Graduation Date

Summer 8-13-2021

Document Type


Degree Name

Doctor of Philosophy (PhD)


Medical Sciences Interdepartmental Area

First Advisor

Eleanor G. Rogan, PhD

Second Advisor

Melissa K. Tibbits, PhD

Third Advisor

John W. Sparks, MD

Fourth Advisor

Christopher S. Wichman, PhD

MeSH Headings

Fetal mortality, Infant mortality, Stillbirth epidemiology, Public health surveillance methods, Health planning methods


Records of births, infant deaths, and fetal deaths are compiled by the US Vital Records System and used to monitor population health and guide health policy. The Perinatal Periods of Risk Approach (PPOR) relies on vital records data to address fetal and infant mortality in US cities. It uses reference groups to estimate preventable mortality by risk period. To avoid biased analyses due to poor data quality for small and early infant and fetal deaths, an expert committee recommended that PPOR analyses exclude fetal deaths delivered at gestational age (GA) <24 >weeks, and infant deaths and live births with birthweights (BW)

We developed a method to quantify underreporting by week of gestation (from 20 to 31 weeks) and by birthweight (in 100-gram intervals below 1500 grams, adjusting for state-level health-related factors. We found that differential reporting remains substantive at GA<24 >weeks, and reporting requirements and health differences do not account for it. We cannot recommend lowering the original PPOR fetal GA limit. We found that a fetal BW limit is redundant once a gestation limit is in place but that an infant death BW limit of 400 or 500 grams is still needed. We then assessed the quality of data elements needed for creating reference groups and formed a subset of states from which to draw a nearly unbiased set of national reference groups for use by communities. Based on a new national reference group and a study population of 100 large counties, we summarized a national analysis using percentile charts for six components of preventable mortality. The charts allow communities to compare their outcomes nationally as well as determining which component is locally predominant.