back to the future: perinatal outcomes in latinos
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Back to the Future: Perinatal Outcomes in Latinos
Elena Fuentes-Afflick, MD, MPHSan Francisco General HospitalUniversity of California, San Francisco
Disclosures
None
Objectives
1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos.
2. To identify areas for future research in perinatal outcomes in Latinos.
US population
0 25 50 75 100
1965
1990
2000
Percent
White African American Latino Asian/ PI
Census Bureau
Births in the US, 1990-2005
0500000
10000001500000200000025000003000000350000040000004500000
1990 1995 2000 2005
Total Latina
National vital statistics reports, 2009
Latino births in the US (%), 1990-2005
0
10
20
30
Percent
1990 1995 2000 2005
National vital statistics reports, 2009
US births (%), by ethnicity: 2006
5.7 14.5
24.4
54.3
African American Latino White Asian American Indian
National Center for Health Statistics, 2009
National Center for Health Statistics
Infant mortality: 1940-1995
Infant mortality rate: 1995-2005
0
5
10
15
20
25
1995 2000 2005
Rate (per 1,000 births)
African American White
National Center for Health Statistics
0
5
10
15
20
25
Year
Rate
(p
er 1
,000 b
irth
s)
White Latina African American
Neonatal mortality rate: Texas, 1970-9
Powell-Griner and Streck, Am J Public Health 1982
“We tentatively conclude from our study that the low neonatal mortality rates observed in Texas among the Spanish surname population are due in part to underreporting of neonatal deaths.”
Powell-Griner and Streck, Am J Public Health 1982
Infant mortality: Harris County Texas, 1974-75
0
5
10
15
20
25
Neonatal Postneonatal
Rat
e (p
er 1
,000
live
bir
ths)
White Latina African American
Selby et al, Am J Public Health 1984
“These consistently paradoxical findings lead us to conclude that the Spanish surname infant mortality rate is not a valid indicator of health status for the Mexican American population of Harris County, Texas.”
Selby et al, Am J Public Health 1984
Infant mortality rate, by ethnicity: CA 1990-93
0.50 0.54
0.0
0.5
1.0
Rate
(%
)
White Latina
Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000
Odds of infant death, by ethnicity
1.080.88
0
0.5
1
1.5
2
Latina White (ref)
Unadjusted Adjusted
Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000
Causes of infant mortality
0 10 20 30 40
Latina
White
Percent
Perinatal/SIDSCongenital anomaliesRespiratoryCirculatoryInfectious
Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000
Population-based indicators of health
Low birth weight and prematurity are significant risk factors for infant mortality
Low birth weight and prematurity are associated with neurologic impairment, cerebral palsy, learning differences
Low birth weight and prematurity: US, 2005
0
5
10
15
20
Rate (% )
LBW Prem
African American White Latina
National Center for Health Statistics, 2008
Low birth weight in the US
0
5
10
15
Rate (%)
2004 2005 2006 2007
www.nchs.gov
Healthy People 2010 goal
Low birth weight: CA, 1981
0
5
10
15
500-1499g 1500-2499g
Rat
e (%
)
US-born White Latina US-born Black
Williams et al, Am J Public Health 1986
Low birth weight: 32 studies
0
5
10
15
Rate
(%
)
African American Latina White
Study
Fuentes-Afflick E and Lurie P, Arch Pediatr Adolesc Med 1997
Low birth weight among Latina and White women in CA, 1992
0
5
10
15
VLBW MLBW
Per
cen
t
White Latina
Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999
Low birth weight: Latinas in CA, 1992
1.10 1.04 1.06*0.93, NS
0.5
1.0
1.5
2.0
VLBW MLBW
Od
ds
rati
o
Unadjusted Adjusted
Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999
* *
Perinatal Outcomes
Behavioral
Nutrition/Diet
Social SupportCultural
Community
Artifact
ObstetricReproductive
Medical Healthy Immigrant
Behavioral factors
Latina women have lower rates of behavioral risk factors (tobacco and alcohol use) than African American or White women
Foreign-born women generally have lower rates of tobacco and alcohol use than US-born women
Healthy nutrition
Micronutrients
Nutrition - Obesity
http://wellroundedmama.blogspot.com
Medical factors
• Are Latina women healthier than women of other ethnic groups?
• Are immigrant Latinas healthier than women in their population of origin?
• Are immigrant Latinas healthier than women in the receiving population?
Obstetric / Reproductive
• Interpregnancy interval?
• Do Latina women have a reproductive advantage?
Summary
Latina women have low rates of infant mortality, low birth weight, and prematurity
We do not understand why Latina women have such favorable perinatal outcomes
Objectives
1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos.
2. To identify areas for future research in perinatal outcomes in Latinos.
Ethnicity ≠ Acculturation
Immigrants in the US
12
0
5
10
15
20
25
%
1990 2000 2005 2005, Canada 2050 (projected)
Acculturation
“… the process by which immigrants adopt the attitudes, values, customs, beliefs and behaviors of a new culture.”
Abraido-Lanza A et al, AJPH 2005
Last names in the US, 2009
#1 Smith
#2 Johnson
#3 Williams
#4 Brown
#5 Jones
#8 Garcia
#9 RodriguezCensus Bureau
Foreign-born childbearing women: US, 2005
0
25
50
75
100
%
African American White Latina Asian/ PI
National Center for Health Statistics
Low birth weight, by birthplace: Latina women in CA, 1992
0
0.5
1
1.5
2
AOR
VLBW MLBW
Foreign-born US-born (ref)
VLBW OR 0.92 (0.80-1.07)
MLBW* OR 0.91 (0.86-0.96)
Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1998
Infant mortality, by birthplace: Latina women CA, 1990-93
0.5
1
1.5
2
Foreign-born US-born (ref)
OR
Unadjusted
OR 1.08 (1.03-1.13)*
Adjusted
OR 0.88 (0.80-0.97)*
Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000
Two dimensions of the epidemiologicparadox
Latina women have surprisingly favorable perinatal outcomes relative to African American and White women
Foreign-born Latinas have surprisingly favorable perinatal outcomes relative to US-born women
Risk factor models – one size fits all?
Interventions – tailored? Universal?
Protective factors versus risk factors
Implications of the epidemiologic paradox
Social support
Community factors
“The paradox of Hispanic health represents a group-level correlation between ethnicity and mortality that cannot be explained in terms of an individual-level model.”
Scribner R, Am J Public Health 1996
Lifecourse approach
Demographic risk factors
Medical/health status
Obstetric/reproductive factors
Promising areas Acculturation
Prematurity
Interpregnancy interval
Challenging areas
Methodologic and challenges
Body mass, maternal
Paternal factors
Community-level factors
Acculturation ‘web’
www.harrycutting.com
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