Measuring and Eliminating Racism and Racial Disparities in MCH:  The Need for New

Paradigms

James W. Collins, Jr.

12/10/08

INFANT MORTALITY RATES IN THE U.S.

0

2

4

6

8

10

12

14

16

African-Americans

PuertoRicans

non-Latinowhites

Mexican-Americans

Asian-Americans

IMR

(p

er

1,0

00 l

iveb

irth

s)

NEONATAL MORTALITY RATES

0

5

10

15

20

25

30

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

NM

R (

per

1,00

0 li

vebi

rths

)

African-American White

Six Decade Trend in Low Birth Weight Rates in the United States

0

2

4

6

8

10

12

14

16

1950 1960 1970 1980 1990 2000

LB

W r

ates

(pe

r 10

0)

African-Americans Whites

Low Birth Weight Rates by Maternal Education and Race

(Chicago, IL)

02468

1012141618

< 12 12 13-15 16 > 16

Maternal education (years)

%L

BW

(<

250

0g)

African-AmericanWhite

RACIAL GAP IN PERINATAL OUTCOME AMONG INFANTS CONCEIVED BY ART

(Schieve et al, Obstet Gynecol, 2004)

0

24

6

810

12

1416

18

TERM-LBW PRETERM-LBW

VLBW

Per

cent

African-AmericansWhites

012345

6789

10

US-born Blacks African-born Blacks US-born Whites

% L

BW

(<

250

0g)

Differing LBW Rates Among Low-risk Women in Illinois

(David and Collins, NEJM, 1997)

MLBW Rates Among Infants of Married Women Across a Generation (Collins et al, AJE, 2002)

02468

10121416

US-BornWhites

Foreign-Born

Whites

US-bornAA

African-Carib-AA

Women's Race and Nativity

ML

BW

rat

es (

per

100)

DaughtersGrand-Daughters

White

AfricanAmerican

Puberty Pregnancy0 5ys

The Racial Gap in Reproductive Potential: A Life-Course Perspective Lu and Halfon,MCHJ, 2003

Rep

rodu

ctiv

e Po

tent

ial

Risk Factors

Life Course

Protective Factors

Race“Race” is not a biological construct that reflects

innate differences, but a social construct that precisely captures the impacts of racism.

(Jones, AJPH, 2000)

RESEARCH QUESTION

To what extent are African-American women’s lifetime exposures to perceived interpersonal racial discrimination a risk factor for preterm-VLBW?

METHODS

• Case-control study of African-American infants admitted to Children’s Memorial, University of Chicago, and Cook County Hospitals 11/97-10/00.

• Cases: mothers of very low birth weight (<1500g, VLBW), preterm (< 37wks) infants.

• Controls: mothers of non-low birth weight ( >2500g, non-LBW), term infants.

• Case to control ratio of 1:2; $10.00 participation reward offered to all eligible subjects.

METHODS • Structured Questionnaire:

- lifetime exposure to interpersonal racial discrimination in 5 domains: “getting work”, “at work”, “at school”, “getting service at a restaurant / store, “getting medical care” (Krieger, 1990).

- full-time employed women were asked an additional 20 questions regarding lifetime and past year exposure to interpersonal racial discrimination at their primary place of employment (McNeilly, 1996).

METHODS • Responses were dichotomized after data collection into

none (“none” or “less than once/ year”) or regularly (“few times/year”, “few times/month”, “at least once/week”, and “nearly everyday”).

• Maternal age, education, marital status, income, prenatal care usage, parity, cigarette smoking, alcohol intake, and social support.

• Stratified and multivariate logistic regression analyses were performed.

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 1 OR MORE DOMAINS AND INFANT BIRTH WEIGHT

(Collins et al, AJPH, 2004)

0

10

20

30

40

50

60

% exposed to racism

VLBW (n=104) non-LBW(n=208)

OR=1.9 (1.2-3.1)

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT

(Collins et al, AJPH, 2004)

02468

101214161820

% exposed to racism

VLBW (n=104) non-LBW(n=208)

OR=2.7 (1.3-5.4)

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, MATERNAL

AGE, AND INFANT BIRTH WEIGHT

0

10

20

30

40

50

60

70

< 20 20-24* 25-29* >30

Maternal Age (yrs)

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, MATERNAL

EDUCATION, AND INFANT BIRTH WEIGHT

0

10

20

30

40

50

60

70

< 12 12 > 12*

Maternal Education (yrs)

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, PRENATAL CARE, AND INFANT BIRTH WEIGHT

0

10

20

30

40

50

60

70

Inadequate* Adequate*

Prenatal Care

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, CIGARETTE

SMOKING, AND INFANT BIRTH WEIGHT

0

10

20

30

40

50

60

Yes No*

Cigarette Smoker

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM , SOCIAL

SUPPORT, AND INFANT BIRTH WEIGHT

0

10

20

30

40

50

60

70

Absent Present*

Social Support

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

LOGISTIC REGRESSION (Collins et al, AJPH, 2004)

• Unadjusted and adjusted OR of VLBW for maternal lifetime exposure to interpersonal racial discrimination in 1 or more domains were 1.9 (1.2-3.1) and 2.3 (1.1-3.6), respectively.

• Unadjusted and adjusted OR of VLBW for maternal lifetime exposure to interpersonal racial discrimination in 3 or more domains were 2.7 (1.3-5.4) and 2.6 (1.2-5.3), respectively.

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM AT THE WORKPLACE AND

INFANT BIRTH WEIGHT

• “Because you are African-American, you are assigned jobs no one else will do”. OR=1.7 (0.7-4.3)

• “Whites often assume that you work in a lower class job than you do and treat you as such”. OR=2.3 (1.0-5.1

• “You are treated with less dignity and respect than you would be if you were white. OR=2.0 (0.8-4.3)

• “You are watched more closely than others because of your race”. OR=2.3 (0.8-6.1)

• “Because you are African-American, you feel that you have to work twice as hard”. OR=1.9 (0.9--4.1)

MATERNAL CHRONIC EXPOSURE TO INTERPERSONAL RACISM IN THE WORKPLACE AND INFANT BIRTH

WEIGHT

05

101520253035404550

1 or more* 3 or more* 7 or more

Racist Events-Workplace

% e

xpos

ed t

o r

acis

m

VLBWnon-LBW

Self-Reported Experiences of Racial Discrimination and the Racial Disparity in Preterm

Delivery: the CARDIA Study (Mustillo et al, AJPH, 2004)

05

1015202530354045

% exposed to racism in 3 or more domains

African-American (n=152) White (n=200)

Racial Discrimination and the Racial Disparity in Low Birth Weight Delivery: the

CARDIA Study (Mustillo et al, AJPH, 2004)

• Unadjusted OR of LBW delivery for African-American (compared to White) women was 4.2 (1.3-13.7).

• Adjusted (racial discrimination) OR of LBW delivery was 2.1 (0.8-5.9).

• Adjusted (racism, SES, depression, alcohol, and tobacco use) OR of LBW delivery was 2.4 (0.8-7.4.

White

AfricanAmerican

Puberty Pregnancy0 5ys

The Racial Gap in Reproductive Potential: A Life-Course Perspective Lu and Halfon,MCHJ, 2003

Rep

rodu

ctiv

e Po

tent

ial

Risk Factors

Life Course

Protective Factors

Positive Income-Incongruity(Collins, Herman, David; AJPH, 1997)

• Median family income of mother’s census tract residence is 1 S.D. above the mean income of non-Latino whites with same of years of parental education and marital status.

• Proxy measure of societal advantages not captured by individual level variables; i.e. generational wealth.

Positive Income-Incongruity(Collins, Herman, David; AJPH, 1997)

0

2

4

6

8

10

12

14

16

African-American(N=32,532)

Whites (N=27,309)

% exposed to positive Income-

Incongruity

Positive Income-Incongruity and VLBW(Collins, Herman, David; AJPH, 1997)

0

0.5

1

1.5

2

2.5

3

3.5

None Positive

Income-Incongruity

VL

BW

rat

es (

per

100

)

African-AmericansWhites

Adverse Environmental conditions

Social policy

Poverty

Racism

Limited Access to Care

Under-Education

Family Support

Lack of access to good Nutrition

Weathering

Stress

Smoking

Poor Working Conditions

Bad Housing

Bad NeighborhoodsUnemployment

Hopelessness

Disparities

Adapted from A. R. James

A 12-Point Plan: Lu and colleagues

• 1. Provide interconception care to women with prior adverse pregnancy outcomes

• 2. Increase access to preconception care for African American women

• 3. Improve the quality of prenatal care• 4. Expand healthcare access over the life course• 5. Strengthen father involvement in African American families• 6. Enhance service coordination and systems integration• 7. Create reproductive social capital in African American communities• 8. Invest in community building and urban renewal• 9. Close the education gap• 10. Reduce poverty among African-Americans• 11. Support working mothers • 12. Undo racism: institutional, interpersonal