National and Regional Trends in African American Birth Outcomes

1. National and Regional Trends in African American Birth Outcomes Karla Damus, RN MSPH PhD Associate Professor Dept OB/GYN and Women’s Health Albert Einstein College of Medicine National March of Dimes

2. Maternal Mortality by RaceUnited States, 1970 -2003 Maternal death per 100,000 live births Note: Rates for 1970-1988 are based on race of child. Rates for 1989-2003 are based on race of mother. Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2006

3. www.healthypeople.gov

4. The Current Agenda • Goal #1: Increase quality and healthy years of life • Goal #2: Eliminate health disparities • gender • race/ethnicity • income and education • disability • geographic location • sexual orientation

5. Questions • What data are needed to describe disparities in birth outcomes in communities? • What data need to be collected to help inform possible reasons for disparities in birth outcomes? • What strategies have been shown to reduce disparities? • What relationships/partnerships need to be in place to address disparities in communities? • What programs need to be developed to address disparities at the community and population level? • What activities has the community tried? What’s worked/ What hasn’t? Why? • What are realistic goals for our organization/ communities? What are we ready to work toward? Opportunities? Venues? Approaches? Other relevant organizations?

6. Births by Race/Ethnicity US 2001-2003 average In 2004 there were 4,112,052 live births registered in the US

7. Infant MortalityUnited States, 1915-2002 Rate per 1,000 live births Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002

8. Unexpected findings- most of increase due to: • non Hispanic white • >30 years • married • >high school • onset PNC first trimester • nonsmoker • private insurance www.cdc.gov/mmwr

9. Infant Mortality by Maternal RaceUnited States, 1990 -2004* Rate per 1,000 live births 2010 0bj Source: National Center for Health Statistics, final mortality data *preliminary data Prepared by March of Dimes Perinatal Data Center, 2007

10. Black/White Infant Mortality Rate RatioUnited States, 1980-2004* Source: NCHS, final mortality data *preliminary mortality data

11. Racial and Ethnic DisparitiesInfant Mortality Rates, US2001 Per 1,000 Live Births HP 2010 Objective 4.5 NCHS 2003

12. Infant Mortality by Race/EthnicityNew York City, 1990-2001 Rate per 1,000 live births Office of Vital Statistics and Maternal, Infant & Reproductive Health Program , NYCDOH Prepared by March of Dimes Perinatal Data Center, 20002

13. Infant Mortality Rates by Race/Ethnicity US Region, 2000-2002 average Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2007

14. Infant Mortality Rates by State, 2003 Source: National Center for Health Statistics, 2003 period linked birth/infant death data.

15. Three Leading Causes of Infant MortalityUnited States, 1990and 2004* Rate per 100,000 live births Source: National Center for Health Statistics *preliminary mortality data for 2004 Prepared by March of Dimes Perinatal Data Center, 2007

16. Three Leading Causes of Infant Deaths by Race/Ethnicity, US , 2000 Per 1,000 Live Births NCHS 2001

17. Preterm Birth RatesUnited States, 1983, 1993, 2003, 2005* Percent > 1 out of 8 births or 508,000 babies born preterm in 2005 Percent HP 2010 Objective >30% Increase Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2005 *preliminary

18. Preterm (<37 wks) Births by Maternal Race/Ethnicity, US, 1990-2004 Source: National Center for Health Statistics, final natality data. Note: All race categories exclude Hispanic births. Data from 1990 excludes NH and OK. Data from 1991 and 1992 excludes NH. The reporting of Hispanic ethnicity was not required in these states during these years.

19. Preterm Birth Rates by Race/Ethnicity and US Region, 2001-2003 average Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2007

20. Preterm Birth Rates by Race/Ethnicity & Education, IOM 2006

21. Singleton Preterm Births by Maternal Race/Ethnicity and Education, 2001-2002 http://diversitydata.sph.harvard.edu

23. Definitions • Preterm birth: • < 37 completed weeks gestation • Late preterm (or Near-Term): • 34-36 completed weeks • Very preterm: • <32 completed weeks

24. Total (<37 weeks), Very (<32 weeks) and Late Preterm Births (34-36 weeks) U.S., 1990- 2003 Percent Late Preterm

25. Distribution of Preterm Births by Gestational Age, US, 2002 (<32 Weeks) “Near term infants had significantly more medical problems and increased hospital costs compared with contemporaneous full term infants Near term infants may represent an unrecognized at-risk neonatal population.” Wang, et al. Clinical Outcomes of Near-Term Infants, Pediatrics (114) 372-6, 2004. (36 Weeks) (32 Weeks) (33 Weeks) ~71% of PTB 34 - 36 weeks late preterm (34 Weeks) (35 Weeks) Source: National Center for Health Statistics, 2002 natality file Prepared by the March of Dimes Perinatal Data Center, 2004

26. Total and Primary Cesarean and VBAC United States, 1993 - 2005 Preliminary (1) Per 100 births(2) Per 100 births to women with no previous cesarean(3) Per 100 births to women with a previous cesarean Source: NCHS, final natality data, 1993-2003 and 2004 preliminary data Prepared by March of Dimes Perinatal Data Center, 2005

27. Human Brain Growth in Gestation Kinney, 2006

28. PEDIATRICS Vol. 118 No. 3 Sept 2006, pp. 1207-1214

29. Differences in Singleton Preterm Birth Rates by Race/Ethnicity, 1992 and 2002

30. Late Preterm Cesarean Section and Labor Induction Rates among Singleton Live Births by Week of Gestation US, 1992 and 2002

31. Birth Weight and Coronary Heart DiseaseBarker Hypothesis Age Adjusted Relative Risk Birthweight (lbs) Rich-Edwards 1997

32. Birth Weight and Insulin Resistance Syndrome Barker Hypothesis Odds ratio adjusted for BMI Barker 1993 Birthweight (lbs)

34. Factors that Contribute to Increasing Rates of Preterm Birth • Increasing rates of births to women 35+ years of age • Independent risk of advanced PATERNAL age • Increasing rates of multiple births • Indicated deliveries • Induction • Enhanced management of maternal and fetal conditions • Patient preference/consumerism (CDMR) • Substance abuse • Tobacco • Alcohol • Illicit drugs • Bacterial and viral infections • Increased stress (catastrophic events, DV, racism)

35. Risk Factors for Preterm Labor/Delivery • The best predictors of having a preterm birth are: • current multifetal pregnancy • a history of preterm labor/delivery or prior low birthweight • mid trimester bleeding (repeat) • some uterine, cervical and placental abnormalities • Other risk factors: • low pre-pregnant weight • obesity • infections • anemia • major stress • lack of social supports • tobacco use • illicit drug use • alcohol abuse • folic acid deficiency • unintended pregnancy • maternal age (<17 and >35 yrs) • black race • low SES • unmarried • previous fetal or neonatal death • 3+ spontaneous terminations • uterine abnormalities • incompetent cervix • cervical procedures • genetic predisposition

36. 1985

38. Folic Acid-Specific KnowledgeMarch of Dimes Folic Acid Survey Percentage of women ages 18-45

39. Folate Levels Drop Significantly • A CDC study released Thursday found an 8 to 16 % decline in folate levels based on results of the NHANES (interviews, PE, and blood tests of about 4,500 US women, ages 15 to 44, done between 1999 and 2004). • It was the first time such a decline has been seen since the start of government health campaigns urging women to make sure they get enough folic acid. • The decline was most pronounced in white women, although black women continue to be the racial group with the least folate in their blood.

41. Smoking Among Women of Childbearing Age US, 2003 Smoking is defined as having ever smoked 100 cigarettes in a lifetime and currently smoking everyday or some days. Percent reported is among women ages 18-44. Source: Smoking: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention..

42. Multiple Birth Ratios by Maternal Race/Ethnicity United States, 1992-2002 Per 1,000 live births Percent Change ‘96-’02 = 21.5% Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2005

43. Higher-Order Multiple Birth RatiosBy Maternal Race, United States, 1980-2002 Ratio per 100,000 live births Source: NCHS, final natality data Prepared by March of Dimes Perinatal Data Center, 2004

44. Institute of Medicine Report, July 2006 The IOM estimates the total national cost of premature births to be at a minimum$26.2 billion. This estimate includes many costs, such as in-patient hospital costs, lost wages and productivity and early intervention programs.

45. Institute of Medicine Report on Preterm Birth, 2006 • - One of the three major themes is disparities in PTB rates among different groups (racial, ethnic, or socioeconomic). • - Literature on causes of racial/ethnic disparities in PTB and effects of nativity need to be developed. • - Studies show that differences in PTB between African-American and white women remain after adjusting for socioeconomic differences. • - Literature on maternal behaviors such as smoking, drug use, and alcohol find that African-American women smoke less than white women during pregnancy and that the prevalence of drugs and alcohol use is no greater among pregnant African-American women compared to white women.

46. Institute of Medicine Report on Preterm Birth, 2006 • Infections may play a role in PTB, and studies have shown that African-American women are more likely than white women to experience infections such as bacterial vaginosis and sexually transmitted infections. The reasons for increased susceptibility to infection among pregnant African-American women are unknown. • Unknown how genes or interactions of genes and the environment contribute to racial/ethnic disparities in PTB or why foreign-born and US-born women of the same race have different PTB rates given a common genetic ancestry. • Concludes that racial-ethnic differences in socioeconomic condition, maternal behaviors, stress, infection, and genetics can not fully account for disparities.

47. Research Agenda • Research agendaRecommendation II-3:Expand research into the causes and methods for the prevention of the racial-ethnic and socioeconomic disparities in the rates of preterm birth. • This research agenda should continue to prioritize efforts to understand factors contributing to the high rates of preterm birth among African American infants and should also encourage investigation into the disparities among other racial-ethnic subgroups. • Proposes that research should be guided by an integrated approach that examines co-occurrence and interactions among multiple determinants of disparities in preterm birth, including racism, which operates at multiple levels and across a life course.

48. Activation of Maternal/Fetal HPA Axis Inflammation Pathological Uterine Distention Decidual Hemorrhage Abruption • Infection: - Chorion-Decidual - Systemic • Multifetal Preg • Polyhydramnios • Uterine abnormalities • Maternal-Fetal Stress • Premature Onset of Physiologic Initiators Prothrombin G20210A Factor V Leiden Proteins C, S, Z Type 1 Plasminogen MTHFR Interleukins IL-1, IL-5, IL-8 TNF-a Fas L Gap jct IL-8 PGE2 Oxytocin recep CRH E1-E3 Mechanical stretch Chorion Decidua Allergic Pathway CYP1A1 GSTT1 + CRH Susceptibility to Environmental toxins + MMPs proteases uterotonins pPROM Uterine Contractions Cervical Change PTB Adapted from: Lockwood CJ, Paediatr Perinat Epidemiol 2001;15:78 and Wang X, et al. Paediatr Perinat Epidemiol 2001; 15: 63

50. Green et al. AJOG 193:626-35, Sept 2005.