National Trends and Disparities in Birth Outcomes

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National Trends and Disparities in Birth Outcomes

• Joann Petrini, PhD, MPH
• Director, Perinatal Data Center
• National March of Dimes, White Plains, NY
• Assistant Professor
• Dept OB/GYN and Womens Health
• Albert Einstein College of Medicine, Bronx, NY

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March of Dimes Birth Defects Foundation

• Mission
• To improve the health of babies by preventing
  birth defects, premature birth and infant
  mortality
• To advance this mission through programs of
  research, community service, education and
  advocacy

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January 30, 2003March of Dimes Prematurity
Campaign

• Raise awareness
• Reduce rates of preterm birth

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www.healthypeople.gov
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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

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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?

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Questions (continued)

• What programs need to be developed to address
  disparities at the community and population
  level?
• What activities has the community tried? Whats
  worked/ What hasnt? Why?
• What are realistic goals for our organization/
  communities? What are we ready to work toward?
  Opportunities? Venues? Approaches? Other relevant
  organizations?

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Births by Race/Ethnicity US 2001-2003 average
In 2004 there were 4,112,052 live births
registered in the US
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Births by Race/Ethnicity US 2001-2003 average
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Infant MortalityUS, 1915-2004
Rate per 1,000 live births
Source National Center for Health Statistics,
final mortality data, 1915-1994 and period
linked birth/infant death data, 1995-present.
preliminary data Prepared by March of Dimes
Perinatal Data Center, 2007
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Infant Mortality by Maternal RaceUnited States,
1990 -2004
Rate per 1,000 live births
0bj
Source National Center for Health Statistics,
final mortality data preliminary data Prepared
by March of Dimes Perinatal Data Center, 2007
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Black/White Infant Mortality Rate RatioUnited
States, 1980-2004
Source NCHS, final mortality data preliminary
mortality data
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Racial and Ethnic DisparitiesInfant Mortality
Rates, US 2004
Per 1,000 Live Births
HP 2010 Objective 4.5
Source National Center for Health Statistics,
National Vital Statistics Reports, Infant
Mortality Statistics from the 2004 period linked
birth/infant death data. Prepared by March of
Dimes Perinatal Data Center, 2007
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Infant Mortality by Maternal Race/Ethnicity US
Regions, 2001-2003 average
Rate per 1,000 live births
All race categories exclude Hispanic births.
Source National Center for Health Statistics,
final mortality data Prepared by March of Dimes
Perinatal Data Center, 2007
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Infant Mortality Rates by State, 2003
Source National Center for Health Statistics,
2003 period linked birth/infant death data.
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Three Leading Causes of Infant Mortality United
States, 1990 and 2004
Rate per 100,000 live births
Source National Center for Health
Statistics preliminary mortality data for
2004 Prepared by March of Dimes Perinatal Data
Center, 2007
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Three Leading Causes of Infant Deaths by
Maternal Race/Ethnicity, US, 2004
Rate Per 100,000 Live Births
All race categories exclude Hispanic births.
Source National Center for Health Statistics,
National Vital Statistics Reports, Infant
Mortality Statistics from the 2004 period linked
birth/infant death data. Prepared by March of
Dimes Perinatal Data Center, 2007
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Preterm Birth RatesUnited States, 1983, 1993,
2003, 2005
Percent
gt 1 out of 8 births or 508,000 babies born
preterm in 2005
Percent
HP 2010 Objective
gt30 Increase
Preterm is less than 37 completed weeks
gestation. Source National Center for Health
Statistics, final natality data Prepared by March
of Dimes Perinatal Data Center, 2005 preliminary
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Definitions

• Preterm birth
• lt 37 completed weeks gestation
• Late preterm (or Near-Term)
• 34-36 completed weeks
• Very preterm
• lt32 completed weeks

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Distribution of Preterm Births by Gestational
Age, US, 2004
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.
(lt32 Weeks)
(32 Weeks)
(36 Weeks)
(33 Weeks)
71.2 of PTBs are late preterm, 34 - 36 weeks
(34 Weeks)
(35 Weeks)
Source National Center for Health Statistics,
2004 final natality file Prepared by the March of
Dimes Perinatal Data Center, 2007
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Human Brain Growth in Gestation
Kinney, 2006
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Total and Primary Cesarean and VBAC United
States, 1993 - 2005
Preliminary
(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 data Prepared by March of Dimes
Perinatal Data Center, 2005
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PEDIATRICS Vol. 118 No. 3 Sept 2006, pp. 1207-1214
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Preterm (lt37 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.
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Preterm Birth Rates by Race/Ethnicity
Education, IOM 2006
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Extremely Preterm Birth by Maternal and Paternal
Race, Missouri, 1989-1997
Paternal black race is associated with an
increased risk of preterm birth
Palomar et al, 2007
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Primary Risk Factors for Preterm Labor/Delivery

• The best predictors of having a preterm birth
  are
• current multifetal pregnancy
• a history of preterm labor/delivery or prior low
  birthweight
• mid trimester bleeding (repeat)
• some uterine, cervical and placental
  abnormalities

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Multiple Birth Ratios by Maternal
Race/Ethnicity US, 1992-2004
Ratio Per 1,000 live births
Multiple deliveries include twin, triplet and
higher order deliveries. Source National Center
for Health Statistics, final natality
data Prepared by March of Dimes Perinatal Data
Center, 2007
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Higher-Order Multiple Birth Ratiosby Maternal
Race, US, 1980-2004
Ratio per 100,000 live births
Higher-order multiple deliveries include triplet
and higher order deliveries. Source NCHS, final
natality data Prepared by March of Dimes
Perinatal Data Center, 2007
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Other Identified Risk Factors for Preterm
Labor/Delivery

• unintended pregnancy
• maternal age (lt17 and gt35 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

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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.
www.iom.edu
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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.
• African-American women smoke less than white
  women during pregnancy and drug and alcohol use
  is no greater among pregnant African-American
  women compared to white women.

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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.
• Racial-ethnic differences in socioeconomic
  condition, maternal behaviors, stress, infection,
  and genetics can not fully account for
  disparities.

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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.
• prioritize efforts to understand factors
  contributing to the high rates of preterm by
  race/ethnicity.
• research should be guided by an integrated life
  course approach.

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In the United States

• 1 in 7 women ages 19-44
• 1 in 6 children under the age of 19
• . live in families with incomes below the
  Federal Poverty Level
• More than 40 of births are covered under
  Medicaid
• While women ages 19-44 and children in the United
  States made up almost 69.7 of Medicaid enrollees
  in 2003, they accounted for only 30.7 of all
  Medicaid spending.

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Women Ages 15-44 who are Uninsured by
Race/Ethnicity, US, 2006
Percent
1 in 5 women of childbearing age was uninsured in
2006 No improvement over 2005
Includes American Indian and Alaska Native All
race categories exclude Hispanics Source U.S.
Census Bureau, March 2007 Current Population
Survey Annual Social and Economic Supplement Data
prepared for the March of Dimes
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Children Under 19 who are Uninsured by
Race/Ethnicity, US, 2006
Percent
9.4 million children were uninsured in 2006 An
increase from 11.2 in 2005 (700,000 children)
Includes American Indian and Alaska Native All
race categories exclude Hispanics Source U.S.
Census Bureau, March 2007 Current Population
Survey Annual Social and Economic Supplement Data
prepared for the March of Dimes
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Closing the Black-White Gap in Birth Outcomes

• Provide interconceptional care to women with
  prior adverse pregnancy outcomes
• Increase access to preconception care
• Improve the quality of prenatal care
• Expand healthcare access over the life course
• Strengthen fathers involvement
• Enhance service coordination and systems
  integration
• Raising public and provider awareness
• Increasing the number and capacity of providers
  in underserved communities
• Invest in community building and urban renewal
• Close the education gap
• Reduce poverty
• Support working mothers and families

M Lu, UCLA, 2006
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March of Dimes Campaign Aims

• 1. Generate concern and action around the problem
  of prematurity.
• 2. Educate women of childbearing age about risk
  reduction and warning signs of preterm birth.
• 3. Provide affected families with information,
  emotional support, and opportunities to help
  other families

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March of Dimes Campaign Aims

• 4. Assist health care practitioners to improve
  prematurity risk detection and address
  risk-associated factors
• 5. Encourage investment of more public and
  private research dollars to identify causes of
  preterm labor and prematurity, and to identify
  and test promising interventions
• 6. Advocate to expand access to health care
  coverage in order to improve maternity care and
  infant health outcomes.

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PREEMIE Act (S. 707) Passes Congress

• 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.
• Dr. Jennifer Howse, President of the March of
  Dimes
• 12/9/06

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Surgeon Generals Conference on Preterm Birth

• In one of its most important provisions, 
  PREEMIE authorizes a SGs conference at which
  scientific and clinical experts from the public
  and private sectors will formulate a national
  action agenda to speed development of prevention
  strategies for preterm labor and delivery.
• Public-Private research and education agenda
• Target date 2008

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PREEMIE Implementation
1 million SG
8 million CDC
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marchofdimes.com/peristats
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March of Dimes

www.marchofdimes.com