Eliminating Racial Disparities in Birth Outcomes Eliminating Racial Disparities in Birth Outcomes

Conference on Ending Family HomelessnessConference on Ending Family HomelessnessWorkshop: Workshop: Healthcare Matters: Providing Health Services to Healthcare Matters: Providing Health Services to

Diverse PopulationsDiverse Populations

February 7, 2008February 7, 2008

Susan Barkan, Public Health Seattle & King CountySusan Barkan, Public Health Seattle & King County

Melanie Whitfield, People of Color Against AIDS NetworkMelanie Whitfield, People of Color Against AIDS Network Maria Carlos, Public Health Seattle & King CountyMaria Carlos, Public Health Seattle & King County

AcknowledgementsAcknowledgementsSusan BarkanSusan Barkan

Kathy Carson Kathy Carson

Maria CarlosMaria Carlos

Eva Wong Eva Wong Doctoral Student, Department of Epidemiology, Doctoral Student, Department of Epidemiology, University of WashingtonUniversity of Washington

Alice ParkAlice Park

Mei Castor Mei Castor Urban Indian Health InstituteUrban Indian Health Institute

Shira RutmanShira Rutman

Jim La RocheJim La Roche

Leslie RandallLeslie Randall Northwest Portland Area Indian Health BoardNorthwest Portland Area Indian Health Board

Leah Henry Leah Henry Native American Women’s Dialog on Infant Native American Women’s Dialog on Infant Tanner Tanner Mortality (NAWDIM)Mortality (NAWDIM)

Jim GaudinoJim Gaudino Oregon State Department of HealthOregon State Department of Health

Parent Child Health, Public Health-Seattle & King Parent Child Health, Public Health-Seattle & King CountyCounty

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Washington State

King County

2004 Infant Mortality Rates:

United States (2003): 6.9 Washington State: 5.5 King County: 4.4 Seattle: 5.4 King County outside Seattle: 4.1

King County outside of Seattle

Infant Mortality RatesInfant Mortality RatesUS, Washington State, King County, US, Washington State, King County,

SeattleSeattleThree Year Rolling Average, 1981-2004Three Year Rolling Average, 1981-2004

Contributions to the Overall Decline Contributions to the Overall Decline in Infant Mortality in King Countyin Infant Mortality in King County

First StepsFirst Steps: MaternityMaternity support and expansion of Medicaid coverage of support and expansion of Medicaid coverage of prenatal servicesprenatal services

Safe Sleep: Safe Sleep: Back to Sleep CampaignBack to Sleep Campaign

Medical Advances: Medical Advances: Neonatal intensive careNeonatal intensive care

Behavioral:Behavioral:Decline in use of tobacco, alcohol, unintendedDecline in use of tobacco, alcohol, unintended pregnancies pregnancies

4.0

11.1

17.2

4.55.5

0

5

10

15

20

25

Rate per 1,000

Live Births

African American

American Indian/ Alaska Native

White

Latino/HispanicAsian

Infant Mortality Rates by Race/Ethnicity, King County, Three Year Rolling

Averages, 1985-2004

Perinatal Periods Of Risk Perinatal Periods Of Risk (PPOR) Approach(PPOR) Approach

A A simple approachsimple approach..

identify gapsidentify gaps in the community. in the community.

target resourcestarget resources for prevention activities. for prevention activities.

mobilize the communitymobilize the community to action. to action.

PPOR guides strategies to PPOR guides strategies to improve birth outcomesimprove birth outcomes

Prematurity and low birthweight Prematurity and low birthweight lead to infant mortality.lead to infant mortality.

PPOR method gives information that PPOR method gives information that guides community strategies to help guides community strategies to help infants be born healthy.infants be born healthy.

PPOR FindingsPPOR FindingsWA State, 2000-2004WA State, 2000-2004

Infant HealthInfant Health is the highest contributor is the highest contributor to preventable FIMR among American to preventable FIMR among American Indian/Alaska Natives Indian/Alaska Natives

Maternal Health/PrematurityMaternal Health/Prematurity is the is the highest contributor among African highest contributor among African Americans and the second highest Americans and the second highest contributor among AI/AN.contributor among AI/AN.

Maternal Care is the third highest Maternal Care is the third highest contributor to among AI/AN.contributor to among AI/AN.

Newborn Care is consistently the lowest Newborn Care is consistently the lowest and is similar for all racial/ethnic groups.and is similar for all racial/ethnic groups.

Implications/”Opportunity Implications/”Opportunity Gaps”Gaps”

Maternal Health/

Prematurity

Infant Health

Preconception Health Health BehaviorsPerinatal Care

+ EXPAND STRATEGIES to address social factors giving rise to disparities

Sleep Position Breast Feeding Injury PreventionMedical Care for Infections and Chronic Conditions

% of Births 2000-2002

Time Trend 1993-2002

% of Births 2000-2002

Time Trend 1993-2002

% of Births 2000-2002

Time Trend 1993-2002

Low Birth Weight (< 2500 g) 10.5* -- 6.6 -- 5.3 2* 1.3Very Low Birth Weight (< 1500 g) 2.2* -- 1.9* 0.8 -- 2.6* 2.3*Preterm (<37 weeks gestation, calc.) 18.9* -- 16.9* -- 11.9 1.6* 1.4*Multiple Birth (twins, triplets, etc.) 4.1 3.2 3.6 1.2 0.9Mother's Age < 18 4.0* 6.4* 1.5 2.7* 4.2*Single Mother 54.1* 58.7* -- 20.5 2.6* 2.9*Late (3rd) or No Prenatal Care 4.8* 6.5* 2.0 2.4* 3.3*Inadequate Prenatal Care (Kotelchuck) 19.2* 18.8* 7.7 2.5* 2.4*Smoking During Pregnancy 11.1* 19.8* 8.0 1.4* 2.5*Alcohol Use During Pregnancy 1.6 4.0 2.7 0.6 1.5

Rates and rate ratios followed by an asterisk (*) are statistically significantly higher than the rate for whites. Indicates a statistically significant increase over the period 1993-2002. Indicates a statistically significant decrease over the period 1993-2002.

American Indian/Alaska Native: White

Rate Ratio(2000-2002)

African Americans American Indian/

Alaska Natives WhitesAfrican

American: White Rate Ratio

(2000-2002)

Prevalence and Trends in Birth Risk Factors Prevalence and Trends in Birth Risk Factors by Race, King Countyby Race, King County

How Stress Can Affect Health:How Stress Can Affect Health: Increased cortisol (fight/flight hormones) results in increased Increased cortisol (fight/flight hormones) results in increased

cardiovascular function cardiovascular function

Can lead to high blood pressure, depressed immune function with Can lead to high blood pressure, depressed immune function with increased vulnerability to infection, and depression. All of these can increased vulnerability to infection, and depression. All of these can contribute to risk of preterm delivery.contribute to risk of preterm delivery.

These stress responses are designed to help us deal with short term These stress responses are designed to help us deal with short term threats, but for many, the stressors don’t go away. threats, but for many, the stressors don’t go away.

Long-term, chronic stress does not allow for system recovery and Long-term, chronic stress does not allow for system recovery and predisposes to adverse health effectspredisposes to adverse health effects

Reported Stressful Life Events During Year Before Delivery

King County, 1999-2001

Stress EventsAfrican

American

American Indian/Alask

a Native White

Changed residence (moved) 44%* 53%* 33%

Argued with partner more than usual 36%* 43%* 17%

Had bills and couldn't pay 31%* 42%* 14%

Someone close died 24%* 25% 15%

Close family member ill and hospitalized 24% 22% 24%

Separated or divorced from partner 20%* 19%* 5%

Someone close had drinking/drug problem 15% 28%* 13%

Partner said he didn't want pregnancy 15%* 21%* 8%

Husband/partner lost job 14% 20%* 8%

Mother lost job 21%* 15%* 5%

Mom or partner went to jail 10%* 22%* 4%

Involved in a physical fight 7% 12%* 4%

Homeless 11%* 15%* 1%

Reported 5 or more stress events 12%* 23%* 4%

Stress factor prevalences followed by an asterisk (*) are statistically significantly higherthan the estimate for whites.

Data Source: Pregnancy Risk Assessment Monitoring System (PRAMS)

Lack of Social Support During Pregnancy by Race/Ethnicity,

King County, 1999-2001

29%

22%

16%

21%24%

17%

11%15%

13%10%

7% 7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

No one to loanme $50

No one to helpme if I was sick

& in bed

No one to give me a ride to the

doctor

No one to talk with aboutmy problems

Pe

rce

nt

African American

American Indian/Alaska Native

White

Data Source: Pregnancy Risk Assessment Monitoring System (PRAMS)

INSTITUTIONALIZED RACISM/INSTITUTIONALIZED RACISM/Historical TraumaHistorical Trauma

DiscriminatioDiscriminationn

PovertyPoverty AbuseAbuse Internalized Internalized RacismRacism• Health CareHealth Care

• HousingHousing• Legal SystemLegal System• EmploymentEmployment• Refused care Refused care

over IHS over IHS statusstatus

• Affordable HousingAffordable Housing• Moving frequentlyMoving frequently• Adequate Adequate

EducationEducation• EmploymentEmployment• Access to Health Access to Health

CareCare• Perceived as Perceived as

wealthywealthy STRESSSTRESS

Direct Effects: Endocrine System Response - Increased cortisol Direct Effects: Endocrine System Response - Increased cortisol levels, decreased immune function, increased levels, decreased immune function, increased vulnerability to infection, trigger onset of laborvulnerability to infection, trigger onset of labor

Indirect Effects: Maternal Behaviors – Smoking, alcohol, substance Indirect Effects: Maternal Behaviors – Smoking, alcohol, substance use, poor nutrition, survival supersedes wellnessuse, poor nutrition, survival supersedes wellness

DISPARITIES IN BIRTH DISPARITIES IN BIRTH OUTCOMEOUTCOME

• InstitutionalInstitutional• InterpersonInterperson

alal• CyclesCycles• Substance Substance

• HopelessnessHopelessness• Self-hatred and blameSelf-hatred and blame• Inability to see family/ Inability to see family/

community as supportcommunity as support• Ancestry seen as Ancestry seen as

hindrance to life’s hindrance to life’s goalsgoals

Mayet Dalila, IntraAfrikan Konnections

Indigenist model of trauma, coping, and Indigenist model of trauma, coping, and health outcomes for American Indian health outcomes for American Indian

women women (Walters K. 2002)(Walters K. 2002)

What more needs to be done:What more needs to be done: Continue support of pregnant women’s Continue support of pregnant women’s

health care: prenatal care, MSS/ICM, health care: prenatal care, MSS/ICM, outreach.outreach.

Find support for community mobilization Find support for community mobilization effortsefforts

Community collaboration around housing, Community collaboration around housing, income equity, access to quality education, income equity, access to quality education, access to culturally relevant, culturally access to culturally relevant, culturally appropriate health care. . .appropriate health care. . .

Decrease the impact of inequalities and Decrease the impact of inequalities and racism on women and families through racism on women and families through community support. community support.

NAWDIM & Brown Sugar BabiesNAWDIM & Brown Sugar Babies

What more needs to be done:What more needs to be done:

Continue the PPOR analysis and community engagement process Continue the PPOR analysis and community engagement process to use the data to target prevention efforts and support the work of to use the data to target prevention efforts and support the work of the communitythe community

Need for prevention to focus on preconceptional health, health Need for prevention to focus on preconceptional health, health behaviors, and specialized perinatal care services behaviors, and specialized perinatal care services

Sustained need for early and continuous prenatal care services, Sustained need for early and continuous prenatal care services, referral of high-risk pregnancies and good medical management of referral of high-risk pregnancies and good medical management of medical problemsmedical problems

Continued need for programs that support infant health such as Continued need for programs that support infant health such as SIDS prevention, access to a medical home, and injury preventionSIDS prevention, access to a medical home, and injury prevention

What You Can Do:What You Can Do:

Work on adequate housing, income equity, quality education, access to culturally appropriate health & social services.

Provide culturally appropriate mental health services for people of color & low-income folks.

Get training on undoing institutionalized racism Undoing Institutionalized RacismUndoing Institutionalized Racism, People’s Institute for Survival & Beyond, People’s Institute for Survival & Beyond PBS Video: PBS Video: Race: The Power of IllusionRace: The Power of Illusion PBS Video: PBS Video: Unnatural Causes: Is Racism Making Us Sick?Unnatural Causes: Is Racism Making Us Sick? (March, 2008) (March, 2008)

Involve community members, clients, consumers in defining your work.

“Injustice anywhere is a threat to justice everywhere.”

Martin Luther King, Jr.

Thank you!Thank you!