Eliminating Racial Disparities in Birth Outcomes

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Eliminating Racial Disparities in Birth Outcomes
Community Psychology Antioch University
September 8, 2007 Susan Barkan, Public Hea
lth Seattle King County Melanie Whitfield, Peop
le of Color Against AIDS Network
Leah Henry Tanner, Native American Womens Dialog
on Infant Mortality Maria Carlos, Public Health S
eattle King County
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Acknowledgements

• Susan Barkan
• Kathy Carson
• Maria Carlos
• Eva Wong Doctoral Student, Department of
  Epidemiology,
  
• University of Washington
• Alice Park
• Mei Castor Urban Indian Health Institute
• Shira Rutman
• Jim La Roche
• Leslie Randall Northwest Portland Area Indian
  Health Board
  
• Leah Henry Native American Womens Dialog on
  Infant
  
• Tanner Mortality (NAWDIM)
• Jim Gaudino Oregon State Department of Health

Parent Child Health, Public Health-Seattle King
County
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Infant Mortality Rates US, Washington State, King
County, Seattle Three Year Rolling Average, 1981
-2004
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Contributions to the Overall Decline in Infant
Mortality in King County

• First Steps
• Maternity support and expansion of Medicaid
  coverage of prenatal services
  
• Safe Sleep
• Back to Sleep Campaign
• Medical Advances
• Neonatal intensive care
• Behavioral
• Decline in use of tobacco, alcohol, unintended
  pregnancies

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Infant Mortality Rates by Race/Ethnicity,
King County, Three Year Rolling Averages,
1985-2004
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Perinatal Periods Of Risk (PPOR) Approach

• A simple approach.
• identify gaps in the community.
• target resources for prevention activities.
• mobilize the community to action.

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PPOR MAP
The cells in the PPOR MAP help indicate the
actions needed
Age at Death
Birthweight
These four groups are given labels that suggest
the primary preventive strategy for preventing
the deaths in that group.
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Preconception Health Health Behaviors Perinatal
Care
Prenatal Care High Risk Referral
Obstetric Care
Perinatal Management Neonatal Care
Pediatric Surgery
Sleep Position Breast Feeding Injury
Prevention
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Perinatal Periods Of Risk (PPOR) Use

• Examine the four Periods of Risk for WA State
  as a whole and then for various population
  groups.
  
• Identify the groups and periods of risk with the
  most deaths and the highest rates.
  
• Use a comparison group to estimate excess or
  preventable deaths for these groups and periods
  of risk.
  
• Comparison group white non-Hispanic 20 years
  of age 13 years of education

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Fetal and Infant Mortality RatesWA State,
2000-2004, (Deaths/1000 births)
Birth Weight Group
Maternal Health/ Prematurity
Infant Health
Maternal Care
Newborn Care
Unknown Birth Weight
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WA State Excess FIMR (Deaths/1000 Births)
2000-2004
White NH (2.1)
African-Am NH (6.7)
AI/AN NH (8.1)
API (1.5)
Hispanic (2.3)
Other/Unknown (16.7)
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WA State Preventable Deaths 2000-2004
Overall (1127)
White (564)
African-Am (109)
AI/AN (70)
API (50)
Hispanic (146)
Unknown (179)
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WA State Preventable FIMR (Deaths/1000 Live
Births) 3-year Rolling Averages (1992-2004)
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WA State AI/AN Preventable FIMR (Deaths/1000 Live
Births) 3-year Rolling Averages (1992-2004)
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Postneonatal Deaths by Cause, 2000-2004 WA State
(rate ratio)
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PPOR FindingsWA State, 2000-2004

• Infant Health is the highest contributor to
  preventable FIMR among American Indian/Alaska
  Natives
  
• Maternal Health/Prematurity component is the
  highest contributor among African Americans and
  the second highest contributor among AI/AN.
  
• Maternal Care is the third highest contributor to
  among AI/AN.
  
• Newborn Care component is consistently the lowest
  and is similar for all racial/ethnic groups.
  

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Implications/Opportunity Gaps
Preconception Health Health Behaviors
Perinatal Care EXPAND STRATEGIES to address soc
ial factors giving rise to disparities
Sleep Position Breast Feeding Injury Preve
ntion Medical Care for Infections and Chronic Con
ditions
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Prevalence and Trends in Birth Risk Factors by
Race, King County
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How Stress Can Affect Health

• Increased cortisol (fight/flight hormones)
  results in increased cardiovascular function
  
• Can lead to high blood pressure, depressed immune
  function with increased vulnerability to
  infection, and depression. All of these can
  contribute to risk of preterm delivery.
• These stress responses are designed to help us
  deal with short term threats, but for many, the
  stressors dont go away.
  
• Long-term, chronic stress does not allow for
  system recovery and predisposes to adverse health
  effects

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INSTITUTIONALIZED RACISM/ Historical Trauma
Discrimination
Poverty
Abuse
Internalized Racism

• Health Care
• Housing
• Legal System
• Employment
• Refused care over IHS status

• Affordable Housing
• Moving frequently
• Adequate Education
• Employment
• Access to Health Care
• Perceived as wealthy

• Institutional
• Interpersonal
• Cycles
• Substance

• Hopelessness
• Self-hatred and blame
• Inability to see family/ community as support
• Ancestry seen as hindrance to lifes goals

STRESS
Direct Effects Endocrine System Response -
Increased cortisol levels, decreased immune
function, increased vulnerability to infection,
trigger onset of labor Indirect Effects Maternal
Behaviors Smoking, alcohol, substance use,
poor nutrition, survival supersedes wellness
Mayet Dalila, IntraAfrikan Konnections
DISPARITIES IN BIRTH OUTCOME
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Indigenist model of trauma, coping, and health
outcomes for American Indian women (Walters K.
2002)
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Genocide

• Article 2
• In the present Convention, genocide means any of
  the following acts committed with intent to
  destroy, in whole or in part, a national,
  ethnical, racial or religious group, as such
• (a) Killing members of the group
• (b) Causing serious bodily or mental harm to
  members of the group
  
• (c) Deliberately inflicting on the group
  conditions of life calculated to bring about its
  physical destruction in whole or in part
  
• (d) Imposing measures intended to prevent births
  within the group
  
• (e) Forcibly transferring children of the group
  to another group.
  
• Adopted by Resolution 260 (III) A of the United
  Nations General Assembly on
  
• 9 December 1948

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Historical Traumas

• Massacre Wounded Knee, Sand Creek
• Forced Relocations Dakota, SE tribes
• The Vermont Eugenics Survey
• Boarding Schools
• Kill the Indian to save the man Richard Pratt
• Dawes Act
• Commodity/Food Ration era

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Historical / Intergenerational Trauma

• First researched among Holocaust survivors and
  descendents
  
• Historical Trauma The collective emotional and
  psychological injury both over the life span and
  across generations, resulting from a cataclysmic
  history of genocide.
• Causes a legacy of genocide
• Effects unsettled trauma, increase of alcohol
  abuse, child abuse and domestic violence
  
• (Dr. Maria Yellow Horse Brave Heart)

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What Public Health is doing

• Providing outreach, education and linkage
  services to high-risk childbearing-age women and
  young families via community-based agencies
  comprising the Infant Mortality Prevention
  Network (IMPN)
• El Centro de la Raza
• Center for MultiCultural Health
• MOMs Plus
• Operational Emergency Center
• People of Color Against AIDS Network
• Seattle Indian Health Board
• United Indians of All Tribes Foundation
• YWCA

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What Public Health is doing

• Working on regional examination of disparities in
  American Indian/Alaska Native fetal and infant
  mortality with NAWDIM, the Urban Indian Health
  Institute, Northwest Portland Area Indian Health
  Board, Oregon Department of Health
• Community Coalition for Healthy Babies
• Vision a world in which every baby is valued,
  nurtured and provided needed support to thrive.
  A world in which African American, American
  Indian/Alaska Native, and low income women and
  their families are empowered against oppression.
• Valuing women and babies in these communities
  improves the health of all women and babies.

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What UIHI is doing

• NAWDIM
• Northern Tier SIDS project
• Regional PPOR analysis with ID, WA OR data, in
  collaboration with PHSKC and NPAIHB
  
• PRAMS collaboration
• MCH Advisory Council
• Youth Risk Behavior Survey Report

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What NAWDIM is doing

• Organizational development
• Raise funds for NAWDIM goals and objectives
• Public education to educate native communities
  and families about NAWDIMs Education Campaign to
  lower infant mortality and advocate / mobilize
  support for the families.

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What more needs to be done

• Continue and expand support for community
  mobilization efforts
  
• NAWDIM
• Community collaboration around housing, hospital
  care, etc.
  
• Decrease the impact of inequalities and racism on
  women and families through community support.
  

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What more needs to be done

• Continue the PPOR analysis and community
  engagement process to use the data to target
  prevention efforts and support the work of the
  community
• Need for prevention to focus on preconceptional
  health, health behaviors, and specialized
  perinatal care services
  
• Sustained need for early and continuous prenatal
  care services, referral of high-risk pregnancies
  and good medical management of medical problems
  
• Continued need for programs that support infant
  health such as SIDS prevention, access to a
  medical home, and injury prevention
  

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What more needs to be done

• Address health literacy of people who are outside
  of health care system.
  
• Health providers health educators need to
  develop culturally appropriate materials.
  

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What You Can Do

• Provide culturally appropriate mental health
  services for people of color low-income folks.
  
• Get training on undoing institutionalized racism
• Undoing Institutionalized Racism, Peoples
  Institute for Survival Beyond
  
• PBS Video Race The Power of Illusion
• PBS Video Unnatural Causes Is Racism Making Us
  Sick? (Jan, 08)
  
• Involve community members, clients, consumers in
  defining your work.
  
• Injustice anywhere is a threat to justice
  everywhere.
  
• Martin Luther King, Jr.

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Thank you!