The ten most important things you need to know about the Perinatal Periods of Risk Approach for reducing infant mortality in urban communities.
- PPOR is a six stage approach used to reduce high feto-infant mortality rates in large urban communities.
- The PPOR Approach allows communities to examine infant mortality using all available information, beginning with vital records data files.
- PPOR brings community partners together to build consensus, support, and partnership by making complicated issues understandable.
- The PPOR Approach encourages a community to move from data to appropriate ACTION.
- PPOR provides a framework for targeting further investigations and actions.
- The underlying premise of PPOR is social justice: "If one population group can have low mortality, then other groups can reach that goal."
- PPOR fosters integration with other key efforts (community coalitions, Fetal Infant Mortality Reviews, needs assessments, asset mapping, Healthy Start, etc.).
- Be ready to run the numbers – you need "raw" data files and someone who can use them; a long-term commitment is beneficial.
- PPOR works best when stakeholders are on board and ready to champion the effort.
- PPOR is about impact and results: It builds data capacity, promotes effective data use, strengthens essential partnerships, encourages evidence-based interventions, helps leverage resources, enables systems change for improved health, and much, much more.
The development of PPOR was a joint initiative of CityMatCH at the University of Nebraska Medical Center, The Centers for Disease Control and Prevention, The National March of Dimes Birth Defects Foundation, and the Health Resources and Services Administration/Maternal and Child Health Bureau.
In 1997 CityMatCH convened a national working group of local and state MCH practitioners and public health scientists to find ways to improve local MCH data and assessment capacity. This group recommended an approach created by Dr. Brian McCarthy and used in developing countries, called the Periods of Risk Approach. With support from the Centers for Disease Control and Prevention (CDC), the National March of Dimes Birth Defects Foundation, the Health Resources and Services Administration/Maternal and Child Health Bureau (HRSA/MCHB), CityMatCH led national efforts to validate, enhance and adapt this approach for use in US cities with high infant mortality rates.
Since 2004, with funding from the CDC and the National Healthy Start Association, CityMatCH has promoted the integration of PPOR with broader MCH practice at the state and local levels, and has provided training and technical assistance to urban health departments, Healthy Start sites, and others who wish to use the approach to reduce infant mortality in their communities.
You can download THE HEALTHY NEWBORN: A REFERENCE MANUAL FOR PROGRAM MANAGERS by Joy Lawn, Brian McCarthy, and Suan Rae Ross at the CARE website Part 2 introduces many of the epidemiology concepts PPOR uses, including the two-dimensional BABIES matrix and the opportunity gap, and demonstrates their use in developing countries.
Designed for use in public health planning, PPOR has six stages that are repeated as the assessments, plans and reports are updated.
The PPOR approach has six stages that generally follow the public health planning cycle:
- Assure Analytic and Community Readiness;
- Conduct Analytic Phases of PPOR;
- Develop Strategic Actions for Targeted Prevention;
- Strengthen Existing and/or Launch New Prevention Initiatives;
- Monitor and Evaluate Approach; and
- Sustain Stakeholder Investment and Political Will.
PPOR can be adopted if a community is just beginning to address infant mortality, or parts of PPOR may be integrated with existing efforts. For example, if a Fetal Infant Mortality Review (FIMR) program already exists, the FIMR Community Action Team might elect to use PPOR analytic methods to gain a population perspective that complements the information provided by the case review process.
The PPOR approach recognizes that community involvement is necessary for understanding population behaviors and systems at the local level, and for creating real, positive change.
PPOR analysis begins with vital records data files - electronic lists of all births, infant deaths, and fetal deaths, to community residents. It provides a simple framework and steps for investigating the reasons for the deaths and prioritizing among potential prevention efforts.
PPOR is based on analysis of vital records data: birth certificates, fetal death certificates, and infant death certificates that have been linked to the birth certificate. The data files used in PPOR are electronic lists of all the births (deaths, or fetal deaths) in the study population, with information that was recorded by attending health professionals. The birth certificates include birth weight, gestational age, maternal characteristics, and details about the pregnancy and birth. Death certificates include the age at death and cause of death. Fetal death certificates include the both sets of data elements. PPOR analysis requires a minimum of 60 deaths over at most a five year period, and works best if there are more deaths.
In Phase 1 of PPOR analysis, the analyst divides fetal and infant deaths into four groups (the four periods of risk) and calculates a feto-infant mortality rate for each period. Then the community must select a reference group, which is a population whose low mortality rate serves as a goal that the study population should be able to reach. In each period of risk, and overall, the reference group's rate is subtracted from the rate for the study population. The differences, (called "gaps" or "excess mortality rates") represent preventable deaths that occurred in the study population. Generally, a community will benefit most from addressing the populations and periods of risk with the largest gaps. Additional (Phase 2) analysis is required to help the community determine what actions will have the most impact.
Phase 2 of PPOR analysis has three steps. In the first step, the community uses vital records and other local, population-based data to determine what causes of fetal and infant mortality are most likely to be contributing to the gaps discovered in Phase 1. Once the most important causes are determined, the second step uses local data to determine which of the known risk factors for those causes are most likely to be contributing to those gaps. The third step estimates the potential impact of addressing the contributing risk factors, so that the community can better prioritize its prevention efforts.
PPOR methods facilitate the use of data sources beyond vital records to identify factors that may be contributing to infant mortality gaps. These might include PRAMS, BRFSS, Child Death Reviews, hospital discharge databases, etc. Communities can benefit from incorporating into the decision making process information about special populations (such as WIC, Medicaid, and low income health clinics), or results from case study methods (such as Fetal Infant Mortality Reviews).
You are free to use any of the materials on this website, however we request that you cite CityMatCH when publishing reports or articles.
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