Trends In African American Birth Outcomes

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

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

www.healthypeople.gov

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

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?

Births by Race/Ethnicity US 2001-2003 average

In 2004 there were 4,112,052 live births registered in the US

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



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

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



*preliminary data


2010 0bj

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

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

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


Office of Vital Statistics and Maternal, Infant & Reproductive Health Program , NYCDOH Prepared by March of Dimes Perinatal Data Center, 20002

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



Infant Mortality Rates by State, 2003

Source: National Center for Health Statistics, 2003 period linked birth/infant death data.

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


Source: National Center for Health Statistics

*preliminary mortality data for 2004


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

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

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.

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


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

Singleton Preterm Births by Maternal Race/Ethnicity and Education, 2001-2002

http://diversitydata.sph.harvard.edu

Definitions

• Preterm birth:

– < 37 completed weeks gestation

• Late preterm (or Near-Term):

– 34-36 completed weeks

• Very preterm:

– <32 completed weeks

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

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

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

Kinney, 2006

Human Brain Growth in Gestation

PEDIATRICS Vol. 118 No. 3 Sept 2006, pp. 1207-1214

Differences in Singleton Preterm Birth Rates

by Race/Ethnicity, 1992 and 2002

Cesarean Section and Labor Induction Rates among Singleton Live Births by Week of Gestation US, 1992 and

2002

Late Preterm

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)

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)

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)

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

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

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.

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..

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


Per 1,000 live births

Percent Change ‘96-’02 = 21.5%

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

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.

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.

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.

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.

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

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.

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

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.

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

Khoury M and Romero R. AJOG (2006) 195, 1503–5

Uninsured WomenUS, 2003-2005 Average

Source: US Bureau of the Census. Data prepared for the March of Dimes using the Current Population Survey.

Uninsured ChildrenUS, 2003-2005 Average

Source: US Bureau of the Census. Data prepared for the March of Dimes using the Current Population Survey.

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

Undo Racism• Internalized

• Personally mediated

• Institutionalized

www. gucchd.georgetown.edu/nccc

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.

March of Dimes

www.marchofdimes.com

http://www.marchofdimes.com/

Trends In African American Birth Outcomes

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