Prenatal Care and Birth Outcomes Among Latina Women: What Do We Know? Oregon Latina Prenatal Summit Providence St. Vincent’s Hospital September 19, 2003.

Prenatal Care and Birth Outcomes Prenatal Care and Birth Outcomes Among Latina Women:Among Latina Women:

What Do We Know?What Do We Know?

Oregon Latina Prenatal SummitOregon Latina Prenatal SummitProvidence St. Vincent’s HospitalProvidence St. Vincent’s Hospital

September 19, 2003September 19, 2003

Michael McGlade, PhDMichael McGlade, PhDWestern Oregon UniversityWestern Oregon University

Salem, OregonSalem, Oregon

Somnath Saha, MD, MPHSomnath Saha, MD, MPHPortland VA Medical CenterPortland VA Medical Center

Portland, OregonPortland, Oregon

Goal: to examine data and research that suggest paths

towards the expansion of prenatal care for Latinas, given the current fiscal

environment

BASIC DEMOGRAPHY OF BASIC DEMOGRAPHY OF OREGON LATINOSOREGON LATINOS

Latino Population Increase 1990-2000 (%)

0 50 100 150 200

Oregon

WA

Idaho

Why did the Latino population grow more Why did the Latino population grow more rapidly in Oregon than other PNW states? rapidly in Oregon than other PNW states?

• Oregon’s growth was concentrated in the Oregon’s growth was concentrated in the northern Willamette Valley and Portland Metro northern Willamette Valley and Portland Metro counties, where a high demand for farm worker counties, where a high demand for farm worker labor happened to be near the Portland and labor happened to be near the Portland and Salem labor markets.Salem labor markets.

• The geographic proximity of labor intensive The geographic proximity of labor intensive agriculture and cities resulted in farm worker agriculture and cities resulted in farm worker labor networks feeding urban labor markets. labor networks feeding urban labor markets. Idaho and Washington did not experience this Idaho and Washington did not experience this process to such a degree.process to such a degree.

OregonOregon LatinosLatinos• 4 of 5 are of Mexican origin4 of 5 are of Mexican origin• poverty rates are among highest in the USpoverty rates are among highest in the US• over half have less than a high school educationover half have less than a high school education• most have family roots in rural Mexican most have family roots in rural Mexican

communitiescommunities• worldview and lifeways in rapid transition from worldview and lifeways in rapid transition from

collectivism (Latin American) to individualismcollectivism (Latin American) to individualism

Oregon Latinos (cont.)Oregon Latinos (cont.)

• are growing more rapidly than any other major are growing more rapidly than any other major ethnic group in Oregonethnic group in Oregon

• currently comprise nearly 9% of Oregon’s total currently comprise nearly 9% of Oregon’s total population, but are 16% of total birthspopulation, but are 16% of total births

• births more than doubled in past decadebirths more than doubled in past decade• are more youthful and have higher birth rates than are more youthful and have higher birth rates than

the other major ethnic groupsthe other major ethnic groups

THE LATINA EXPERIENCE THE LATINA EXPERIENCE DURING PREGNANCYDURING PREGNANCY

Disparities in 1st-trimester Disparities in 1st-trimester Prenatal CarePrenatal Care

About how many weeks pregnant were you when you had your 1st prenatal visit?

0102030405060708090

100

<13 weeks >13 weeks

%

Latinas

non-Latinas

Oregon PRAMS 2000

Barriers to Getting Prenatal CareBarriers to Getting Prenatal Care

• Low incomeLow income

• Lack of insuranceLack of insurance

• Documented status & related fearsDocumented status & related fears

• Low levels of formal educationLow levels of formal education

• Lack of awareness of prenatal care or need for Lack of awareness of prenatal care or need for prenatal careprenatal care

• Cultural differencesCultural differences

• LanguageLanguage

• DiscriminationDiscrimination

Lack of InsuranceLack of Insurance

0

10

20

30

40

50

60

70

80

90

100

NO YES

%

Latinasnon-Latinas

At the time of your 1st pregnancy test, At the time of your 1st pregnancy test, were you insured for prenatal care?were you insured for prenatal care?

Oregon PRAMS 2000

Barriers to Early Prenatal CareBarriers to Early Prenatal Care

ReasonReason LatinasLatinasNon-Non-

LatinasLatinas

Couldn’t get an appointmentCouldn’t get an appointment 23.6%23.6% 13.3%13.3%

Lack of money to pay for visitsLack of money to pay for visits 8.4%8.4% 8.5%8.5%

Lack of insuranceLack of insurance 5.5%5.5% 13.0%13.0%

Didn’t know I was pregnantDidn’t know I was pregnant 9.2%9.2% 10.4%10.4%

Oregon PRAMS 2000

Lack of Perceived NeedLack of Perceived Need

0

10

20

30

40

50

60

70

80

90

100

NO YES

%

Latinasnon-Latinas

Did you get prenatal care as early as you wanted?Did you get prenatal care as early as you wanted?

Oregon PRAMS 2000

Life Events Before/During PregnancyLife Events Before/During Pregnancy

EventEvent LatinasLatinasNon-Non-

LatinasLatinas

Separated/divorced from partnerSeparated/divorced from partner 9.4%9.4% 9.3%9.3%

Moved to a new addressMoved to a new address 42.2%42.2% 42.1%42.1%

HomelessHomeless 7.9%7.9% 2.1%2.1%

Lost jobLost job 19.9%19.9% 15.1%15.1%

Partner lost jobPartner lost job 21.9%21.9% 10.2%10.2%

Oregon PRAMS 2000

Life Events Before/During PregnancyLife Events Before/During Pregnancy

EventEvent LatinasLatinasNon-Non-

LatinasLatinas

Partner did not want pregnancyPartner did not want pregnancy 6.1%6.1% 7.4%7.4%

Unable to pay billsUnable to pay bills 31.0%31.0% 27.9%27.9%

Involved in physical fightInvolved in physical fight 4.4%4.4% 2.3%2.3%

In jail or partner in jailIn jail or partner in jail 4.2%4.2% 3.1%3.1%

Oregon PRAMS 2000

Who Is Providing Prenatal Care?Who Is Providing Prenatal Care?

0

10

20

30

40

50

60

70

80

Hospital Clinic Health Dept.Clinic

Private doctor/HMO

Other

%

Latinas

non-Latinas

Where did you go most of the time for prenatal care?Where did you go most of the time for prenatal care?

Oregon PRAMS 2000

Participation in WICParticipation in WIC

0

10

20

30

40

50

60

70

80

90

100

<5 5-9 9-13 13-17 17 or more Total

%

Latinasnon-Latinas

How many weeks pregnant at time of 1How many weeks pregnant at time of 1stst WIC visit? WIC visit?

WeeksOregon PRAMS 2000

Discrimination in Prenatal CareDiscrimination in Prenatal Care

LatinasLatinasNon-Non-

LatinasLatinas

RaceRace 4.3%4.3% 1.0%1.0%

CultureCulture 4.8%4.8% 1.3%1.3%

Ability to speak/understand EnglishAbility to speak/understand English 11.9%11.9% 1.4%1.4%

Do you think you were treated differently by health care providers during prenatal care, labor or delivery because of your :

Oregon PRAMS 2000

LATINA BIRTH OUTCOMES: LATINA BIRTH OUTCOMES:

A MIXED PICTUREA MIXED PICTURE

• Compared with non-Latina white women, Latinas Compared with non-Latina white women, Latinas in the U.S. have:in the U.S. have:

34% higher rate of maternity-related deaths34% higher rate of maternity-related deaths

3-fold higher rate of gestational diabetes3-fold higher rate of gestational diabetes

Slightly higher rate of preterm deliverySlightly higher rate of preterm delivery

Maternal and Infant OutcomesMaternal and Infant Outcomes

BUT…BUT…

• Despite lower income and less prenatal care Despite lower income and less prenatal care than non-Latino whites, Latinos have: than non-Latino whites, Latinos have: Similar rates of low birth weight (LBW)Similar rates of low birth weight (LBW)

Similar rates of infant mortalitySimilar rates of infant mortality

• AND…when compared to African-American AND…when compared to African-American women with similar income, Latinos have:women with similar income, Latinos have: Much lower rates of LBWMuch lower rates of LBW

Much lower rates of infant mortalityMuch lower rates of infant mortality

Does Prenatal Care Make a Does Prenatal Care Make a Difference in Latino Birth Outcomes?Difference in Latino Birth Outcomes?

• A national study of 1.1 million Mexican-American A national study of 1.1 million Mexican-American births found that infant mortality rates were 2.5 births found that infant mortality rates were 2.5 times greater for those who did not get prenatal times greater for those who did not get prenatal care vs. those who didcare vs. those who did

• Prenatal care matters most for U.S.-born LatinasPrenatal care matters most for U.S.-born Latinas

Zukevas, A, Wells BL, Lefkowitz B. Mexican American infant mortality rate: implications for public policy. Zukevas, A, Wells BL, Lefkowitz B. Mexican American infant mortality rate: implications for public policy.

Journal of Health Care for the Poor and Underserved. 2000;11:243-257Journal of Health Care for the Poor and Underserved. 2000;11:243-257

Prenatal Care Makes Prenatal Care Makes Economic SenseEconomic Sense

• A California study showed that for every dollar A California study showed that for every dollar cut from prenatal care for undocumented cut from prenatal care for undocumented women, $3.33 in postnatal costs were women, $3.33 in postnatal costs were accruedaccrued

Lu MC, Lin YG, Prietto, NM, Garite TJ. Elimination of public funding of prenatal care for Lu MC, Lin YG, Prietto, NM, Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis. American Journal of undocumented immigrants in California: a cost/benefit analysis. American Journal of

Obstetrics and Gynecology;2000;182:233-239Obstetrics and Gynecology;2000;182:233-239

Useful knowledge about Useful knowledge about the context of Latina birthsthe context of Latina births

Why Latinas overall do not have worse Why Latinas overall do not have worse birthing outcomes, given their high rates of birthing outcomes, given their high rates of poverty, lack of access to prenatal care, and poverty, lack of access to prenatal care, and

other disadvantages:other disadvantages:

1.1. Informal prenatal care systemsInformal prenatal care systems

2.2. Cultural protective factorsCultural protective factors

What are informal prenatal care systems?What are informal prenatal care systems?

• Supportive grandmothers and other maternal Supportive grandmothers and other maternal figuresfigures

• Helpful extended family members and other Helpful extended family members and other community peoplecommunity people

• Life partnersLife partners• Community-based Community-based parteras and health parteras and health

promoterspromoters• Others outside of the wage economy who Others outside of the wage economy who

provide a context for healthy maternityprovide a context for healthy maternity

INFORMAL FORMAL

clinics

clinicians

immediate family

friends

trusted community members

communityhealth workers

extended family

Systems of Care and Support for Latina Mothers

promotores

hospitalsparteras

birthingcenters

General Attributes of Systems of Care

Informal Systems of Care Formal Systems of Care

inexpensive

expensive

culturally specific,

relationship oriented

modern & sometimes alien

abundant human resources

scarce human resources

emphasis on early lifestyle-

based prevention, reproduction as a normal

process

emphasis on prevention and curative medicine

Informal Systems of Care Informal Systems of Care Make a Difference Make a Difference

• A growing body of evidence suggests that A growing body of evidence suggests that social support is the missing element in social support is the missing element in understanding why:understanding why:

– N. Europe has lower infant mortality than the US N. Europe has lower infant mortality than the US – Immigrant women have better birthing outcomes Immigrant women have better birthing outcomes

than their US born coethnics (Latinas & African than their US born coethnics (Latinas & African origin women)origin women)

Informal systems of care combine with Informal systems of care combine with cultural protective factors, including:cultural protective factors, including:

• healthy dietary traditions healthy dietary traditions • strong cultural approval and support of strong cultural approval and support of

maternitymaternity• the expectation of self-sacrificing motherhood the expectation of self-sacrificing motherhood

((marianismomarianismo))• the cultural prohibition of unhealthy behaviors the cultural prohibition of unhealthy behaviors

for mothers such as drinking and smokingfor mothers such as drinking and smoking

The beneficial effects of cultural protective The beneficial effects of cultural protective factors and informal systems of care tend to factors and informal systems of care tend to erode with acculturation to the “descending erode with acculturation to the “descending limb” of US mass culture…limb” of US mass culture…

Birthing outcomes worsen, and the formal Birthing outcomes worsen, and the formal medical system ends up picking up some of medical system ends up picking up some of the costs.the costs.

Negative Effects of AcculturationNegative Effects of Acculturation

• In a study of 22,872 Mexican American births in Illinois:In a study of 22,872 Mexican American births in Illinois:

– Mexican immigrantMexican immigrant women in low income census women in low income census tracts had low birth weight rates of tracts had low birth weight rates of 3%3%

– US bornUS born women of Mexican ancestry in the same women of Mexican ancestry in the same census tracts had low birth weight rates of census tracts had low birth weight rates of 14%14%

Collins JW, Shay, DK. Prevalence of Low Birth Weight among Hispanic infants with Unites States-born and Collins JW, Shay, DK. Prevalence of Low Birth Weight among Hispanic infants with Unites States-born and

foreign-born mothers: the effect of urban poverty. Am J Epidemiol 1994;139:184-192foreign-born mothers: the effect of urban poverty. Am J Epidemiol 1994;139:184-192

Indirect yet strong evidence of the positive role of a Indirect yet strong evidence of the positive role of a supportive Latino community, and the protective effects of supportive Latino community, and the protective effects of Mexican culture, comes from a study of over 1 million Mexican culture, comes from a study of over 1 million Southwest US Mexican-American infants:Southwest US Mexican-American infants:

• Mortality ranged from 4.3 in counties with high Mortality ranged from 4.3 in counties with high proportions of Mexican births, to 5.5 in counties with proportions of Mexican births, to 5.5 in counties with low proportions of Mexican births. low proportions of Mexican births.

• However, this community context association was However, this community context association was limited to US-born Mexican mothers, whose rates limited to US-born Mexican mothers, whose rates ranged from 7.0 in low concentration counties to 4.4 ranged from 7.0 in low concentration counties to 4.4 in high concentration counties. For births to Mexico-in high concentration counties. For births to Mexico-born mothers, there was no association between born mothers, there was no association between community context and mortality. community context and mortality.

Jenny AM, Schoendorf KC, Parker JD. The association between community context and Jenny AM, Schoendorf KC, Parker JD. The association between community context and mortality among Mexican-American infants. Ethnicity and Disease. 2001;11:722-731mortality among Mexican-American infants. Ethnicity and Disease. 2001;11:722-731

CONCLUSIONSCONCLUSIONS

• Formal and informal prenatal care improve birthing Formal and informal prenatal care improve birthing outcomesoutcomes

• Acculturation erodes informal systems of care and Acculturation erodes informal systems of care and cultural protective factorscultural protective factors

• Health systems that integrate some components Health systems that integrate some components of the informal systems of care might save lives & of the informal systems of care might save lives & money!money!