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BACKGROUND: Clark County compared well nationally in infant mortality, at 5.3 infant deaths per 1,000 live births in 2011, versus a national rate of 6.1 in the same year. Nonetheless, fetal mortality (stillbirths and miscarriages) as a proportion of perinatal deaths rose from 40% to 51.5% over the period 2003-12. To help target resources for opportunity gaps, the Perinatal Period of Risk (PPOR) protocol was adopted to help investigate the causal mechanisms underlying feto-infant mortality disparities in the community.
METHODS: Data from the live birth/fetal death and linked infant death registries for the period 2003-12 (combined up to five years) were used to partition feto-infant deaths (FID) into the PPOR risk periods (Maternal Health/Prematurity, Maternal Care, Newborn Care and Infant Health). Data were further analyzed by race/ethnicity to examine excess perinatal mortality risks attending population subgroups (relative to the non-Hispanic white [NHW] reference group) across the risk periods. The Kitagawa analysis was conducted to determine whether excess Maternal Health/Prematurity (MH/prem.) deaths were due to a higher frequency of very low birth weight (VLBW) births (birthweight pathway) or higher mortality rates at given birth weights (mortality pathway). In addition, underlying causes of death from linked live birth/death records were examined to determine predominant causes of excess Infant Health deaths.
RESULTS: The vast majority of FIDs occurred in the MH/prem. and Maternal Care periods. Non-Hispanic blacks (NHB) had FID rates well in excess of the reference group for all risk periods. Importantly, the birthweight pathway (high rates of VLBW), rather than that of mortality (poor survival rates), was the predominant cause of excess MH/prem. deaths among NHBs, accounting for 85.6% of the excess deaths. The potential for more immediate prevention of Infant Health mortality on the other hand, is greater for injury than other postneonatal causes of death. Suffocation was the primary mechanism for injury-related Infant Health deaths, accounting for over three-quarters of the injury-attributable Infant Heath mortality among NHBs, compared to 69% in NHWs and 58% in Hispanics.
CONCLUSIONS: The work reported here represents a first attempt to apply the PPOR principle in guiding feto-infant mortality reduction in Clark County. It underscores the challenges facing perinatal mortality reduction efforts including preconception health disparities and extreme prematurity, as well as the necessity of identifying risk factors related to excess infant mortality. The analysis also supports the fundamental importance of data capacity building, community mobilization and alignment to develop evidence-based interventions using the PPOR approach.