk (PPOR) can provide a framework and offer analytic methods that move communities to productiveaction to address infant mortality. Between 1999 and 2002, the infant mortality rate in the Antelope Valleyregion of Los Angeles County increased from 5.0 to 10.6per 1,000 live births. Of particular concern, infant mortalityamong African Americans in the Antelope Valley rosefrom 11.0 per 1,000 live births (7 cases) in 1999 to 32.7 per1,000 live births (27 cases) in 2002. In response, the Los Angeles County Department of Public Health , Maternal, Child, and Adolescent Health Programs partnered with acommunity task force to develop an action plan to addressthe issue. Three stages of the PPOR approach were used:(1) Assuring Readiness; (2) Data and Assessment, whichincluded: (a) Using 2002 vital records to identify areas withthe highest excess rates of feto-infant mortality (Phase 1PPOR), and (b) Implementing Infant Mortality Review(IMR) and the Los Angeles Mommy and Baby (LAMB)Project, a population-based study to identify potentialfactors associated with adverse birth outcomes. (Phase 2PPOR); and (3) Strategy and Planning, to develop strategicactions for targeted prevention. A description of stakeholders'commitments to improve birth outcomes and monitor infant mortality is also given. The Antelope Valleycommunity was engaged and ready to investigate the localrise in infant mortality. Phase 1 PPOR analysis identifiedMaternal Health/Prematurity and Infant Health as the mostimportant periods of risk for further investigation and potential intervention. During the Phase 2 PPOR analyses, IMR found a significant proportion of mothers with previousfetal Los s (45%) or low birth weight/preterm (LBW/PT) birth, late prenatal care (39%), maternal infections(47%), and infant safety issues (21%). After adjusting forpotential confounders (maternal age, race, education level, and marital status), the LAMB case-control study (279controls, 87 cases) identified additional factors associatedwith LBW births: high blood pressure before and duringpregnancy, pregnancy weight gain falling outside of therecommended range, smoking during pregnancy, and feeling unhappy during pregnancy. PT birth was significantlyassociated with having a previous LBW/PT birth, not taking multivitamins before pregnancy, and feelingunhappy during pregnancy. In response to these findings, community stakeholders gathered to develop strategicactions for targeted prevention to address infant mortality.Subsequently, key funders infused resources into thecommunity, resulting in expanded case management ofhigh-risk women, increased family planning services and local resources, better training for nurses, and public Health initiatives to increase awareness of infant safety. Communityreadiness, mobilization, and alignment in addressinga public Health concern in Los Angeles County enabledthe integration of PPOR analytic methods into the establishedIMR structure and [the design and implementationof a population-based l study (LAMB)] to monitor thefactors associated with adverse birth outcomes. PPORproved an effective approach for identifying risk and socialfactors of grea Test concern, the magnitude of the problem, and mobilizing community action to improve infant mortalityin the Antelope Valley.