The Promising Approaches to Improve Birth Outcomes: Fetal Infant Mortality Review (FIMR), Perinatal Periods of Risk (PPOR), and the Los Angeles Mommy and Baby (LAMB) Project targets maternal, child and adolescent health professionals, community based organizations, and policy makers. Between 1999 and 2002, the infant mortality rate in the Antelope Valley (AV) area of LAC increased 112%, from 5.0 per 1,000 live births to 10.6. In response the Los Angeles County Health Department, Maternal, Child, and Adolescent Health Programs (LACPH MCAH) collaborated with the local health officer and community stakeholders to adopt the Perinatal Periods of Risk (PPOR) approach, initiate the Fetal Infant Mortality Review (FIMR) process, and implement a population-based survey of postpartum women, the Los Angeles Mommy and Baby (LAMB) Survey, to identify areas of need during fall, 2004.
The collaborative County-Community best practice resulted in the identification of 12 short term and 4 long term strategies to improve infant mortality and the formation of the Antelope Valley Best Babies Collaborative (AVBBC), a partnership of over 40 local agencies, health care providers, the faith community, and residents, which continues to implement and coordinate programs and policies. The goals of this practice were to decrease infant mortality and improve birth outcomes in the Antelope Valley area. The following objectives were also addressed:
Adopted PPOR approach to engage the AV community in determining steps needed to investigate the reasons for excess infant deaths.
Implemented FIMR and LAMB projects to identify potential risk factors associated with adverse birth outcomes associated with infant mortality.
Collaborated with the AV community to form and support strategies to improve birth outcomes based on findings from FIMR and LAMB.
The outcomes of practice include:
PPOR approach was used to engage the AV local community in identifying steps needed to investigate the increased infant mortality rate.
FIMR and LAMB projects were implemented to identify potential risk factors associated with poor birth outcomes.
Collaborated with the local community to form and support strategies to improve birth outcomes, based on findings from PPOR, FIMR and LAMB. The Antelope Valley Best Babies Collaborative (AVBBC), a community collaborative, was formed to improve birth outcome in the AV.
This practice addresses the 112% rise in infant mortality between 1999 and 2002 in the Antelope Valley (SPA1) area of LAC. LAC is geographically divided into eight Service Planning Areas (SPAs). Although the number of infant deaths in SPA 1 represented only 6% of the infant deaths reported in LAC, the infant mortality rate (number of deaths per 1,000 live births) exceeded that of all other SPAs. The AV area is unique among LAC SPAs. Located in the northeast region of LAC, this desert area is the largest, least densely populated area of the county. Transportation and services are limited. It is an area of rapid growth and demographic change.
Over half the population is comprised of racial/ethnic minorities. The availability of middle income housing has attracted many young families to the area.PPOR empowered the community to take action based on the data findings. A FIMR process was quickly formed through collaborative efforts of the Area Health Officer, the LHD, and community-based stakeholders, and community health providers to the finalize data collection form, facilitate the data collection process, and mobilize resources (Public Health nurses). FIMR provided detailed medical and some pychosocial factors related to fetal/infant deaths. LHD researchers and epidemiologists engaged community to develop survey through four focus groups and input from community stakeholders. The LAMB survey captured concerns expressed by AV resident mothers, such as poor transportation, difficulty accessing care, limited high-risk obstetrical care services, and other risk factors. LAMB identified factors associated with adverse birth outcomes associated with infant mortality.
Adopting PPOR approach involved a new community analytical framework for fetal infant mortality and integrating it with FIMR and the Los Angeles Mommy and Baby Survey Project. This proces involved five major steps: Engage community early to gain consensus and support; Map fetal;/infant mortality by birth weight and age of deaths; Focus on reducing the overall feto-infant mortality rate; Examine potential opportunity gaps between population groups; and Target further investigation and prevention efforts on the gaps.
While the PPOR approach in data analyses provided a general direction to the potential prevention efforts, the collaborative went one step further to conduct Fetal Infant Mortality Review on the 53 infant deaths and a population-based survey of postpartum women (LAMB) to identify the specific risk factors associated with infant deaths. Results of both studies were presented to the community collaborative to identify areas of intervention (i.e. evidence-based process). Based on the findings, derived specific objectives and action steps to address the disparities in infant mortality. The three approaches effectively engaged the community to translate data into action.
Agency Community RolesIn response to the report, “Key Indicators of Health by Service Planning Area” issued by the LAC Department of Health Services, LHD initiated the investigation of infant mortality and continues to provide consultation, technical support and assistance with funding opportunities. Epidemiologists and researchers compiled and analyzed data. The Area Health Officer and Director of the LHD Maternal, Child, and Adolescent Health Programs acted as liaisons between the LHD and community and directed all activities. From the beginning, LHD invited community stakeholders to planning meetings; together the resulting collaborative was instrumental in the development and implementation of strategies adopted to improve birth outcomes.
The community stakeholders included the media, community-based organizations, and health providers.The Antelope Valley Best Babies Collaborative (AVBBC), which was formed during 2005, consists of over 40 local agencies, health care providers, the faith community, residents, the SPA 1 Area Health Office, LHD staff, and staff from the Los Angeles Best Babies Network (LABBN). Major local agencies participating include the Antelope Valley Black lnfant Health Project, Healthy Homes of Antelope Valley Hospital, and Antelope Valley Partners for Health. AVBBC was recently selected to receive a planning grant as part of the Healthy Births Initiative funded by First Five LA.
The AVBBC has become the main driving force in the planning and implementation of the strategies adopted to improve birth outcomes. As the AVBBC continues its efforts, it recognizes the need and challenge to evaluate the collective efforts. It is in the process of developing an evaluation plan, process, and tool to evaluate the effectiveness of the collaborative effort. The LHD is committed to providing data for evidence-based planning and program development involving community stakeholders.
Costs and ExpendituresFunding sources included Title V funds through the California Department of Health Services, Maternal, Child and Adolescent Health Branch.The practice describes a collaborative effort. Implementation, start-up and in-kind costs were absorbed by participating partners within the collaborative.
ImplementationLHD initially met with community providers to present the public health issue and explain how PPOR could be used to identify areas of need and suggest the next steps necessary to formulate evidence-based solutions. LHD and the AV Area Health Officer met with members of the community infrastructure to discuss strategies and set a timeline for strategic implementation and report of findings. Group discussed community and family support, research and information needed, legislation, and public policy.
1.PPOR approach was used to engage the AV local community in identifying steps needed to investigate the increased infant mortality rate (April – June 2004).
Conducted PPOR analysis using 2001 linked birth-death data.
Presented PPOR findings to AV community.
Reached consensus to launch the FIMR and LAMB projects.
2.FIMR and LAMB projects were implemented to identify potential risk factors associated with poor birth outcomes (May 2004 – March 2005).
Public Health nurses investigated 53 infant cases using National FIMR forms and procedures.
Surveyed over 1,000 mothers residing in the AV area that had a live birth 0-7 months previously.
Summarized findings from FIMR and LAMB projects.
3.Collaborated with local community to identify interventions/strategies to improve birth outcomes based on findings from the PPOR analyses, FIMR, and LAMB Project (May 2005 – ongoing).
Disseminated findings from LAMB to the community.
Worked with AV community to identify intervention/strategies to improve birth outcomes based on findings form LAMB/FIMR.
Objective 1: Adopt PPOR approach to engage the AV community stakeholders to determine steps needed to investigate the increased infant mortality rate in AV.
Performance Measures: Over 50 community stakeholders attended AV Community Group meetings (April, May, June 2004); PPOR approached was presented; Identified necessary steps to investigate increased infant mortality in AV.
Feedback: Early engagement of community, strong leadership, and media coverage instrumental in publicizing public health issue and gaining community cooperation. LHD established an enhanced surveillance system to monitor fetal/infant mortality.
Outcomes: Short-term - Community engaged; PPOR determined excess mortality and potential areas for intervention. Intermediate & Long-term - Community involvement through collaborative continued; continuation of policy and programmatic work.
Objective 2: FIMR and LAMB projects were implemented to identify potential risk factors associated with poor birth outcomes.
Performance Measures: LHD completed FIMR case reivew; LHD completed implementation of the LAMB project.
Feedback: FIMR - Timely implementation depends on strong collaboration and support between the LHD and community; Establishment of population-based survey of mothers who experienced fetal or infant loss. Survey captures information collected through traditional FIMR process. LAMB - Community support contributed to high response rate and advocacy for countywide survey.
Outcomes: Short-term - Conduct FIMR case review of deceased infants & identify factors associated with adverse birth outcomes associated with infant mortality. Intermediate & Long-term - Established ongoing, countywide surveillance system for fetal/infant mortality. LAMB expanded countywide.
Objective 3: Collaborated with local community to identify strategies in improving birth outcomes, based on findings from PPOR, FIMR and LAMB.
Performance Measures: Community meeting in Mary 2005. Interventions were identified by the community.
Feedback: Improved birth outcomes requires effective collaboration among the County and community, strong leadership, the media, and commitment of all involved.
Outcomes: Short-term - Community identified 12 short-term interventions to pursue. Intermediate & Long-term: Community identified 4 long-term interventions to pursue.
SustainabilityStakeholder commitment is sustained through the leadership of the AV Healthy Births Learning Collaborative, the local health department and the newly funded Antelope Valley Best Babies Collaborative. The LHD continues to work with community partners on policy initiatives that will sustain funding for the programs to address infant mortality over time. The LHD’s commitment to provide data for community partners through PPOR, FIMR and LAMB will sustain the interest in the issue.
Lesson learned include:
Early engagement of community, strong leadership, and media coverage instrumental in publicizing public health issue and gaining community cooperation.
FIMR - Timely implementation depends on strong collaboration and support between the LHD and community; Establishment of population-based survey of mothers who experienced fetal or infant loss. Survey captures information collected through traditional FIMR process.
LAMB - Community support contributed to high response rate and advocacy for countywide survey.
Improved birth outcomes requires effective collaboration among the County and community, strong leadership, the media, and commitment of all involved.