Back to the Future: Perinatal Outcomes in Latinos

Elena Fuentes-Afflick, MD, MPHSan Francisco General HospitalUniversity of California, San Francisco

Disclosures

None

Objectives

1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos.

2. To identify areas for future research in perinatal outcomes in Latinos.

US population

0 25 50 75 100

1965

1990

2000

Percent

White African American Latino Asian/ PI

Census Bureau

Births in the US, 1990-2005

0500000

10000001500000200000025000003000000350000040000004500000

1990 1995 2000 2005

Total Latina

National vital statistics reports, 2009

Latino births in the US (%), 1990-2005

0

10

20

30

Percent

1990 1995 2000 2005

National vital statistics reports, 2009

US births (%), by ethnicity: 2006

5.7 14.5

24.4

54.3

African American Latino White Asian American Indian

National Center for Health Statistics, 2009

National Center for Health Statistics

Infant mortality: 1940-1995

Infant mortality rate: 1995-2005

0

5

10

15

20

25

1995 2000 2005

Rate (per 1,000 births)

African American White

National Center for Health Statistics

0

5

10

15

20

25

Year

Rate

(p

er 1

,000 b

irth

s)

White Latina African American

Neonatal mortality rate: Texas, 1970-9

Powell-Griner and Streck, Am J Public Health 1982

“We tentatively conclude from our study that the low neonatal mortality rates observed in Texas among the Spanish surname population are due in part to underreporting of neonatal deaths.”

Powell-Griner and Streck, Am J Public Health 1982

Infant mortality: Harris County Texas, 1974-75

0

5

10

15

20

25

Neonatal Postneonatal

Rat

e (p

er 1

,000

live

bir

ths)

White Latina African American

Selby et al, Am J Public Health 1984

“These consistently paradoxical findings lead us to conclude that the Spanish surname infant mortality rate is not a valid indicator of health status for the Mexican American population of Harris County, Texas.”

Selby et al, Am J Public Health 1984

Infant mortality rate, by ethnicity: CA 1990-93

0.50 0.54

0.0

0.5

1.0

Rate

(%

)

White Latina

Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Odds of infant death, by ethnicity

1.080.88

0

0.5

1

1.5

2

Latina White (ref)

Unadjusted Adjusted

Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Causes of infant mortality

0 10 20 30 40

Latina

White

Percent

Perinatal/SIDSCongenital anomaliesRespiratoryCirculatoryInfectious

Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Population-based indicators of health

Low birth weight and prematurity are significant risk factors for infant mortality

Low birth weight and prematurity are associated with neurologic impairment, cerebral palsy, learning differences

Low birth weight and prematurity: US, 2005

0

5

10

15

20

Rate (% )

LBW Prem

African American White Latina

National Center for Health Statistics, 2008

Low birth weight in the US

0

5

10

15

Rate (%)

2004 2005 2006 2007

www.nchs.gov

Healthy People 2010 goal

Low birth weight: CA, 1981

0

5

10

15

500-1499g 1500-2499g

Rat

e (%

)

US-born White Latina US-born Black

Williams et al, Am J Public Health 1986

Low birth weight: 32 studies

0

5

10

15

Rate

(%

)

African American Latina White

Study

Fuentes-Afflick E and Lurie P, Arch Pediatr Adolesc Med 1997

Low birth weight among Latina and White women in CA, 1992

0

5

10

15

VLBW MLBW

Per

cen

t

White Latina

Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999

Low birth weight: Latinas in CA, 1992

1.10 1.04 1.06*0.93, NS

0.5

1.0

1.5

2.0

VLBW MLBW

Od

ds

rati

o

Unadjusted Adjusted

Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999

* *

Perinatal Outcomes

Behavioral

Nutrition/Diet

Social SupportCultural

Community

Artifact

ObstetricReproductive

Medical Healthy Immigrant

Behavioral factors

Latina women have lower rates of behavioral risk factors (tobacco and alcohol use) than African American or White women

Foreign-born women generally have lower rates of tobacco and alcohol use than US-born women

Healthy nutrition

Micronutrients

Nutrition - Obesity

http://wellroundedmama.blogspot.com

Medical factors

• Are Latina women healthier than women of other ethnic groups?

• Are immigrant Latinas healthier than women in their population of origin?

• Are immigrant Latinas healthier than women in the receiving population?

Obstetric / Reproductive

• Interpregnancy interval?

• Do Latina women have a reproductive advantage?

Summary

Latina women have low rates of infant mortality, low birth weight, and prematurity

We do not understand why Latina women have such favorable perinatal outcomes

Objectives

1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos.

2. To identify areas for future research in perinatal outcomes in Latinos.

Ethnicity ≠ Acculturation

Immigrants in the US

12

0

5

10

15

20

25

%

1990 2000 2005 2005, Canada 2050 (projected)

Acculturation

“… the process by which immigrants adopt the attitudes, values, customs, beliefs and behaviors of a new culture.”

Abraido-Lanza A et al, AJPH 2005

Last names in the US, 2009

#1 Smith

#2 Johnson

#3 Williams

#4 Brown

#5 Jones

#8 Garcia

#9 RodriguezCensus Bureau

Foreign-born childbearing women: US, 2005

0

25

50

75

100

%

African American White Latina Asian/ PI

National Center for Health Statistics

Low birth weight, by birthplace: Latina women in CA, 1992

0

0.5

1

1.5

2

AOR

VLBW MLBW

Foreign-born US-born (ref)

VLBW OR 0.92 (0.80-1.07)

MLBW* OR 0.91 (0.86-0.96)

Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1998

Infant mortality, by birthplace: Latina women CA, 1990-93

0.5

1

1.5

2

Foreign-born US-born (ref)

OR

Unadjusted

OR 1.08 (1.03-1.13)*

Adjusted

OR 0.88 (0.80-0.97)*

Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Two dimensions of the epidemiologicparadox

Latina women have surprisingly favorable perinatal outcomes relative to African American and White women

Foreign-born Latinas have surprisingly favorable perinatal outcomes relative to US-born women

Risk factor models – one size fits all?

Interventions – tailored? Universal?

Protective factors versus risk factors

Implications of the epidemiologic paradox

Social support

Community factors

“The paradox of Hispanic health represents a group-level correlation between ethnicity and mortality that cannot be explained in terms of an individual-level model.”

Scribner R, Am J Public Health 1996

Lifecourse approach

Demographic risk factors

Medical/health status

Obstetric/reproductive factors

Promising areas Acculturation

Prematurity

Interpregnancy interval

Challenging areas

Methodologic and challenges

Body mass, maternal

Paternal factors

Community-level factors

Acculturation ‘web’

www.harrycutting.com