trends in african american birth outcomes
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National and Regional Trends in African American Birth Outcomes
Karla Damus, RN MSPH PhDAssociate Professor
Dept OB/GYN and Women’s Health
Albert Einstein College of Medicine
National March of Dimes
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Maternal Mortality by RaceUnited States, 1970 -2003
0
10
20
30
40
50
60
70
1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003
All Races White Black
Maternal death per 100,000 live births
Note: Rates for 1970-1988 are based on race of child. Rates for 1989-2003 are based on race of mother.
Source: National Center for Health Statistics, final mortality data
Prepared by March of Dimes Perinatal Data Center, 2006
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www.healthypeople.gov
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The Current Agenda
• Goal #1: Increase quality and healthy years of life
• Goal #2: Eliminate health disparities– gender– race/ethnicity– income and education– disability– geographic location– sexual orientation
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Questions • What data are needed to describe disparities in birth outcomes
in communities? • What data need to be collected to help inform possible reasons
for disparities in birth outcomes?• What strategies have been shown to reduce disparities?• What relationships/partnerships need to be in place to address
disparities in communities?• What programs need to be developed to address disparities at
the community and population level?• What activities has the community tried? What’s worked/ What
hasn’t? Why?• What are realistic goals for our organization/ communities?
What are we ready to work toward? Opportunities? Venues? Approaches? Other relevant organizations?
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Births by Race/Ethnicity US 2001-2003 average
In 2004 there were 4,112,052 live births registered in the US
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Infant MortalityUnited States, 1915-2002
0
20
40
60
80
100
120
1915 1925 1935 1945 1955 1965 1975 1985 1995
Rate per 1,000 live births
Source: National Center for Health Statistics, final mortality data
Prepared by March of Dimes Perinatal Data Center, 2002
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www.cdc.gov/mmwr
• Unexpected findings- most of increase due to:– non Hispanic white– >30 years– married– >high school– onset PNC first trimester– nonsmoker– private insurance
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Infant Mortality by Maternal RaceUnited States, 1990 -2004*
9.2 8.9 8.5 8.4 8.0 7.6 7.3 7.2 7.2 7.0 6.9 6.8 7.0 6.8 6.8
4.5
0.0
4.0
8.0
12.0
16.0
20.0
1990 1992 1994 1996 1998 2000 2002 2004
All Races White Black
Rate per 1,000 live births
Source: National Center for Health Statistics, final mortality data
*preliminary data
Prepared by March of Dimes Perinatal Data Center, 2007
2010 0bj
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Black/White Infant Mortality Rate RatioUnited States, 1980-2004*
2
2.1
2.2
2.3
2.4
2.5
2.6
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Source: NCHS, final mortality data
*preliminary mortality data
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Racial and Ethnic DisparitiesInfant Mortality Rates, US 2001
13.3
9.78.5
7.3
5.7 5.5 5.24.2 4
3.2
0
2
4
6
8
10
12
14
Per 1,000 Live Births
NCHS 2003
HP 2010 Objective
4.5
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Infant Mortality by Race/EthnicityInfant Mortality by Race/EthnicityNew York City, 1990-2001New York City, 1990-2001
0
4
8
12
16
20
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Other White Other Black Puerto Rican Other Hispanic Asian
Rate per 1,000 live births
Office of Vital Statistics and Maternal, Infant & Reproductive Health Program , NYCDOH Prepared by March of Dimes Perinatal Data Center, 20002
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Infant Mortality Rates by Race/Ethnicity US Region, 2000-2002 average
US West Midwest NE South
Hispanic 5.5 5.4 6.6 6.1 5.3
White 5.7 5.2 6.1 4.9 6.2
Black 13.6 11.6 15.5 12.4 13.6
Native Am 8.8 8.7 10.5 5.8 8.2
Asian 4.7 4.9 5.6 3.4 4.0
Total 6.9 5.7 5.4 6.2 7.7
Source: National Center for Health Statistics, final mortality data
Prepared by March of Dimes Perinatal Data Center, 2007
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Infant Mortality Rates by State, 2003
Source: National Center for Health Statistics, 2003 period linked birth/infant death data.
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Three Leading Causes of Infant Mortality
United States, 1990 and 2004*
51.2
113.8
136.6
130.3
96.5
198.1
0 50 100 150 200 250
SIDS
Preterm / LBW
Birth Defects
1990
2004
Rate per 100,000 live births
Source: National Center for Health Statistics
*preliminary mortality data for 2004
Prepared by March of Dimes Perinatal Data Center, 2007
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Three Leading Causes of Infant Deaths
by Race/Ethnicity, US , 2000
1.7 1.8
1.4
1.11.3
3
1.1
0.78 0.69 0.76
1.31.5
0.33 0.310.56
0
0.5
1
1.5
2
2.5
3
3.5
AfricanAmerican
NativeAmerican
Hispanic Asian/PI White
Birth Defects
Preterm/LBW
SIDS
Per 1,000 Live Births
NCHS 2001
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9.611.0
12.3
7.6
12.7
0
5
10
15
1983 1993 2003 2005
Preterm is less than 37 completed weeks gestation.Source: National Center for Health Statistics, final natality dataPrepared by March of Dimes Perinatal Data Center, 2005*preliminary
Pe
rce
nt
HP 2010 Objective>30%
Increase
Preterm Birth RatesUnited States, 1983, 1993, 2003, 2005*
Percent> 1 out of 8 births or 508,000 babies born preterm in
2005
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10.6 10.8 10.7 11.0 11.0 11.0 11.0 11.4 11.6 11.8 11.6 11.9 12.1 12.3 12.5
0
2
4
6
8
10
12
14
16
18
20
1990 1992 1994 1996 1998 2000 2002 2003 2004
Total White Black Hispanic
Percent
Preterm (<37 wks) Births by Maternal Race/Ethnicity, US, 1990-2004
Source: National Center for Health Statistics, final natality data.
Note: All race categories exclude Hispanic births.
Data from 1990 excludes NH and OK. Data from 1991 and 1992 excludes NH.
The reporting of Hispanic ethnicity was not required in these states during these years.
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Preterm Birth Rates by Race/Ethnicity and US Region, 2001-2003 average
US West Midwest NE South
Hispanic 11.6 11.0 11.4 12.0 12.4
White 11.0 10.1 11.0 10.0 12.0
Black 17.7 15.6 17.9 16.2 18.4
Native Am 13.2 13.5 13.0 11.9 13.1
Asian 10.4 10.5 10.4 9.5 11.0
Total 12.1 10.8 12.0 11.2 13.5
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2007
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Preterm Birth Rates by Race/Ethnicity & Education, IOM 2006
Years of Ed
Non Hispanic
Black
NonHispanic
White
Asian Pacific
Islander
Am
Indian
Hispanic
< 8 19.6 11.0 11.5 14.8 10.7
8-12 16.8 9.9 10.5 11.8 10.4
13-15 14.5 8.3 9.1 9.9 9.3
>16 12.8 7.0 7.5 9.4 8.4
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Singleton Preterm Births by Maternal Race/Ethnicity and Education, 2001-2002
http://diversitydata.sph.harvard.edu
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Definitions
• Preterm birth:
– < 37 completed weeks gestation
• Late preterm (or Near-Term):
– 34-36 completed weeks
• Very preterm:
– <32 completed weeks
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Total (<37 weeks), Very (<32 weeks) and Late Preterm Births (34-36 weeks) U.S., 1990- 2003
12.310.6
0
2
4
6
8
10
12
14
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Preterm Late Preterm Very Preterm
Percent
Late Preterm
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Distribution of Preterm Births by Gestational Age, US, 2002
Source: National Center for Health Statistics, 2002 natality file
Prepared by the March of Dimes Perinatal Data Center, 2004
16.2
5
7.6
12.9
21.1
37.1
(34 Weeks)
(33 Weeks)
(32 Weeks)
(<32 Weeks)
(35 Weeks)
(36 Weeks)
“Near term infants had significantly more medical problems and increased hospital costs compared with contemporaneous full term infants
Near term infants may represent an unrecognized at-risk neonatal population.”Wang, et al. Clinical Outcomes of Near-Term Infants, Pediatrics (114) 372-6, 2004.
~71% of PTB 34 - 36 weekslate preterm
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0
5
10
15
20
25
30
35
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Total (1) Primary (2) VBAC (3)
(1) Per 100 births(2) Per 100 births to women with no previous cesarean(3) Per 100 births to women with a previous cesarean Source: NCHS, final natality data, 1993-2003 and 2004 preliminary dataPrepared by March of Dimes Perinatal Data Center, 2005
Total and Primary Cesarean and VBAC
United States, 1993 - 2005
Preliminary
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Kinney, 2006
Human Brain Growth in Gestation
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PEDIATRICS Vol. 118 No. 3 Sept 2006, pp. 1207-1214
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Differences in Singleton Preterm Birth Rates
by Race/Ethnicity, 1992 and 2002
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Cesarean Section and Labor Induction Rates among Singleton Live Births by Week of Gestation US, 1992 and
2002
Late Preterm
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Birth Weight and Coronary Heart Disease
Barker Hypothesis1.5
1.251.15
10.9
0.7
0
0.25
0.5
0.75
1
1.25
1.5
1.75
<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0
Ag
e A
dju
sted
Rel
ativ
e R
isk
Rich-Edwards 1997
Birthweight (lbs)
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Birth Weight and Insulin Resistance Syndrome
Barker Hypothesis18
8.4 8.5
4.9
2.21
0
5
10
15
20
<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5
Od
ds
rat i
o a
dj u
s ted
fo
r B
MI
Barker 1993 Birthweight (lbs)
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Factors that Contribute to Increasing Rates of Preterm Birth
• Increasing rates of births to women 35+ years of age– Independent risk of advanced PATERNAL age
• Increasing rates of multiple births• Indicated deliveries
– Induction– Enhanced management of maternal and fetal conditions– Patient preference/consumerism (CDMR)
• Substance abuse– Tobacco– Alcohol– Illicit drugs
• Bacterial and viral infections • Increased stress (catastrophic events, DV, racism)
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Risk Factors for Preterm Labor/Delivery• The best predictors of having a preterm birth are:
current multifetal pregnancya history of preterm labor/delivery or prior low birthweightmid trimester bleeding (repeat) some uterine, cervical and placental abnormalities
• Other risk factors:
–unintended pregnancy–maternal age (<17 and >35 yrs)–black race–low SES–unmarried–previous fetal or neonatal death–3+ spontaneous terminations–uterine abnormalities–incompetent cervix–cervical procedures–genetic predisposition
–low pre-pregnant weight
–obesity
–infections
–anemia
–major stress
–lack of social supports
–tobacco use
–illicit drug use
–alcohol abuse
–folic acid deficiency
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1985
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Folic Acid-Specific KnowledgeMarch of Dimes Folic Acid Survey
4
10
13 14
20 21
24
19
2
6 7
10
7
10 1012
7
19
0
5
10
15
20
25
1995 1997 1998 2000 2001 2002 2003 2004 2005
Prevents birth defects Should be taken before pregnancy
Percentage of women ages 18-45
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Folate Levels Drop Significantly
• A CDC study released Thursday found an 8 to 16 % decline in folate levels based on results of the NHANES (interviews, PE, and blood tests of about 4,500 US women, ages 15 to 44, done between 1999 and 2004).
• It was the first time such a decline has been seen since the start of government health campaigns urging women to make sure they get enough folic acid.
• The decline was most pronounced in white women, although black women continue to be the racial group with the least folate in their blood.
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Smoking Among Women of Childbearing AgeUS, 2003
Smoking is defined as having ever smoked 100 cigarettes in a lifetime and currently smoking everyday or some days. Percent reported is among women ages 18-44. Source: Smoking: Behavioral Risk Factor Surveillance System. Behavioral Surveillance Branch, Centers for Disease Control and Prevention..
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Multiple Birth Ratios by Maternal Race/EthnicityUnited States, 1992-2002
24.4 25.2 25.7 26.1 27.4 28.630.0 30.7 31.1 32.0 33.3
0
5
10
15
20
25
30
35
40
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
All Births Non-Hispanic White Non-Hispanic Black
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2005
Per 1,000 live births
Percent Change ‘96-’02 = 21.5%
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Higher-Order Multiple Birth RatiosBy Maternal Race, United States, 1980-2002
37.0 38.2 40.3 43.3 45.151.2 48.3
56.2 61.069.2
81.4
95.5104.2
116.2127.5
152.6
193.5184.9 184.0
173.6 180.5185.6
72.8
0
40
80
120
160
200
240
All races White Black
Ratio per 100,000 live births
Source: NCHS, final natality dataPrepared by March of Dimes Perinatal Data Center, 2004
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Institute of Medicine Report, July 2006
The IOM estimates the total national cost of premature births to be at a minimum $26.2 billion. This estimate includes many costs, such as in-patient hospital costs, lost wages and productivity and early intervention programs.
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Institute of Medicine Report on Preterm Birth, 2006
• - One of the three major themes is disparities in PTB rates among different groups (racial, ethnic, or socioeconomic).
• - Literature on causes of racial/ethnic disparities in PTB and effects of nativity need to be developed.
• - Studies show that differences in PTB between African-American and white women remain after adjusting for socioeconomic differences.
• - Literature on maternal behaviors such as smoking, drug use, and alcohol find that African-American women smoke less than white women during pregnancy and that the prevalence of drugs and alcohol use is no greater among pregnant African-American women compared to white women.
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Institute of Medicine Report on Preterm Birth, 2006
• Infections may play a role in PTB, and studies have shown that African-American women are more likely than white women to experience infections such as bacterial vaginosis and sexually transmitted infections. The reasons for increased susceptibility to infection among pregnant African-American women are unknown.
• Unknown how genes or interactions of genes and the environment contribute to racial/ethnic disparities in PTB or why foreign-born and US-born women of the same race have different PTB rates given a common genetic ancestry.
• Concludes that racial-ethnic differences in socioeconomic condition, maternal behaviors, stress, infection, and genetics can not fully account for disparities.
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Research Agenda
• Research agenda Recommendation II-3: Expand research into the causes and methods for the prevention of the racial-ethnic and socioeconomic disparities in the rates of preterm birth.
• This research agenda should continue to prioritize efforts to understand factors contributing to the high rates of preterm birth among African American infants and should also encourage investigation into the disparities among other racial-ethnic subgroups.
• Proposes that research should be guided by an integrated approach that examines co-occurrence and interactions among multiple determinants of disparities in preterm birth, including racism, which operates at multiple levels and across a life course.
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proteases
Uterine Contraction
s
Cervical Change
• Infection: - Chorion-Decidual - Systemic
DecidualHemorrhag
eAbruption
CRHE1-E3
Prothrombin G20210AFactor V LeidenProteins C, S, ZType 1 PlasminogenMTHFR
PathologicalUterine
Distention
• Multifetal Preg• Polyhydramnios• Uterine
abnormalities
Inflammation
•Maternal-Fetal Stress• Premature Onset of Physiologic Initiators
Activation of Maternal/Feta
l HPA Axis
CRH
+
+
ChorionDeciduaChorionDecidua
uterotonins
Mechanical stretchGap jct
IL-8 PGE2
Oxytocin recep
pPROM
InterleukinsIL-1, IL-5, IL-8TNF- Fas L
Adapted from: Lockwood CJ, Paediatr Perinat Epidemiol 2001;15:78 and Wang X, et al. Paediatr Perinat Epidemiol 2001; 15: 63
Susceptibility to
Environmental toxins
CYP1A1GSTT1
MMPs
PTB
Allergic Pathway
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PATHWAYS
FA
CT
OR
S
External Environment
Immune Status
Nutrition
Behaviors
Medical Conditions
Medical Interventions
Psychosocial
Oth
ers: Ho
rmo
nes?
Toxin
s?
Bleed
ing
/ Th
rom
bo
ph
ilias
Ab
no
rmal U
terine D
istentio
n
Matern
al / Fetal S
tress
Inflam
matio
n / In
fection
PRETERM BIRTH
OUTCOMES
Preterm Labor / pPROM
Racial / Ethnic Disparities
Genetics / Family History
Fetal Growth
Green et al. AJOG 193:626-35, Sept 2005.
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The 2006 PRI Grantees
• A Comprehensive Study of Genetic Susceptibility to Preterm Delivery
• Pharmacological Investigation of Novel Anti-inflammatory Therapeutic Strategies for the Treatment and Prevention of Preterm Birth using Human Ex-Vivo Models
• Maternal and Infant Genetic Contributions to Preterm Birth: the Inflammatory Response
• Abruption-induced Preterm Delivery Elicits Functional Endometrial Progesterone Receptors
• Progesterone Receptor Dysregulation and Preterm Birth
• Cytokines from Periodontal Disease Induce Premature Birth
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PTB Risk Factors Revisited• The strongest risk factors for PTB suggest a maternal or fetal genetic
predisposition • Women born preterm are more likely to deliver preterm• ~20% of women who deliver preterm have recurrence with the same
partner– changing partners reduces the risk by one third
• The heritability of PTB is estimated to be 17%-36%• 18 studies reviewed on genetic polymorphisms showed that
polymorphisms in TNF alpha showed the most consistent increase in PTB• Environmental factors such as infection, stress, and obesity suggest that
environmental and genetic RF might operate and interact through related pathways.
Crider, et al. Genetic variation associated with preterm birth: a HuGE Review. Genetics in Med 7(9) 593-604, 2005.
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Gene Clue to Premature Birth• A genetic marker that could help to predict the risk of an
unexpected preterm birth has been discovered
–may also help explain why AfAm women seem to be more at risk of having a preterm birth than other women
–AfAm babies were 3 times more likely than babies of European descent to carry the key genetic variant,
• SERPINH1 controls production of the protein collagen, a key component of many body tissues, including cartilage, ligaments, tendons, bone and teeth
–variation of the gene can result in reduced amounts of collagen which could lead to weakened fetal membranes, increasing the chance of rupture triggering preterm birth.
–The SERPINH1 T allele population attributable risk of PPROM is estimated to be 12.3%
• “With better understanding of this genetic variation, we hope to be able to identify pregnancies at great risk of preterm birth and intervene to prevent it”, Jerome Strauss, MD
Wang, et al. “A Functional SNP in the Promoter of the SERPINH1 Gene Increases Risk of PPROM in African Americans” Online Proceedings of the National Academy of Sciences, Aug 2006
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Khoury M and Romero R. AJOG (2006) 195, 1503–5
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Uninsured WomenUS, 2003-2005 Average
Source: US Bureau of the Census. Data prepared for the March of Dimes using the Current Population Survey.
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Uninsured ChildrenUS, 2003-2005 Average
Source: US Bureau of the Census. Data prepared for the March of Dimes using the Current Population Survey.
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Closing the Black-White Gap in Birth Outcomes: A 12-Point Plan
• Provide interconceptional care to women with prior adverse pregnancy outcomes
• Increase access to preconception care for African American women
• Improve the quality of prenatal care• Expand healthcare access over the life course• Strengthen father involvement in African American families• Enhance service coordination and systems integration• Create reproductive social capital in African American
communities• Invest in community building and urban renewal• Close the education gap• Reduce poverty among Black families• Support working mothers and families
M Lu, UCLA, 2006
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Undo Racism• Internalized
• Personally mediated
• Institutionalized
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www. gucchd.georgetown.edu/nccc
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PREEMIE Act (S. 707) Passes Congress• Dec. 9, 2006-- Dr.. Howse, president of the March of Dimes,
made the following statement as the Congress sent the “PREEMIE” Act to President Bush for his signature:
• “Congress has responded to the growing crisis of premature birth by approving a bill that will increase federal support for research and education on prematurity. On behalf of 3 million active volunteers and 1400 staff of the March of Dimes working in every state, the District of Columbia and Puerto Rico, I thank the United States Congress for approving the “PREEMIE” Act.
• In one of it’s most important provisions, the bill authorizes a Surgeon General’s conference at which scientific and clinical experts from the public and private sectors will sit down together to formulate a national action agenda designed to speed development of prevention strategies for preterm labor and delivery.