Measuring and Eliminating Racism and Racial Disparities in MCH: The Need for New Paradigms James W. Collins, Jr. 12/10/08

INFANT MORTALITY RATES IN THE U.S.

NEONATAL MORTALITY RATES

Six Decade Trend in Low Birth Weight Rates in the United States

Low Birth Weight Rates by Maternal Education and Race (Chicago, IL)

RACIAL GAP IN PERINATAL OUTCOME AMONG INFANTS CONCEIVED BY ART (Schieve et al, Obstet Gynecol, 2004)

Differing LBW Rates Among Low-risk Women in Illinois (David and Collins, NEJM, 1997)

MLBW Rates Among Infants of Married Women Across a Generation (Collins et al, AJE, 2002)

White African American Puberty Pregnancy 05ys The Racial Gap in Reproductive Potential: A Life-Course Perspective Lu and Halfon,MCHJ, 2003 Reproductive Potential Risk Factors Life Course Protective Factors

Race Race is not a biological construct that reflects innate differences, but a social construct that precisely captures the impacts of racism. (Jones, AJPH, 2000)

RESEARCH QUESTION To what extent are African-American womens lifetime exposures to perceived interpersonal racial discrimination a risk factor for preterm-VLBW?

METHODS Case-control study of African-American infants admitted to Childrens Memorial, University of Chicago, and Cook County Hospitals 11/97-10/00. Cases: mothers of very low birth weight (<1500g, VLBW), preterm (< 37wks) infants. Controls: mothers of non-low birth weight ( >2500g, non- LBW), term infants. Case to control ratio of 1:2; $10.00 participation reward offered to all eligible subjects.

METHODS Structured Questionnaire: - lifetime exposure to interpersonal racial discrimination in 5 domains: getting work, at work, at school, getting service at a restaurant / store, getting medical care (Krieger, 1990). - full-time employed women were asked an additional 20 questions regarding lifetime and past year exposure to interpersonal racial discrimination at their primary place of employment (McNeilly, 1996).

METHODS Responses were dichotomized after data collection into none (none or less than once/ year) or regularly (few times/year, few times/month, at least once/week, and nearly everyday). Maternal age, education, marital status, income, prenatal care usage, parity, cigarette smoking, alcohol intake, and social support. Stratified and multivariate logistic regression analyses were performed.

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 1 OR MORE DOMAINS AND INFANT BIRTH WEIGHT (Collins et al, AJPH, 2004)

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT (Collins et al, AJPH, 2004)

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, MATERNAL AGE, AND INFANT BIRTH WEIGHT

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, MATERNAL EDUCATION, AND INFANT BIRTH WEIGHT

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, PRENATAL CARE, AND INFANT BIRTH WEIGHT

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, CIGARETTE SMOKING, AND INFANT BIRTH WEIGHT

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM, SOCIAL SUPPORT, AND INFANT BIRTH WEIGHT

LOGISTIC REGRESSION (Collins et al, AJPH, 2004) Unadjusted and adjusted OR of VLBW for maternal lifetime exposure to interpersonal racial discrimination in 1 or more domains were 1.9 ( ) and 2.3 ( ), respectively. Unadjusted and adjusted OR of VLBW for maternal lifetime exposure to interpersonal racial discrimination in 3 or more domains were 2.7 ( ) and 2.6 ( ), respectively.

MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM AT THE WORKPLACE AND INFANT BIRTH WEIGHT OR=1.7 ( )Because you are African-American, you are assigned jobs no one else will do. OR=1.7 ( ) OR=2.3 ( Whites often assume that you work in a lower class job than you do and treat you as such. OR=2.3 ( OR=2.0 ( )You are treated with less dignity and respect than you would be if you were white. OR=2.0 ( ) OR=2.3 ( )You are watched more closely than others because of your race. OR=2.3 ( ) OR=1.9 ( )Because you are African-American, you feel that you have to work twice as hard. OR=1.9 ( )

MATERNAL CHRONIC EXPOSURE TO INTERPERSONAL RACISM IN THE WORKPLACE AND INFANT BIRTH WEIGHT

Self-Reported Experiences of Racial Discrimination and the Racial Disparity in Preterm Delivery: the CARDIA Study (Mustillo et al, AJPH, 2004)

Racial Discrimination and the Racial Disparity in Low Birth Weight Delivery: the CARDIA Study ( Mustillo et al, AJPH, 2004) 4.2 ( ).Unadjusted OR of LBW delivery for African- American (compared to White) women was 4.2 ( ). 2.1 ( ).Adjusted (racial discrimination) OR of LBW delivery was 2.1 ( ). 2.4 ( Adjusted (racism, SES, depression, alcohol, and tobacco use) OR of LBW delivery was 2.4 (

White African American Puberty Pregnancy 05ys The Racial Gap in Reproductive Potential: A Life-Course Perspective Lu and Halfon,MCHJ, 2003 Reproductive Potential Risk Factors Life Course Protective Factors

(Collins, Herman, David; AJPH, 1997) Positive Income-Incongruity (Collins, Herman, David; AJPH, 1997) Median family income of mothers census tract residence is 1 S.D. above the mean income of non-Latino whites with same of years of parental education and marital status. Proxy measure of societal advantages not captured by individual level variables; i.e. generational wealth.

(Collins, Herman, David; AJPH, 1997) Positive Income-Incongruity (Collins, Herman, David; AJPH, 1997)

(Collins, Herman, David; AJPH, 1997) Positive Income-Incongruity and VLBW (Collins, Herman, David; AJPH, 1997)

Adverse Environmental conditions Social policy Poverty Racism Limited Access to Care Under- Education Family Support Lack of access to good Nutrition Weathering Stress Smoking Poor Working Conditions Bad Housing Bad Neighborhoods Unemployment Hopelessness Disparities Adapted from A. R. James

A 12-Point Plan: Lu and colleagues 1. Provide interconception care to women with prior adverse pregnancy outcomes 2. Increase access to preconception care for African American women 3. Improve the quality of prenatal care 4. Expand healthcare access over the life course 5. Strengthen father involvement in African American families 6. Enhance service coordination and systems integration 7. Create reproductive social capital in African American communities 8. Invest in community building and urban renewal 9. Close the education gap 10. Reduce poverty among African-Americans 11. Support working mothers 12. Undo racism: institutional, interpersonal