Disclaimers

2. Disclaimers • The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the CDC • No personal financial relationships with commercial interests relevant to this presentation to disclose

3. A Healthy Baby Begins With You Campaign (DHHS/OMH)

4. Cause-Specific Infant Mortality RatesBy Maternal Race, United States, 2005

5. Trends in Preterm Birth RatesU.S. 1990-2004, All Births

6. Preterm Birth, United States, 2007 Gestational Age (weeks) at Delivery

7. Racial & Ethnic Disparities:Preterm Birth Initiatives • Prematurity Research Expansion and Education for Mothers who deliver Infants Early: PREEMIE Act(P.L. 109-450) • Surgeon General’s Conference on the Prevention of Preterm Birth, 2009 • Institute of Medicine, Preterm Birth: Causes, Consequences and Prevention, 2006 • March of Dimes: National Prematurity Campaign Initiative • NICHD Initiative to Reduce Elective Late Preterm Deliveries

8. Epidemiology of Preterm Birth • Mortality • # 1 cause of infant death • # 1 factor in racial/ethnic differences in infant deaths • Morbidity • lung disease, vision and hearing impairment, developmental delays, cerebral palsy, chronic disease • Financial Costs (2005 estimates from IOM report) • Minimally $26.2 billion nationally • $51,600 per preterm infant

9. What’s included in the preterm cost estimates? • Are extra costs compared to those for term infants • Medical care services $16.9 billion • 85% in 1st year • Maternal delivery costs $1.9 billion • Early intervention services $611 million • 4 conditions: Cerebral palsy, mental retardation, vision impairment, hearing loss • Special education services $1.1 billion • lost household/labor market productivity costs $5.7 billion • Long-term estimates for other conditions not included • Personal suffering

10. Preterm Outcomes • Psychosociallyhave higher rates of • Major & minor developmental disabilities • Learning disabilities • Enrollment in special education programs • Lower scores on IQ, language skills, visual-motor, visual-spatial, academic achievement tests • Attention problems • Repeating a grade, not graduating high school • Importance of Prevention

11. Trends in Preterm Birth RatesU.S. 1990-2004, All Births

12. Trends in Birth Weight Outcomes Non-Hispanic Black InfantsU.S. Singleton Births, 1991-2004 • Observed rate

13. Trends Findings • 1991-2001 10% decrease in moderately low birth weight among non-Hispanic Black women • Earlier entry into prenatal care • Reduced smoking • Increased maternal education • More appropriate pregnancy weight gain • Increase in foreign-born mothers • Unable to explain the 5.6% increase in moderately low birth weight 2001-2004 • Ferré et al. Maternal and Child Health J 2010

14. Trajectories leading to race/ethnic health disparities • Higher exposure to risk • may be imposed by environmental and social policies • Higher vulnerability/susceptibility • may be determined by chronic environmental and social exposures • Insufficient resources to protect health • lack of time, money, etc…for health promotion, health care access • Unequal access to care • Lower quality of care

15. Theory Behavior Environmental Stressors Risk of Infection Neuroendocrine Changes Immunosuppression Proinflammatory response Increased Risk of Preterm Birth Demographic

16. Qualitative Findings: Stressors among African American Women • There are pervasive, multiple, on-going and simultaneous stressors • Stressors occur in many domains • partner • children • family • friends • discrimination • work • community • income • cultural expectations • housing • Pregnancy is a catalyst which increases the magnitude and severity of stressors within each domain • Health care is often perceived as a stressor

17. Qualitative Findings: Stressors among African American Women • Stressors affect health through daily social interactions, not just acute life events • Decreased physical well-being during pregnancy is a stressor

18. Improve Health Care Strengthen Families and Communities Address social and economic inequities Interconception care Preconception care Prenatal care quality Health care over life course Father involvement Coord/integrate family support services Reproductive social capital Community building and urban renewal Close education gap Reduce poverty Support working mothers and families Undo racism Michael Lu’s 12 Point Plan Lu et al. Ethnicity and Disease 2010

19. Trends in 1st Trimester Entry into Prenatal Care U.S. 1980 - 2004

20. Prenatal Care • Part of women’s health continuum • Starting point for child health • Ideally to address risks that develop during pregnancy (e.g gestational diabetes or hypertension) • Cannot adequately address chronic risk factors in 3-6 months • Issues in access and quality of health care

21. Qualitative Findings: Health care providers alienate African American women by • failing to meet needs of women, including treating known risks and illnesses • demeaning statements and assumptions • inadequate or no explanations or instructions • long waiting times • spending only brief moments with women • no inquiry into social circumstances • discontinuity of providers and records • deteriorating facilities • assuming women are irresponsible

22. Qualitative Findings: • Women receive conflicting advice between their social networks and providers • Demands of the health care process often conflict with other personal responsibilities, such as work, child care, and other services • Women often have a limited physiologic understanding of what happens and what to expect during pregnancy

23. Prenatal Care • Developing Families Center in northeast D.C. • Collaboration of 3 non-profits • DC Birth Center • Healthy Babies Project • Nation’s Capital Child and Family Development • www.developingfamilies.org

24. Prenatal Care • Developing Families Center in D.C. • Group prenatal care • Health education • Childbirth education classes • Community health workers • Breastfeeding peer counselors • Volunteer doulas • Minimal wait times • Familiarity with provider • Women feel valued and cared for • Community ownership

25. Prenatal Care • Developing Families Center in D.C. • Perinatal Outcomes • 7.0 % PTB rate (versus DC African American rate of 14.8%) • 6.0% LBW rate (versus 14.2%) • 13.0% C-section rate (versus 32.0%) • $1,240,798 estimated total savings in 2005 • Savings potentially greater than operating budget • Realized only thru reimbursement • If model used nationwide, $12.9 billion per year in savings

26. Early prenatal care may be too late! Perinatal Periods of Risk projects (New York City, Tulsa, and Kansas City) racial and ethnic disparities in feto-infant mortality were largely related to maternal health interventions to reduce feto-infant mortality should include preconception care and improvements in women’s health • Besculides M, Laraque F. Racial and ethnic disparities in perinatal mortality: applying the perinatal periods of risk model to identify areas for intervention. JAMA 2005;97:1128–32. • Cai J, Hoff GL, Dew PC, Guillory VJ, Manning J. Perinatal periods of risk: analysis of fetal-infant mortality rates in Kansas City, Missouri. Matern Child Health J 2005;9:199–205. • Burns PG. Reducing infant mortality rates using the perinatal periods of risk model. Public Health Nurs 2005;22:2–7.

27. Consensus on Need to Act Before Pregnancy Recommendations and clinical practice guidelines published by many organizations MOD ACOG AAP AAFP • ACNM • USPHS Expert Panel on • the Content of PNC, 1989 • HP 2000 • More than 30 organizations worked, and continue to work, together to promote PCC

29. Evidence-Based Clinical Content for PPC • AJOG 199(Suppl2). December 2008

30. Preconception Care CDC Recommendations • Recommendations • Individual responsibility across the lifespan • Consumer awareness • Preventive primary care visits • Interventions for identified risks • Interconception care • Pre-pregnancy checkup • Health insurance coverage for low-income women • Public health programs and strategies • Research • Monitoring improvements

31. Reproductive Social Capital • Features of social organization that facilitate coordination and cooperation to promote reproductive health within a community • 100 Acts of Intentional Kindness toward a Pregnant Woman • Healthy African American Families project in Los Angeles • 100 Acts for a New Mother

32. Healthy African American Families100 Acts of Kindness toward a Pregnant Woman • What families, friends, and strangers can do to support women during pregnancy • Families and Friends • Emotional Support (e.g. encouragement) • Instrumental Support (e.g. transportation) • Strangers • Respect for Personal Space (e.g. ask permission before touching) • Common Courtesy (e.g. allow to go ahead in lines) • Increase social support and community awareness • “It takes a Village . . . “

33. 100 Acts of Kindness Examples • Give me quiet time • Help me carry my things • Provide transportation • Ask me if you can help with anything • Take me to dinner • Bring me information about pregnancy • Pamper me

35. Text4Baby • Healthy Mothers, Healthy Babies • Free • Text messages during pregnancy & 1st year of baby’s life • English and Spanish • Innovative, culturally appropriate

36. Reducing Poverty • High prevalence for African Americans • 40-50% for female-headed households • 25-30% for all Blacks • Increased adverse pregnancy outcomes

37. LBW and Poverty: U.S., 1989-2006,Non-Hispanic Blacks FHP = Female-headed household

38. Qualitative Findings: Economics • Low income women struggle to put resources together • Middle income women experience employment marginality and job insecurity • Physical stress of pregnancy increases job stressors • There are also stressors concerning: • having multiple jobs • jobs without benefits • lack of control over schedules • pace of work • community economic status

39. Qualitative Findings: Racism • Is encountered daily • Neighborhoods, health care, workplace, housing, service provision, retail business • Older women reported more experiences with discrimination • How racism affects black children is a major stressor for mothers • “Racism” and “discrimination” are not commonly used terms

40. Summary • Racial disparities result from many factors • Many risks cannot be solved through health care alone • Addressing disparities requires an integrated multilevel approach • Interaction & multiplicity of risks on many levels is a force affecting the lives of women • Disparities can be reduced • Importance of community participation, leadership, and solutions • Political advocacy and media involvement • Valuing and caring for people and how this translates within the realization of each of the 12 action steps

41. All Public Health Is Local This is where the multitude of multi-level and multi-dimensional factors play out

42. Thank You Cynthia Ferré cferre@cdc.gov