Eliminating Racial Disparities in Birth Outcomes
Conference on Ending Family Homelessness
Workshop: Healthcare Matters: Providing Health Services to Diverse Populations
February 7, 2008
Susan Barkan, Public Health Seattle & King County
Melanie Whitfield, People of Color Against AIDS Network
Maria Carlos, Public Health Seattle & King County
Acknowledgements
Susan Barkan
Kathy Carson
Parent Child Health, Public Health-Seattle & King County
Maria Carlos
Eva Wong
Doctoral Student, Department of Epidemiology,
University of Washington
Alice Park
Mei Castor
Urban Indian Health Institute
Shira Rutman
Jim La Roche
Leslie Randall
Northwest Portland Area Indian Health Board
Leah Henry
Tanner
Native American Women’s Dialog on Infant
Mortality (NAWDIM)
Jim Gaudino
Oregon State Department of Health
Infant Mortality Rates
US, Washington State, King County, Seattle
Three Year Rolling Average, 1981-2004
12
Seattle
Washington State
Rate per 1,000 Live Births
10
United States
8
6
2004 Infant Mortality Rates:
4
2
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
King
County
0
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
-8 2-8 3-8 4-8 5-8 6-8 7-8 8-9 9-9 0-9 1-9 2-9 3-9 4-9 5-9 6-9 7-9 8-0 9-0 0-0 1-0 2-0
1
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
9
0
0
0
Contributions to the Overall Decline
in Infant Mortality in King County

First Steps:
Maternity support and expansion of Medicaid coverage of
prenatal services

Safe Sleep:
Back to Sleep Campaign

Medical Advances:
Neonatal intensive care

Behavioral:
Decline in use of tobacco, alcohol, unintended pregnancies
Infant Mortality Rates by Race/Ethnicity,
King County, Three Year Rolling Averages,
1985-2004
Perinatal Periods Of Risk (PPOR)
Approach

A simple approach.

identify gaps in the community.

target resources for prevention activities.

mobilize the community to action.
PPOR guides strategies to improve birth
outcomes


Prematurity and low birthweight lead to infant
mortality.
PPOR method gives information that guides
community strategies to help infants be born
healthy.
PPOR Findings
WA State, 2000-2004

Infant Health is the highest contributor to
preventable FIMR among American Indian/Alaska
Natives

Maternal Health/Prematurity is the highest
contributor among African Americans and the
second highest contributor among AI/AN.

Maternal Care is the third highest contributor to
among AI/AN.

Newborn Care is consistently the lowest and is
similar for all racial/ethnic groups.
Implications/”Opportunity Gaps”
Maternal
Health/
Prematurity
Preconception Health
Health Behaviors
Perinatal Care
+ EXPAND STRATEGIES to
address social factors
giving rise to disparities
Infant
Health
Sleep Position
Breast Feeding
Injury Prevention
Medical Care for Infections
and Chronic Conditions
Prevalence and Trends in Birth Risk Factors
by Race, King County
American Indian/
African Americans Alaska Natives
% of
Births
20002002
Low Birth Weight (< 2500 g)
10.5*
Very Low Birth Weight (< 1500 g)
2.2*
Preterm (<37 weeks gestation, calc.)
18.9*
Multiple Birth (twins, triplets, etc.)
4.1
Mother's Age < 18
4.0*
Single Mother
54.1*
Late (3rd) or No Prenatal Care
4.8*
Inadequate Prenatal Care (Kotelchuck) 19.2*
Smoking During Pregnancy
11.1*
Alcohol Use During Pregnancy
1.6
Time
Trend
19932002
----
% of
Births
20002002
6.6
1.9*
16.9*
3.2
6.4*
58.7*
6.5*
18.8*
19.8*
4.0
Time
Trend
19932002
---
--
Whites
% of
Births
20002002
5.3
0.8
11.9
3.6
1.5
20.5
2.0
7.7
8.0
2.7
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.
Time
Trend
19932002
--
American
African
Indian/
American: Alaska
White
Native:
Rate
White
Ratio
Rate Ratio
(2000-2002) (2000-2002)
2*
2.6*
1.6*
1.2
2.7*
2.6*
2.4*
2.5*
1.4*
0.6
1.3
2.3*
1.4*
0.9
4.2*
2.9*
3.3*
2.4*
2.5*
1.5
How Stress Can Affect Health:
 Increased cortisol (fight/flight hormones) results in increased
cardiovascular function
 Can lead to high blood pressure, depressed immune function
with increased vulnerability to infection, and depression. All of
these can contribute to risk of preterm delivery.
 These stress responses are designed to help us deal with
short term threats, but for many, the stressors don’t go away.
 Long-term, chronic stress does not allow for system recovery
and predisposes to adverse health effects
Reported Stressful Life Events
During Year Before Delivery
King County, 1999-2001
African
American
American
Indian/Alask
a Native
White
Changed residence (moved)
Argued with partner more than usual
44%*
36%*
53%*
43%*
33%
17%
Had bills and couldn't pay
Someone close died
Close family member ill and hospitalized
Separated or divorced from partner
Someone close had drinking/drug problem
Partner said he didn't want pregnancy
31%*
24%*
24%
20%*
15%
15%*
42%*
25%
22%
19%*
28%*
21%*
14%
15%
24%
5%
13%
8%
Husband/partner lost job
Mother lost job
Mom or partner went to jail
Involved in a physical fight
Homeless
Reported 5 or more stress events
14%
21%*
10%*
7%
11%*
12%*
20%*
15%*
22%*
12%*
15%*
23%*
8%
5%
4%
4%
1%
4%
Stress Events
Stress factor prevalences followed by an asterisk (*) are statistically significantly higher
than 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
40%
African American
35%
American Indian/Alaska Native
30%
White
Percent
25%
20%
15%
29%
24%
22%
10%
21%
17%
16%
13%
5%
10%
15%
11%
7%
7%
0%
No one to loan No one to help
me $50
me if I was sick
& in bed
Data Source: Pregnancy Risk
Assessment Monitoring System (PRAMS)
No one to
give me a
ride to the
doctor
No one to
talk with about
my problems
INSTITUTIONALIZED RACISM/
Historical Trauma
Discrimination
•
•
•
•
•
Health Care
Housing
Legal System
Employment
Refused care
over IHS status
Poverty
•
•
•
•
•
•
Abuse
Affordable Housing
Moving frequently
Adequate Education
Employment
Access to Health Care
Perceived as wealthy
•
•
•
•
Institutional
Interpersonal
Cycles
Substance
Internalized Racism
• Hopelessness
• Self-hatred and blame
• Inability to see family/
community as support
• Ancestry seen as
hindrance to life’s goals
STRESS
Direct Effects:
Endocrine System Response - Increased cortisol levels,
decreased immune function, increased vulnerability to
infection, trigger onset of labor
Indirect Effects: Maternal Behaviors – Smoking, alcohol, substance use, poor
nutrition, survival supersedes wellness
DISPARITIES IN BIRTH OUTCOME
Mayet Dalila,
IntraAfrikan
Konnections
Indigenist model of trauma, coping, and health
outcomes for American Indian women (Walters K. 2002)
What more needs to be done:
Continue support of pregnant women’s
health care: prenatal care, MSS/ICM,
outreach.
 Find support for community mobilization
efforts




Community collaboration around housing,
income equity, access to quality education,
access to culturally relevant, culturally
appropriate health care. . .
Decrease the impact of inequalities and
racism on women and families through
community support.
NAWDIM & Brown Sugar Babies
What more needs to be done:

Continue the PPOR analysis and community engagement process
to use the data to target prevention efforts and support the work of
the community

Need for prevention to focus on preconceptional health, health
behaviors, and specialized perinatal care services

Sustained need for early and continuous prenatal care services,
referral of high-risk pregnancies and good medical management of
medical problems

Continued need for programs that support infant health such as
SIDS prevention, access to a medical home, and injury prevention
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 Racism, People’s Institute for Survival & Beyond
PBS Video: Race: The Power of Illusion
PBS Video: Unnatural Causes: Is Racism Making Us Sick? (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!