Audra D. Robertson, MD, MPHBrigham and Women’s Hospital

Harvard Medical SchoolApril 8, 2010

Babies born to Black womenin the US, Texas, and Tarrant

County are more than twice as likely to die in the first year of

life compared to babies born to White women.

In Boston, three times as likely.

Infant mortality is a significant indicator of a community’s health

andsocial welfare

1. Defining the disparity Review national, state, local data to identify

the disparity

2. Understanding the cause of the disparity Preterm Birth Risk versus Care

3. Addressing the disparity Understanding the life course approach Stress and preterm birth

▪ Barker Hypothesis, Allostatic Load, Weathering Implementing a Life Course Approach

4. Discussion

Infant death: Death of an infant in the 1st year of life

Infant mortality rate: Number of infant deaths per 1,000 live births.

Term birth: Birth from 37 to 41 completed weeks of gestation.

Preterm birth: Birth before 37 weeks

Very preterm birth: Birth before 32 weeks

Late preterm birth: Birth from 34 to 36 weeks

DHHS NCHS National Vital Statistics Reports, 2002

United States, Table 1: Health 2008

7.26.9

6.46.3

6.2

5.45.2

5.155

4.94.7

4.64.4

4.24.2

4.14

3.93.8

3.73.6

3.53.4

3.13

2.82.42.4

2.1

6.2

0 1 2 3 4 5 6 7 8

SlovakiaUnited States

PolandN. Ireland

CubaHungaryCanada

ScotlandNew Zealand

AustraliaEngland

NetherlandsItaly

IsraelDenmark

AustriaSwitzerland

SpainIreland

GermanyGreece

BelgiumFrance

PortugalCzech Republic

NorwayFinland

JapanHong Kong

SwedenSingapore IMR: Deaths per 1,000 live

births

0

2

4

6

8

10

12

14

16

US (1) Boston (2) TX (3) Tarrant County (3)

HP HP 20102010

1National Center for Health Statistics, 20072Massachusetts Dept of Public Health, 20083Texas Dept of State Health Services and Tarrant County Public Health, 2009

4.54.5

Black White

2.4x2.4x 2.3x2.3x 2.3x2.3x3.7x3.7x

A Case of Infant Mortality

A healthy 34 year-old African American woman presented to a teaching hospital with bleeding and abdominal pain at 27 weeks gestation

Despite current medical intervention, she delivered a ounce boy prematurely

He lived 24 days

The mother has yet to recover emotionally from this loss

2 National Center for Health Statistics, 2010

All Races………………………………….…….White ..……………………………………..…..Black …………………………………………….Native American ……………………………Asian …………………………………………….Hispanic ………………………………………… Mexican …..………………………………… Puerto Rican …………………………….… Cuban ……………………………………….. Central and South American ………….

1995

7.66.3

14.69.05.36.36.08.95.35.5

2005

6.95.713.6

8.14.95.65.58.34.44.7

Hispanic groups have lower socioeconomic status, but better than expected health and mortality outcomes

Explanation (unknown) Healthy migrant effect Return migration effect Social capital, resiliency

Reasons for this paradox are likely to be multifactorial and social in origin

Outcomes worsen after acculturation

1. Defining the disparity Review national, state, local data to identify the

disparity

2. Understanding the cause of the disparity Preterm Birth Risk versus Care

3. Addressing the disparity Understanding the life course approach Stress and preterm birth

▪ Barker Hypothesis, Allostatic Load, Weathering Implementing a Life Course Approach

4. Discussion

CDC/NCHS National Vital Statistics System, 2008

46%

Estimated total annual health care charges for babies born in the US:

Estimated $52 Billion (for 4.3 million live births)

Total cost for babies born premature

$26 Billion (for 546,000 preterm births)

Average health care cost for a baby born healthy $4,551

Average health care cost for a baby born premature$49,000

The Cost of Preterm Births

Source: March of Dimes 2009, AHRQ Healthcare Costs and Utilization 2007, and Institute of Medicine 2006

Collins and David NEJM 1997 Examined LBW of African-born blacks living

in U.S., U.S. born African Americans, and U.S. born whites.

LBW among African-born blacks closer to U.S. born whites, but by 2nd generation black to white gap started to emerge.

Collins and David NEJM 1997

Collins et al. 1997 Women with 16 years or more Education Small-for-Dates Rate

▪ African-Americans 2.8%▪ Whites 1.2%▪ Odds Ratio 2.9 (CI 1.4-4.5)

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101214161820

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Adapted from D. Williams

1. Defining the disparity Review national, state, local data to identify the

disparity

2. Understanding the cause of the disparity Preterm Birth Risk versus Care

3. Addressing the disparity Understanding the life course approach Stress and preterm birth

▪ Barker Hypothesis, Allostatic Load, Weathering

Implementing a Life Course Approach

4. Discussion

Health is shaped by the biological, behavioral/social and psychosocial pathways operating throughout life, as well as across generations

Study of independent, cumulative and interactive effects of biological, social and psychological risk factors/exposures during gestation, childhood, adolescence,

young adulthood and later adult life on women's health and birth outcomes

Kuh D and Hardy R. A Life Course Approach to Women’s Health. 2002

Understanding the exposure–outcome associations across an individual lifespan accounting for:

critical or sensitive period of exposureexposure trajectory intensity of exposure over time

(accumulation)

Kuh D and Hardy R. A Life Course Approach to Women’s Health. 2002

Pre-conception

Prenatal

Inter-conception

•View life, not in stages, but as integrated continuum

•Begin to understand critical/sensitive periods of risk as well as cumulative effects

i.e. Barker Hypothesis

e.g. Environmental Pollution

e.g. Mental Health

Reproductive capacity begins with menarche and ends with menopause

Yet, reproductive health begins in utero and is influenced by: Life circumstances such as neighborhood

environment, relationship interactions and social support structures

An individual's stress coping skills and disposition

Mishra G, Cooper R, and Kuh D. Maturitas 65;2:2010 (92-97)

A large body of evidence supports maternal psychosocial stress as an independent and significant risk factor for preterm birth1

Evidence supports a correlation between maternal psychological stress and the placental–adrenal endocrine axis 2

Research implicates CRH as a contributor to the initiation of labor in term and preterm birth31 Hedegaard, 1993; Hobel, 2003; Ruiz, 2003; Zambrana, 1999

2 Lockwood, 1999; Wadhwa et al, 20013 Holzman, 2001; McGrath, 2002; Moawad, 2002

The fetal origins of adult disease

Biologic ProgrammingExposures during critical periods of growth and development in utero may “program” the structure or function of organs, tissues, or body systems

Previous Theory adult lifestyle model social causation

Barker DJP. Fetal and infant origins of adult disease. London: British Medical Publishing Group, 1992.

Physi

olo

gic

R

esp

onse

Stress Recovery

“Stressed” Increased cardiac output

Increased available glucose

Enhanced immune function

Growth of neurons

“Stressed Out” Hypertension, CV disease, MI

Obesity, glucose intolerance & insulin resistance

Infection & inflammation

Atrophy & death of neurons

Time

No Recovery

Physi

olo

gic

R

esp

onse

Adapted from M. Lu and B McEwen

Homeostasis: remaining stable by constancy Allostasis: fluctuation of the physiologic

systems within the body to meet demands from external forces, causes activation of neural, neuroendocrine and neuroendocrine-immune mechanisms

Allostatic Load: the physiologic “cost” of an individuals reaction to repeated challenge (thus chronic exposure to fluctuating or heightened neural or neuroendocrine responses)

McEwen BS. Ann N Y Acad Sci. 1998

An individual may age prematurely because of exposure to chronic stress early in life

Stress Age versus Chronologic Age Geronimus and Weathering

associated with adverse pregnancy outcomes and hypertension among black and poor women

McEwen and Allostatic load

the cumulative wear and tear that the body experiences as a result of daily life

Geronimus AT.Ethn Dis 1992 and McEwen Metabolism 2003

The Barker Hypothesis of the fetal origins of adult disease

The HPA axis remains plastic throughout life and is molded and remodeled by environmental exposures

Animal studies support that chronic stress can program the fetal brain’s reaction to novel stressors

Stress exposure up-regulates gene expression of CRH which may create exaggerated physiologic responses to stressors

Thus, programming future stress responsesRosen JB et al. Behav Neurosci 1996.

Young Adult/ AdultAdolescence

WhiteAfrican

American

Perinatal

Repro

duct

ive Pote

nti

al

Repro

duct

ive Pote

nti

al

Life CourseLife Course

AfricanAmerican

Childhood

Age 0

Adapted from Lu and Halfon. Matern Child Health J. 2003;7:13-30.

Risk Factors Protective Factors

Adapted from McGinnis et al., Health Affairs 2002

• Address the root cases• Chronic Maternal Stress• Preterm birth and low birth weight birth

• Address social determinant of health

• Incorporate a life course approach to scientific investigation, program integration, and policy development

Atwood K et el. Am J of Pub Health 1997. 87(10):1603-6 .Richmond and Kotelchuck. from Oxford Textbook of Public Health. 1991

Reduce the number of high-risk pregnancies Preconception Health Optimal Social Determinants of Health Optimal Reproductive Life Plan

Reduce LBW and preterm birth Health promotion Optimal PNC (e.g. progesterone for previous PTB, group prenatal

care)

Improve birthweight specific survival Access to quality OB care and high volume NICU -> Regionalized

care

Reduce death from sudden infant death syndrome Support services, parent education, and health promotion

1. Provide inter-conception care to women with prior adverse pregnancy outcomes

2. Increase access to preconception care for African American women

3. Improve the quality of prenatal care4. Expand healthcare access over the life course5. Strengthen father involvement in African American

families6. Enhance service coordination and systems

integration7. Create reproductive social capital in African

American communities8. Invest in community building and urban renewal9. Close the education gap10. Reduce poverty among Black families11. Support working mothers and families12. Undo racismLu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes:

A life-course approach. Ethnicity and Disease. 2008

Audra D. Robertson, MD, MPHBrigham and Women’s Hospital

Harvard Medical SchoolApril 8, 2010