2018 March of Dimes Annual Conference: Advancing Healthy Equity to Improve Maternal & Neonatal Outcomes November 2018 Hilton Irvine

Transcription

1 The Root Causes of Perinatal Health Disparities: A Life Course Perspective Terri Lynn Major-Kincade MD MPH Attending Neonatologist Chair of Steering Committee for African American Outreach, March of Dimes, Texas 2018 March of Dimes Annual Conference: Advancing Healthy Equity to Improve Maternal & Neonatal Outcomes November 2018 Hilton Irvine

2 Disclosures Dr. Major-Kincade has no financial relationships/incentives to disclose Dr. Major-Kincade speaks fast normally and is not on medication Dr. Major-Kincade may become emotional during a portion of this talk please feel free to share Kleenex Dr. Major-Kincade loves her job and considers it a privilege and a blessing to care for babies and their families Dr. Major-Kincade has two healthy children who are the products of normal pregnancies

3 OBJECTIVES 1. Distinguish between Health Equity and Health Equality as they relate to Perinatal Health Outcomes 2. Describe the Social Determinants of Health as they relate to Perinatal Health Disparities 3. Detect the historical Impact of Historical Racism and Implicit Bias on Perinatal Health Disparities 3

4 THE PROBLEM

5 Why Should we care? 11/7/2018 Prepared By: Dr. Terri Major-Kincade 5

6 TREND IN PREMATURITY Premature/preterm is less than 37 weeks of gestation. Preterm birth rate is defined as the percentage of live births born preterm. Source: National Center for Health Statistics, final natality data. Prepared by March of Dimes Perinatal Data Center, February 2018.

7 INCREASING PREMATURITY & DISPARITY Premature/preterm is less than 37 weeks of gestation. Preterm birth rate is defined as the percentage of live births born preterm. Maternal rate based on bridged race; race categories exclude Hispanics. Source: National Center for Health Statistics, 2014 and 2016 natality data Prepared by March of Dimes Perinatal Data Center, February 2018.

8 DISPARITIES IN INFANT DEATH An infant death occurs within the first year of life. Infant mortality rate is the number of infant deaths per 1,000 live births. Maternal rate based on bridged race; race categories exclude Hispanics. Source: National Center for Health Statistics, period linked birth/infant death data. Prepared by March of Dimes Perinatal Data Center, February 2018.

9 DISPARITIES IN MATERNAL DEATH Pregnancy-related mortality ratio is the number of pregnancy-related deaths per 100,000 live births. A pregnancy-related death is the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Source: CDC, ( Prepared by March of Dimes Perinatal Data Center, February 2018.

10 March of Dimes 2018 Prematurity Report Card

11 March of Dimes 2018 Report Card: Race & Ethnic Disparities

12 March of Dimes 2018 Report Card

13 March of Dimes Prematurity Report Card

14 Infant mortality is the most sensitive index we possess of social welfare... (A)nnual (R)eport of the (M)edical (O)fficer of (H)ealth, of the(l)ocal (G)overnment (B)oard, Thirty-ninth Report, PP.1910, Cd5263 (XXXIX), supplement on Infant and Child Mortality, Report of Dr Arthur Newsholme.

15 The Internet Newspaper: News, Blogs, Video, Community US Infant Mortality Rate Higher Than Other Wealthy Countries The CDC's 2016 world rankings indicate that an African-American baby would have a better chance of survival if born in Russia or Bulgaria than in the United States. The fact that the United States has the highest infant mortality is not because of a lack of specialists or facilities for neonatal births; on the contrary, America has more neonatologists and neonatal intensive care beds per person than Australia, Canada, or the United Kingdom. Among the factors contributing to these lopsided outcomes are disparities in prenatal care, nutritional supplementation for pregnant women, and inadequate social welfare. Yet even if we eliminate this racial disparity and compare only the infant mortality rate of Caucasian Americans, our ranking versus the competitor countries is unaffected.

16 HOW DID WE GET HERE?

17 How many of you work with agencies that serve a large AA Population? Audience Survey How many of you have Programs that Provide targeted interventions using the life course perspective or the social determinants of health? How many of you have high levels of participation by AA families in your programs? Why? Why not?

18 Higher rates of premature death Higher rates of all adverse health outcomes Anticipated: Black women have higher rates of preterm birth and infant mortality-----ses Status is not protective for this outcome Blackwomen have higher rates of maternal morbidity and mortality

19 Black patients will have worse outcomes.there is only so much we can do Accepted Patients living in conditions of poverty will have worse outcomes there is only so much we can do Patients and Providers are surrounded with as sense of futility

20 Negated Racial Bias in medicine: U.S. Healthcare providers see black patients as less personally responsible for their health Black patients are more likely to be blamed for their health outcomes Black patients are less likely to receive appropriate pain management for the same diagnosis of back pain in the emergency room

21 Understanding how we got here But where is here? The preterm birth rate in the United States has increased for the second year, rising 2 percent to 9.8 percent in This year s Report Card also reveals major racial/ethnic and geographic disparities signifying that babies have a higher chance of a preterm birth based simply on race and ZIP code.

22 Flash from the Past Where is here?

23 Where is here? The Land of Persistent Birth Disparities NEJM June 4, 1992: Mortality among infants of Black as compared with white College Educated Parents Schoendorf, KC. et al National Linked Birth and Infant Death Files for to calculate IMR for children born to college educated parents IMR was 10.2/1000 for black infants and 5.4/1000 for white infants Adjusted OR of 1.82 LBS 2x as high for black infants as compared to white infants 3x as likely to die from perinatal events Black infants born to college educated parents have higher mortality rates than similar white infants because of the higher rates of LBW.

24 Why are there birth disparities? What do we know? A research timeline 1. What are black mothers doing wrong? Diet? Weight? Access? Relationships? Teen Pregnancy? 2. In the 1980s, health officials began focusing on access to prenatal care as a way to reduce these perceived risk factors--> more women getting care, but little improvement in birth outcomes. Instead, the racial gap grew. 4. Some researchers suggested that black women were genetically predisposed to poor birth outcomes, and began to hunt for preterm birth genes. 5. Foreign-born black women living in the United States have birth outcomes almost identical to white American women s. (Lu and Collins) Differing birth weight among infants of U.S.-born blacks, Africanborn blacks, and U.S.-born whites. N Engl J Med Oct 23;337(17):

25 And it s not genetics either David RJ, Collins JW (1997). Differing birth weight among infants of U.S.-born blacks, Africanborn blacks, and U.S.-born whites. New England Journal of Medicine, 337(17),

26 Why are there birth disparities? What do we know? A research timeline.6. Poverty and lack of education were to blame, as black women consistently experience higher poverty levels. 7. After evaluating 46 different factors, alone and in combination including smoking, employment status, and education the authors of one 1997 study could account for less than 10 percent of the variation in birth weight between black and white babies. 9. Even black women with advanced degrees doctors, lawyers, MBAs were more likely to lose infants than white women who hadn t graduated from high school. 10. Racial discrimination, rather than race itself, as the dominant factor in explaining why so many black babies are dying. The research suggests that what happens outside a woman s body not just during the nine months

27 Today in Maternal Mortality Disparities Black mothers in the U.S. die at three to four times the rate of white mothers, one of the widest of all racial disparities in women's health. A black woman is: 22 percent more likely to die from heart disease than a white woman 71 percent more likely to perish from cervical cancer, 243 percent more likely to die from pregnancy- or childbirth-related causes. In a national study of five medical complications that are common causes of maternal black women were two to three times more likely to die death and injury, than white women who had the same condition. That imbalance has persisted for decades, and in some places, it continues to grow. nfanthealth/pmss.html

28 Why do we have disparities? 11/7/

29 HEALTH DISPARITIES Persistent, avoidable and, therefore, unfair health differences between socially advantaged and socially disadvantaged groups

30 Differences in distribution of resources = social inequity Falling off the Cliff of Good Health Differences in exposures and opportunities Differences in underlying health status Differences in access to care Primary prevention Secondary prevention Medical/tertiary care Jones, et al, 2009 Differences in quality of care

31 HEALTHY PEOPLE 2020 Goal: Achieve health equity, eliminate disparities, & improve the health of all groups

32 HEALTH EQUITY Everyone has the same opportunities to be healthy

33 HEALTH EQUITY Everyone has the same opportunities to be healthy

34 Equity vs. Equality

35 We can now predict your health status and life span based on your zip code! This should not be! 35

36 Your Zip Code is more important than your genetic code..

37 Social Determinants of Health The social determinants of health are the contexts of our lives the determinants of health which are outside of individual behaviors and beyond individual genetic endowment.

38 An interactive perspective

39 What is the Life Course Perspective? A complex interplay of biological, behavioral, psychological, and social protective and risk factors contributes to health outcomes across the span of a person s life.

40 Life Course Perspective

41 Life Course Perspective

42 Life Course Perspective, Dr. Michael Lu

43 Chronic Stress and Weathering may lead to Health Disparities and Poor Birth Outcomes

44 Chronic Stress and Preterm Birth

45 African-American pregnant women report more stressors and greater emotional distress than pregnant women from other racial/ethnic groups

46 The Reality in Media for Poor Birth Outcomes: A different :Lens 46

47 Reality in Media for Poor Birth Outcomes: A Different Lense

48 The Reality in Media: A Different Lens

49 Why do we have disparities? How did we get here? 49

50 R A C I S M... a likely fundamental cause of the nation s enduring racial/ethnic disparities in health

51 A Gardener s Tale Three Levels of Racism: Institutionalized Interpersonal Internalized You.tube/7M0du3lS7rA

52 Persistent Racial Disparities and the Slavery Timeline

53 MOTHER S Birthweight Gestational age INFANT S Birthweight Gestational age Fetal Growth Gestational age

54 RISK ACROSS THE LIFE COURSE In childhood: Cerebral palsy, epilepsy, chronic lung disease, deafness, blindness, ADHD, cognitive deficits, learning disabilities In adulthood: Cardiovascular disease, diabetes, hypertension

55 =Longstanding Effects of Chronic Stress Increase rates of Maternal Morbidity in Pregnancy Increase rates or Preterm Birth Increased rates of Infant Death Generational Disease Hypertension Diabetes Obesity Effects of Health Disparities on AA Women

56 Barriers to Accessing Prenatal and Perinatal Intervention Support Programs for AA Patients Mistrust of the Medical Community and the Perception of Research Loss.Death Mistreatment is a Legacy of the Black Community in America Fear of Blame/Not Beating the Statistics Faith Community that doesn t often allow for Despair Strong Black Woman Myth Lack of Non-Traditional Support Modalities

57 Mistrust of the Medical Community: The Tuskegee Syphilis Experiment

58 Mistrust of the Medical Community: Dr. Marion J. Sims: Father of Obstetrics and Gynecology

59 A Legacy of Loss for Black Women: Learning to put others before themselves

60 A Legacy of Separation

61 Fear of Blame: Not Beating the Statistics

62 John Kasich Blames Black People For High Infant Mortality Rates After Cutting Program That Helped: The Ohio governor just cut funding for a program that helped over 2,800 black mothers in /john-kasich-black-infantmortality_us_56fec449e4b0daf53aefa 809?ir=Black+Voices&section=us_blac k-voices&utm_hp_ref=blackvoices&ncid=fcbklnkushpmg The issue of infant mortality is a tough one. We have taken that on and one of the toughest areas to take on is in the minority community, he said. And the community itself is going to have to have a better partnership with all of us to begin to solve that problem with infant mortality in the minority community, because we re making gains in the majority community.

63 Starbucks Arrest Flint Water Crisis and Lead Poisoning Crisis Mistrust of Society

64 The Pardox of the Strong Black Woman: Bearing Silent Pain

65 Strong Black Woman Myth

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67 Removing The Mask: Stress and AA Women

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69 Life Course Perspective: Generational Stressors

70 Life Course, Birth Disparities and the first preemie I ever cared for Gender Race Education Economics Geography Family History

71 Not a those people problem, Photo credit: but an us problem

72 Address the Problem at Multiple Levels WIDER COMMUNITY Understand that nature of the problem for your community. Promote social equity (equal access and opportunity) Health care access, equitable and culturally sensitive care, life course perspective, meaningful engagement of patients/communities, effective health promotion, service integration, data systems, name and challenge isms HEALTH SYSTEM INDIVIDUAL Health education, counseling, screening, access to resources, respect inherent worth and dignity of each person, name and challenge isms

73 WHAT CAN YOU DO? DO GOOD! Good done anywhere is good done everywhere As long as you are breathing, it s never too late to do some good. -Maya Angelou

74 HP 2020: MAP IT! M = Mobilize partners A = Assess needs P = Plan for action I = Implement action plan T = Track progress

75 Objective: An Overview of Global Health Disparities and their Effects on Maternal Health and Infant Mortality Global Enviornmental, Economic, Social, Educational Effects Generational Effects The Role of Social Determinants of Health Solutions-How can we affect change

76 Improving provider knowledge about disparities Improving provider awareness of disparities Closely evaluating how different populations are represented in research Improving access to health care Patient centered health systems Reducing Health Disparities: Systems Empowering individuals to advocate for their health care needs

77 Any Questions?