Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses

Carol S. Gilbert, Pamela K. Xaverius, Melissa K. Tibbits, William M. Sappenfield

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)2396-2406
Number of pages11
JournalMaternal and Child Health Journal
Issue number12
StatePublished - Dec 2022


  • Community planning
  • Feto-infant mortality
  • Health disparities methodology
  • Infant mortality prevention
  • Perinatal Periods of Risk

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Epidemiology
  • Obstetrics and Gynecology
  • Public Health, Environmental and Occupational Health


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