Racial-Ethnic Disparities in Birth Outcomes A Life-Course - - PowerPoint PPT Presentation
Racial-Ethnic Disparities in Birth Outcomes A Life-Course Perspective Michael C. Lu, MD, MPH Associate Administrator Maternal and Child Health Health Resources and Services Administration U.S. Department of Health and Human Services Equity,
Racial-Ethnic Disparities in Birth Outcomes A Life-Course Perspective Michael C. Lu, MD, MPH
Associate Administrator Maternal and Child Health Health Resources and Services Administration U.S. Department of Health and Human Services Equity, Race, and Access to Midwifery National Association of Certified Professional Midwives January 4, 2017
We hold these truths to be self-evident, that all men are created equal ….
Declaration of Independence 1776
I have a dream that one day … little black boys and black girls will be able to join hands with little white boys and white girls and walk together as sisters and brothers.
Martin Luther King, Jr (1963)
Deaths Per 1,000 Live Births
NCHS 2015
Year 2010 Goal
Percent of Live Births
Percent of Live Births
Percent of Live Births
NCHS 2015
Percent of Live Singleton Births
NCHS 2014
NCHS 2015
Per 1,000 Live Births
NCHS 2015
Foreign-Born Black US-Born Black
Infant Deaths Per 1,000 Live Births
NCHS 2015 7.04 11.65
Birth weight distribution of African-born blacks is more closely related to US-born whites than to US-born blacks
David RJ, Collins JW. Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997 Oct 23;337(17):1209-14.
African American White
NCHS 2002 Percent of Women Who Reported Smoking During pregnancy 9.3% 13.6%
African American Non-Smokers White American Smokers
Infant Deaths Per 1,000 Live Births
NCHS 2002 13.2 9.2
10 20 30 40 50 60 70 80 90 100 African American Native American Hispanic Asian/PI White Percent of Live Births with First Trimester Prenatal Care
74% 85% 74% 84% NCHS 2002 70%
African Americans First Trimester Prenatal Care White Americans First Trimester Prenatal Care
Infant Deaths Per 1,000 Live Births
NCHS 1999 12.7 5.2
African Americans First Trimester Prenatal Care White Americans Prenatal Care After 1st Trimester or None Infant Deaths Per 1,000 Live Births
NCHS 2002 12.7 7.1
Infant Mortality & Education
Infant Mortality 12 or More Years of School
NCHS 2002 14.1 5.7 African American African American Hispanic 74% Hispanic 51%
African Americans 16+ years
White Americans <9 years of schooling Infant Deaths Per 1,000 Live Births
NCHS 2002 10.2 6.8
Multiple Determinants of Birth Outcomes
level of living, psychological, social, exposures, “newly defined”)
remained
covariates
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course
Birth Weight and Coronary Heart Disease
0.25 0.5 0.75 1 1.25 1.5 <5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0 Birthweight (lbs)
Age Adjusted Relative Risk
Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.
Birth Weight and Hypertension
155 160 165 170 Systolic Pressure (mmHg) <=5.5 5.6-6.5 6.6-7.5 7.6-8.5 >8.5 Birthweight (lbs)
Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in utero and its amplification throughout life. Br Med J 1993;306:24-27.
Birth Weight and Insulin Resistance Syndrome
2 4 6 8 10 12 14 16 18 <5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5 Birthweight (lbs)
Odds ratio adjusted for BMI
Barker DJP, Hales CN, Fall CHD, Osmond C, Phipps K, Clark PMS. Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (Syndrome X): Relation to reduced fetal growth. Diabetologia 1993;36:62-67.
Hypothalamus Pituitary Adrenal
+ CRH + ACTH CRH
Placenta
(+) Cortisol DHEA-S
(+) (+)
Hypothalamus Pituitary Adrenal
(+)
CRH ACTH Cortisol Norepinephrine
11-B HSD II
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain. J Neuroendocrinol 2001;13:113-28.
Prenatal Programming of the Hypothalamic-Pituitary-Adrenal Axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain. J Neuroendocrinol 2001;13:113-28.
Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003
Same Genome, Different Epigenome
R.A. Waterland, R.A. Jirtle, "Transposable elements: targets for early nutritional effects on epigenetic gene regulation," Mol Cell Biol, 23:5293-300, 2003.
Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
McEwen BS. Protective and damaging effects of stress
McEwen BS. Protective and damaging effects of stress
glucose
functions
hippocampus & prefrontal cortex
cardiovascular diseases
insulin resistance
neurons in hippocampus & prefrontal cortex
McEwen BS. Stressed or stressed out: What is the difference? J Psychiatry Neurosci 2005; 30:315-8
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
Source: NCHS, linked birth/infant death data set
Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)
Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth
Smith et al Lancet 2001;357:2002-06
Equity, Race and Access to Midwifery
Closing the Black-White Gap in Birth Outcomes:
A 12-Point Plan
1.
Provide interconception care to women with prior adverse pregnancy outcomes
Lu MC, Kotelchuck M, Hogan V, Jones L, Jones C, Halfon N. Closing the Black-White gap in birth outcomes: A life-course approach. Ethnicity and Disease 2010;20:S2-62-76
Racism
MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT
(Collins et al, AJPH, 2004)
Jones CP. Levels of racism: A theoretical framework and a gardener’s tale. AJPH 2000;90:1212-5