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Back to the Future: Perinatal Outcomes in Latinos
Elena Fuentes-Afflick, MD, MPHSan Francisco General HospitalUniversity of California, San Francisco
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Disclosures
None
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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.
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US population
0 25 50 75 100
1965
1990
2000
Percent
White African American Latino Asian/ PI
Census Bureau
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Births in the US, 1990-2005
0500000
10000001500000200000025000003000000350000040000004500000
1990 1995 2000 2005
Total Latina
National vital statistics reports, 2009
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Latino births in the US (%), 1990-2005
0
10
20
30
Percent
1990 1995 2000 2005
National vital statistics reports, 2009
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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
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National Center for Health Statistics
Infant mortality: 1940-1995
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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
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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
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“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
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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
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“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
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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
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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
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Causes of infant mortality
0 10 20 30 40
Latina
White
Percent
Perinatal/SIDSCongenital anomaliesRespiratoryCirculatoryInfectious
Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000
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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
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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
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Low birth weight in the US
0
5
10
15
Rate (%)
2004 2005 2006 2007
www.nchs.gov
Healthy People 2010 goal
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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
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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
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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
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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
* *
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Perinatal Outcomes
Behavioral
Nutrition/Diet
Social SupportCultural
Community
Artifact
ObstetricReproductive
Medical Healthy Immigrant
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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
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Healthy nutrition
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Micronutrients
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Nutrition - Obesity
http://wellroundedmama.blogspot.com
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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?
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Obstetric / Reproductive
• Interpregnancy interval?
• Do Latina women have a reproductive advantage?
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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
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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.
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Ethnicity ≠ Acculturation
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Immigrants in the US
12
0
5
10
15
20
25
%
1990 2000 2005 2005, Canada 2050 (projected)
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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
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Last names in the US, 2009
#1 Smith
#2 Johnson
#3 Williams
#4 Brown
#5 Jones
#8 Garcia
#9 RodriguezCensus Bureau
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Foreign-born childbearing women: US, 2005
0
25
50
75
100
%
African American White Latina Asian/ PI
National Center for Health Statistics
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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
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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
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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
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Risk factor models – one size fits all?
Interventions – tailored? Universal?
Protective factors versus risk factors
Implications of the epidemiologic paradox
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Social support
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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
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Lifecourse approach
Demographic risk factors
Medical/health status
Obstetric/reproductive factors
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Promising areas Acculturation
Prematurity
Interpregnancy interval
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Challenging areas
Methodologic and challenges
Body mass, maternal
Paternal factors
Community-level factors
Acculturation ‘web’
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www.harrycutting.com