Ethnic Disparities in Perinatal Outcomes in the U.S. Vijaya K. Hogan, Dr.P.H. Pregnancy and Infant Health Branch Divisio

1. Ethnic Disparities in Perinatal Outcomes in the U.S. Vijaya K. Hogan, Dr.P.H. Pregnancy and Infant Health Branch Division of Reproductive Health Centers for Disease Control and Prevention

2. Factors contributing to race/ethnic health disparities • Higher exposure to risk • may be imposed by environmental and social policies • Higher vulnerability/susceptibility • may be determined by chronic environmental and social exposures • Insufficient resources to protect health • lack of time, money, etc…for health promotion, health care access • Unequal access to care • “snowball” exposure effect • Lower quality of care

3. Outline • Extent of race/ethnic disparities in perinatal health • Example of complexity of prevention: Preterm Delivery • Limits of scientific knowledge • Practice limitations • Social context • Proposed approach to addressing health disparity

4. Part IData: Disparities in Perinatal Outcomes

5. Maternal Mortality Ratios by RaceUnited States, 1987-1996 Danel, et al, 1999

6. Infant Mortality Rates by Maternal Race and Ethnicity, 1997 U.S. Death Cohort

7. Ten Leading Causes of Infant MortalityUnited States, 1997 Rate per 100,000 live births

8. Leading Cause-Specific Infant Mortality RatesBy Maternal Race, United States, 1997 Rate per 100,000 live births

9. Distribution of Deaths Due to Top Five Causes of Infant Mortality, 1995

10. Infant Mortality Rates Due to SIDS, United States by race, 1973-1998* AAP Campaign *Preliminary Data

11. Infant Deaths due to NTDs by Race/Ethnicity, United States, 1996 Rate per 100,000 live births Source: National Center for Health Statistics, 1996 period linked birth/infant death file Prepared by March of Dimes Perinatal Data Center, 1999

12. LBW Among Singletons by Race US, 1991-1997 Percent Source: National Center for Health Statistics, 1996 period linked birth/infant death file Prepared by March of Dimes Perinatal Data Center, 1999

13. Trends in overall* PTD by race--United States, 1989-1996

14. Rate* of Singleton PTD by Maternal Race/Ethnicity, United States, 1989-1997

15. Part II:Complexity of Race/ethnic disparities:Focus on Preterm Delivery (PTD) • Affects many infants • 11% of live births (400,000 infants/year) • Mortality: • # 1 cause of infant death among blacks • # 2 cause of infant death overall • # 1 contributor to infant mortality disparity • Morbidity: • lung disease, vision and hearing impairment, developmental delays, cerebral palsy

16. Preterm Delivery • Good illustration of multiple dimensions to causal pathway leading to disease and disparity • If we can successfully address this health outcome, we will likely have the keys to addressing all disparities

17. Limitations of Science • To eliminate disparities in preterm delivery, we would need: • Evidence-based interventions to prevent preterm delivery • Evidence-based interventions/activities to eliminate disparities

18. 6 Guidelines: Evidence- based Strategies Process for Defining Evidence-Based Strategies 5 Review and synthesis of existing published evidence 4 Evaluation studies published in peer-reviewed literature 3 Evaluation Studies conducted on existing programs 2 Existing programs refine implementation 1 Programs implemented using conceptually validstrategies 0 Many potential approaches: Scientific guidance needed at this stage to define conceptually valid strategies

19. Race/Ethnicity Incompetent cervix Marital Status Substance use Number of prenatal care visits Smoking Multiple Births Mother's Pre-Pregnancy Weight Previous Obstetric History Bacterial vaginosis Congenital Anomalies Stress Maternal Age Preterm Delivery: Epidemiologic Risk Factors

20. Patient Outcomes Research Team (PORT) Studyon Infant MortalityGoldenberg, et al, 1998 • None of the main OB or behavioral modification strategies are effective in reducing PTD • No additional benefit from: Increasing quality and quantity of PNC, maternal weight gain and nutritional supplements • Ineffective against PTD: Bed rest, risk scoring systems, iron supplementation, tocolytics, substance use programs, IV hydration, HUAM

21. Bacterial Vaginosis (BV) • Lower tract marker of upper reproductive tract infection • Can be assessed during pregnancy

22. Syndrome resulting from alteration in normal vaginal flora • Reduction in hydrogen peroxide-producing lactobacilli • Reduction in natural protection against overgrowth of more harmful bacteria • mycoplasmas, gardnerella vaginalis, bacteroides • Microbe concentration increases to level of stool Bacterial Vaginosis (BV)

23. Bacterial Vaginosis, cont. • BV is 2 x more prevalent among African American women • Higher prevalence not explained by sexual behaviors or most known risk factors. • High BV rates in African-American women may account for up to 30% of excess risk of PTD

24. Prevalence of BV among Pregnant Black and White Women by Diagnostic Method Gram stain MD Assessment White 27% 18.7% 95%CI (19-35) (11-26) Black64.4% 40.5 % 95%CI (61-69) (36-45) Hogan et al, SPEAC Study, Philadelphia

25. Treatment of BV Studies demonstrate a reduction of PTD with tx. • Morales WJ et al. Am J Obstet Gynecol 1994;171:345-349. • Hauth JC et al. N Engl J Med 1995;333:1732-1736. • McDonald HM et al. Br J Obstet Gynaecol 1997;104:1391-1397.

26. Treatment Guidelines Treatment for BV during Pregnancy: CDC (November 1997): • screening high risk women in early 2nd trimester • 250 mg metronidazole t.i.d. x 7 days • ACOG (February, 1998) • screening high risk women in 2nd trimester • 500 mg oral metronidazole b.i.d. x 7 days

27. Limits of Medical Practice in Reducing PTDSPEAC STUDY- Philadelphia Public Health Clinics • There were 389 true cases of BV • Of these true cases, 46 were high risk • Thus, 46 women should have been treated (using gram stain diagnosis, CDC Rec) • Actual treated= 24 ; 48% true high risk cases missed

28. Limits of Practice.cont • Clinicians treated 67% of high risk, BV positive women id’d via clinical assessment Scenario 1: improved treatment coverage • If they treated 100% high risk women id’d by their assessment: 31 women would have been treated (Actual = 24; 7 women missed) Scenario 2: improved diagnostics • If they used gram stain to assess BV, and trt’d 67%: 36 women would be treated; actual = 24; 12 women missed

29. Potential Impact on Preterm Birth Morales 1994: PTD rate among : • treated =18% • untreated=39% If all 46 high risk women were treated Expected PTD rate= 18%; Only 24/46 were trt’d: {.18 * 24) + (.39 * 22) /46} 100 = 28% PTB rate (8.2 vs 12.9 PTB’s) There would be a 36 % lower PTB rate among high risk women if all were treated.

30. Stress: Physiologic Effects • Stress harms health: • Seeman TE et al “Price of Adaptation: allostatic load and its consequences” Arch Int Med 157:2259-2268;1997 • Biondi M et al “ Psychological Stress, neuroimmunomodulation and susceptibility to infectious diseases in animals and man: a Review” Psychotherapy and Psychsomatics 66:3-26; 1997

31. Stress and Pregnancy • Stress has negative physiologic effects • Stress is associated with Preterm Delivery

32. How Does Stress Affect Health? • Stress can affect: • Endocrine system (corticotropin-releasing hormone (CRH) production • Immune system response • Maternal Behaviors • smoking • nutrition • substance use

33. Stress and the Infection Interaction Chronic stress can suppress immune response Acute stress can increase immune response (slows or halts shut-off of immune response leading to over -production of cytokines) (auto-immune response leading to PTD?) Shulkin, McEwen , Gold; 1993 Chrousos, Gold; 1992 McEwen; 1998

34. Stress and Vulnerability Pregnant women who were moderately or highly stressed were over 2 times more likely to be BV positive compared to women in the low stress group “Maternal Stress is associated with bacterial vaginosis in human pregnancy” • Culhane, Rauh, McCollum, Hogan, Agnew and Wadhwa; MCH Journal 5(2) 2001

35. Fetal Effects of Stress Source: New Scientist, 17 July 1999

36. Practice Limitations:Timing of Intervention

37. Analysis of Feto-Infant Mortality, Georgia 1991-1993

38. How do we determine which strategy has the greatest potential for reducing maternal, perinatal, and infant mortality?Age at Death

39. Complexity of Causation:Social Context

40. Characteristics of the "Ideal" Pregnant Woman Based on Epidemiologic Data • She is married • She planned her pregnancy and her baby is "wanted" • She came early for prenatal care • She attends all prenatal visits, on time, asks appropriate questions

41. Composite "Ideal" Woman Based on Epidemiologic Data, continued • She has a level of education that allows her to understand and comply with caregiver • She engages in healthy lifestyle and behaviors (eats healthy, doesn't drink, smoke, use drugs, etc..) • She was actively engaged in healthy, protective behaviors before pregnancy (e.g. took folic acid)

42. The Reality: • Experiences of Black Women Documented from Qualitative Research • Harlem BirthRight, NYC • Healthy African American Families, Los Angeles • Development of a Chronic Stress Scale for African American Women, Atlanta • Influence of Social Networks on Access to Prenatal Care, Chicago

43. Complex web of social support sought to replace or supplement father involvement. • Partner support not dependent on marriage. Other configurations of partnership exist. • Women hold traditional views about marriage • Social factors which affect males affect options for partnership Findings:

44. Findings "I feel we are losing our black men"87.7% Jackson, Phillips, Hogue; Atlanta, Ga.

45. "You have to justify the building of these prisons so that means you've got to have inmates. What you do is deprive them of an education … deprive them of employment … So, if they can't get money legitimately, they get it illegitimately..." Mullings and Wali, Harlem BirthRight Report, 1997

46. Public Health Ideal: "She planned her pregnancy and baby is "wanted" • Public Health Questions: • Why are unplanned pregnancies so prevalent? • Implicit Assumptions ??: • Women are irresponsible about contraception • Women have adequate knowledge about physiology • Available contraceptives are effective and acceptable to all women

47. Findings: • "Unplanned" pregnancies result even with active efforts to prevent pregnancy • Contraceptive failure commonly reported"Condoms broke", "got pregnant while taking the pill" • Lack of availability of acceptable contraceptive methodsDiscomfort with oral contraceptives and diaphragm reported

48. Findings: • Male influences and unprotected intercourse • Perceptions of ability to conceive • "I thought I was infertile" • Perceptions that previous PID or other infections affected ability to get pregnant

49. Public Health Ideal: “She came early for prenatal care” • Public Health Questions: • Why don't women come early for prenatal care? • Implicit Assumptions ??: • Access to care defined by individual choice and availability of health insurance only, independent of other forces • Only formal prenatal services provide pregnancy care

50. Social Networks Project - Chicago The Ideal Road to Formal Prenatal Care Intercourse Vigilance Suspicion Confirmation Decision Acceptance Access to Formal PNC