This study used the PPOR model to categorize fetal and infant deaths in New York City, describe racial/ethnic disparities and guide interventions. During 1996-2000, the average feto-infant mortality rate was 11.5/1,000 live births plus fetal deaths for the city. Statistically significant racial/ethnic differences in feto-infant mortality were found with black non-Hispanic women experiencing a much higher rate of feto-infant mortality compared to other groups.
According to the analysis, conditions related to maternal health and prematurity were the leading contributing factors to feto-infant mortality for both the city as a whole and for each racial/ethnic group. If the hypotheses behind the PPOR model are true, interventions to further reduce fetal and infant deaths in New York City should include the provision of primary care for all women and preconception care to those who wish to conceive. Improving access to primary care for women will help control or eliminate factors that negatively impact pregnancy, HIV infection (treating HIV infection when used along with other medicines), nutritional deficiencies, smoking, alcohol and drug use, and unintended pregnancy. Since few pregnancies are planned, preconception care is best given through routine primary care visits, with a focus on preparing for pregnancy and promoting the use of folic acid, genetic counseling and reducing noxious environmental exposures on both future mother and father. Of course, preconception care should be provided in addition to—and not instead of—proven interventions, such as prenatal care, use of surfactant for premature infants and putting infants to sleep on their back, to name only a few interventions. These interventions, however, can only be useful if accessible to all women. Documented disparities in access to care as well as difficulties accessing routine women and child care found in New York City make preconception care an elusive goal unless access to care is improved. Thus, a main area for intervention is to increase access to care, particularly for low-income and minority groups.
There are numerous arguments for starting pregnancy and infant health interventions before pregnancy, such as:
1) the association between unintended and unwanted pregnancies and poorer pregnancy and infant outcomes,
2) the link between low socioeconomic status and poor health of the mother and consequent higher infant mortality rates,
3) the association between chronic illnesses (diabetes, HIV-infection) and poor pregnancy outcomes and increased infant mortality, and
4) the relationship between receipt of little or late
prenatal care, smoking, use of alcohol or illicit
drugs during pregnancy and increased infant
Figure 3. Excess fetal and infant deaths among black non-Hispanics compared to white non-Hispanics, New York City, 1996-2000
The PPOR model was a useful tool for investigating disparities in fetal and infant deaths in New York City and serving as a guide for interventions, demonstrating that racial/ethnic disparities were mainly related to maternal health factors and prematurity and pointing toward the need for improving maternal health and providing preconception care. To that end, we believe that an important step in improving perinatal health is to provide better access to primary care, pregnancy planning and to disseminate the concept of preconception care while making greater efforts to reduce racial/ethnic disparities in health outcomes. Such programs could include greater access to medical insurance for low-income families or more publicly funded primary health¬care, providing family planning and preconception care during medical visits for child health or during visits for sexually transmitted diseases.