Puerto Rican Maternal and Infant Health Project

1. Puerto Rican Maternal and Infant Health Project Nancy S. Landale R.S. Oropesa Department of Sociology & Population Research Institute The Pennsylvania State University Ana Luisa Dávila Graduate School of Public Health University of Puerto Rico

2. PRMIHS Study Design • In-person interviews with 2,763 Puerto Rican mothers of infants born in 1994-95. - sampled from birth and death records of Connecticut Florida Massachusetts New Jersey New York City Pennsylvania Puerto Rico

3. PRMIHS Study Design • Oversampled low-birth-weight infants and infant deaths. • Mothers located from addresses on vital records • Interviews in English or Spanish • Response rates - 79% for birth certificate sample - 74% for death certificate sample

4. PRMIHS Website www.pop.psu.edu/prmihs/prmihs‑begin.html Photo credit: Jack Delano

5. Question Modules • Prior to pregnancy - family of origin - socioeconomic • During pregnancy - socioeconomic - prenatal care - household composition - health habits - proximity of relatives - delivery of infant - social support - role of baby’s father

6. Question Modules (cont.) • After baby’s birth - socioeconomic - role of baby’s father - household composition - infant health - proximity of relatives - infant development - social support - child care • Histories - unions - pregnancies and births - migration and acculturation

7. Unresolved Issues: Migration & Infant Health • Foreign-born more likely to have positive birth outcomes than native-born, despite low SES. - generalizability of Mexican immigrant experience - selective migration - assimilation and lifestyles of pregnant women

8. Table 1. Means and Percentages

9. Means and percentages (cont.)

10. Table 2.Odds Ratios from Logistic Regressions: Infant Mortality among P.R. Infants in U.S.

11. Figure 1. Relative Odds of Infant Mortality

12. Table 3. Odds Ratios for Significant Predictors: Additive Model of Infant Mortality in U.S.

13. Figure 1. Relative Odds of Infant Mortality

14. Table 4.Odds Ratios from Logistic Regressions: Infants Born in the U.S. and Puerto Rico

15. Figure 2. Relative Odds of Infant Mortality

16. Conclusions: Mainland Puerto Ricans • Women living in the U.S. the longest have the highest risk of infant mortality - net of demographic and socioeconomic controls - consistent with cultural explanation

17. Conclusions: Mainland and Island Puerto Ricans • Infant mortality risk lower for migrants with few years of US residence than non-migrants in PR - net of demographic and socioeconomic controls • Migrants may be self-selected on characteristics related to the survival chances of their infants • More consistent with selective migration than protective cultural content

18. Prenatal Care: Barriers and Utilization • Active debate on role of prenatal care for birth outcomes, but prenatal care is the “foundation for improving the health of the pregnant woman, infant, and family…a cornerstone of health care delivery” (US Dept of Health and Human Services). • Puerto Ricans singled out for special attention in past national health promotion objectives -  88% NLW and 77% Puerto Ricans first trimester PNC -  4-5% NLW and 17% Puerto Ricans inadequate PNC

19. Objectives • Document self-reported barriers to prenatal care • Demonstrate linkages of barriers and utilization with socioeconomic and psychological factors

20. Data and Methods • Mainland birth sample - N = 1,255 • Multiple imputation • Imputed datasets analyzed with SUDAAN

21. Dependent Variables: APCUI • Adequacy of Prenatal Care Utilization Index - month initiated & number of visits given ACOG standards for gestational age - inadequate care defined as care initiated beyond first 4 months and less than 50% of recommended visits - dichotomize here, inferences generally not sensitive

22. Dependent Variables: Barriers • Did you have problems with…? childcare transportation to doctor/clinic finding a doctor/nurse to take R as patient getting appointments feel uncomfortable in Dr.’s office getting enough money or insurance to pay for visits finding out where to go unaware of pregnancy concern about others finding out about pregnancy unsure wanted to carry the pregnancy to term

23. Independent Variables • Used survey and vital records to measure… migration Status: PR born vs. mainland born socioeconomic: income, employment, method of payment, education demographic: age, previous births, English social capital: marital status, mother’s proximity, emotional support lifestyle: alcohol/drugs, smoked, stressful events medical risk: conditions during pregnancy, prior negative outcomes

24. Results • Nearly 1 in 5 women have inadequate utilization - 17% inadequate - 18% intermediate - 55% adequate or adequate+

25. Half identified one (26%) or two+ (21%) barriers • Psychological barriers most common ____________________________________ Type of Barrier % Unsure about carrying to term 21 Keep pregnancy secret 13 Uncomfortable at Dr.’s 11 Unaware pregnant 10 Transportation 9 Money 8 Getting appointments 5 Child care 5 Acceptance by provider 4 Locating provider 3

26. Table 5. Inadequate Utilization and Barriers Problem % Inadequate Number of Barriers 2 27 p < .001 1 23 0 9 Unaware pregnant Yes 31 p < .001 No 15 Uncomfortable at Dr.’s Office Yes 28 p < .05 No 15 Money Yes 31 p < .05 No 16 Child Care Yes 38 p < .001 No 16 Acceptance by provider Yes 40 p < .05 No 16

27. Table 6. Prevalence of Barriers among Inadequate Utilizers % of Inadequate Utilizers with Barrier Unsure about carrying to term 25 psychological Unaware pregnant 19 46% Keep pregnancy secret 17 -- -- -- -- -- -- -- Uncomfortable in Dr.’s office 18 -- -- -- -- -- -- -- Money 14 monetary Transportation 12 28% Child Care 11 -- -- -- -- -- -- -- -- Acceptance by provider 9 provider Getting appointments 7 19% Locating providers 7

28. Table 7.Odds Ratios from Logistic Regressions (Inadequate =1) Bivariate Multivariate N of Barriers 2+ 3.33*** 2.52*** 1 2.60*** 2.02* 0 (ref.) 1.0 1.0 Income .98+ 1.0 Employed .43*** .58+ note: union status Payment mother’s proximity Insurance .41*** .70 stressful events Government (ref.) 1.0 1.0 excluded from table Education College .64 1.31 High School .58* .81 Less than high school 1.0 1.0 N of children 1.36*** 1.27** Emotional support/advice .55* .75 Smoked 1.74* 1.44 Pregnancy Wantedness Wanted baby in future 1.52* 1.48 Did not want baby 3.33*** 2.31* Never thought about it 2.13* 1.46 Wanted pregnancy (ref.) 1.0 1.0 + p < .10, * p < .05, ** p < .01, *** p < .001

29. Conclusions Non-trivial levels of inadequate PNC utilization and barriers Foundations of PNC complex, not reducible to economics & migration - psychological: awareness, uncertainty, wantedness - sociological: social ties - socioeconomic: employment and “things money can buy”