1 Foreign-born uninsured women and prenatal care New Mexico Pregnancy Risk Assessment & Monitoring System Presenter: Ssu Weng Maternal & Child Health Epidemiology Conference December 2003

Acknowledgments Opinions in this presentation do not necessarily reflect official views of these individuals or organizations PRAMS Susan Nalder, Director NM PRAMS Dorin Sisneros, Operations Manager NM PRAMS CDC PRAMS team – Nedra Whitehead NM PRAMS Steering Committee NM Office of Vital Records Kimberley Peters, Brian Woods; formerly with NMVR: Vicky Howell NM Department of Health Survey Unit Mothers who responded Funding sources and sponsors CDC Cooperative Agreement U50/CCU Title V MCH Block Grant, NM Dept of Health Family Preservation and Support Project (NM Children Youth and Families Department) Joint Powers of Agreement with Medical Assistance Division (NM Department of Human Services)

3 Epidemiologic paradox Foreign-born women v. US-born Demographic and socioeconomic risks Outcomes Similar: low birth weight and infant mortality Singh et al. 1996; Cervantes et al. 1999; Guendelman et al. 1999; Fuentes-Afflick et al. 1998; Buekens et al Better birth outcomes than state-born: preterm delivery, low birth weight, teen birth Sappenfield et al., MMWR 51:1091-5(Dec ) MCHEP presentations Maternal characteristics and behaviors Allen et al., in progress Adequacy of prenatal care Mitchell and Denk

4 Original purpose of study Goal Provide data for PNC network taskforce Seek Medicaid coverage for undocumented pregnant women Compare “Undocumented” with Women who had Medicaid for PNC But legal and citizenship status unavailable Foreign-born may not be immigrant No information on documentation

5 Revised questions Independent variable Foreign-born uninsured No attempt to identify undocumented “Outcomes” - were there differences in Maternal characteristics Access to and utilization of PNC Outcomes of mother or infant

6 Methods Two sources of data Birth certificates for Demographics Prenatal care entry and visits Infant’s birth weight PRAMS: maternal behaviors, healthcare, hospital stay Both: maternal medical risks, gestational age Descriptive study Later, select outcome(s) for multivariate analysis Survey analysis Stata: svymean, svylc to test for statistical significance Display of data Charts show 95% confidence intervals Data tables with p-values on request

What is PRAMS? Survey of new mothers, led by CDC, 32 states Ongoing since 1987 (NM since 7/97)

NM PRAMS frame Population-based From NM Vital Records live births NM resident mothers ~27,000 in year 2001 Exclusions Out-of-state births Multiple births >3 Adoptions

9 Survey design Stratified systematic sample Approximately 1/12 of frame Over-sampled from year Low birth weight infants Native Americans Equal allocation from year Stratified by geographic region Weighting at CDC based on Response rates Sampling fraction Non-coverage

10 Data collection Mailed survey: three times Telephone follow-up interviews 70.0% overall response rate, weighted 68.4% foreign-born (65.6% if Hispanic) 70.6% US-born

11 Definition “Foreign-born uninsured” Maternal country of birth U.S. states, excluding territories Foreign: ~75% from Mexico Payer of prenatal care Uninsured: 2 groups, foreign- or U.S.-born No Indian Health Service (IHS), Medicaid, or private insurance Insured – hierarchy of payers IHS  Medicaid  private Combined foreign- and U.S.-born

12 Five groups: US-born divided Focus on comparing group #1 with #2 or #3 1.Foreign-born uninsured 2.US-born, uninsured 3.Medicaid paid prenatal care, no other payer (“Medicaid”) 4.Indian Health Service (“IHS”) 5.Private insurance, includes HMO, military

13 Sample and population Births July 1997-Dec respondents Restrict to 7150 mothers of singletons 232 missing data for country of birth or payer

14 Maternal characteristics Challenges and advantages (?) US-born uninsured: standard errors > 2.5%

15 Maternal and family characteristics and experiences Intention of pregnancy Smoking cigarettes, drinking alcohol Partner abuse Stressful experiences Social support Medical risks: diabetes, BMI, hypertension

16 Intended pregnancy % of mothers who wanted the pregnancy sooner or then

17 Unwanted pregnancy % of mothers who did not want the pregnancy then or ever

18 Alcohol % of mothers who drank frequently or binged during the 3 months before pregnancy

19 Cigarettes % of mothers who smoked during the last 3 months of pregnancy

20 Stressful events % of mothers with 6 to 12 stressful experiences during the 12 months before delivery

21 Stressful experiences % of mothers with each stressful experience by payer-birth country Standard error > 2.5% for several estimates for US-uninsured

22 Partner abuse % of mothers physically abused by partner during 12 months before pregnancy

23 Social support % with help raising the baby from husband/partner or family/friends

24 Medical risks % treated for hypertension during pregnancy

25 Maternal medical risks % of mothers who were hospitalized during pregnancy

26 Medical risks % overweight before pregnancy BMI>25.9kg/m 2 Signif. higher than US-born uninsured

27 Medical risks % treated for diabetes during pregnancy n.s.

28 Access to and utilization of care Entry to PNC Adequacy of PNC Satisfaction with time of entry Facility providing PNC Medicaid as payer of labor & delivery

29 Late entry to prenatal care % of mothers starting after first 3 months of pregnancy

30 Cultural factors? Among women with late/no PNC, % who started as early as desired

31 Adequacy of prenatal care % with inadequate level Kotelchuck index % with intermediate level similar for all groups

32 “Safety net” % of women using CHC or PHD for prenatal care

33 Delivery – safety-net lacking Among foreign-born without prenatal payer, % with delivery paid by these sources Multiple responses allowed and not all shown 58.5%  6.0% did not have third-party payer or indigent fund

34 Outcomes Infant: birth weight, gestational age, nights in hospital Mother: problems during pregnancy, hospitalization during pregnancy

35 Infant’s birth weight (BW) % of mothers with infant in each BW category by PNC payer/maternal birthplace Cells shaded to indicate significant difference between foreign- born uninsured and Medicaid. Other differences not significant.

36 Infant’s gestational age (GA) % of mothers with infant in each GA category by PNC payer/maternal birthplace Cells shaded to indicate significant difference between foreign- born uninsured and Medicaid. Other differences not significant.

37 Hospital stay Mother Median number days same for all groups Mean difference n.s., although point estimate lower for foreign-born unininsured than Medicaid Infant Admission to ICU similar for all groups except private insurance, which was lower than foreign- born uninsured Stay for 6 days or more: n.s. difference

38 Paradox: Foreign-born uninsured are challenged Socioeconomic factors Education Income Homelessness Divorce, partner abuse before pregnancy Access to and utilization of prenatal care Financial barriers Language Late entry Inadequate utilization

39 Paradox Outcomes comparable or better compared with Medicaid mothers Low birth weight < Medicaid Preterm delivery < Medicaid Newborn stay in ICU n.s. difference Nights in hospital n.s. difference

40 Factors contributing to outcomes Foreign-born uninsured: Behavior - less likely to Smoke cigarettes Use alcohol Social issues Stressful events Attitudes: intended pregnancy Healthcare resources Community health centers

41 Implications for practice and policy Community health centers and public health clinics play important role in prenatal care Payer of delivery needed for 60% of foreign- born uninsured Adequacy of prenatal care Requires motivating women to get PNC

42 Paradox – not always? Future studies Role of financial access to care Foreign-born uninsured sometimes resemble US-born uninsured Need to consider financial situation as well as country of birth

43 Paradox – exception? Future studies: HBW and LGA Large for gestational age (LGA) HBW data: increased risk among foreign-born uninsured? Maternal BMI higher Multivariate study Binary Compare with appropriate for gestational age (AGA) Exclude SGA Or multinomial model Refine definition of AGA Standards specific for maternal ethnicity/race and infant’s sex Fetal or newborn measures?

44 Future Outcomes based on data from sources outside PRAMS Mortality Birth defects: neural tube Hospital discharge data Length of stay Diagnoses Outcomes leading to cost estimates Compare foreign-born uninsured with and without Medicaid-paid delivery

45 Limitations Potential misclassification of payer Within prenatal period, time period not specified for multiple payers Medicaid outcomes Uninsured US citizens with medical risks may shift to Medicaid during pregnancy “Healthy immigrant” effect

46 Limitations Lower rates of hospitalization Role of provider’s practices Response or non-response Admitting or denying high-risk behaviors Out of state births excluded Higher risk? Foreign-born? In % of all resident births 19% of Dona Ana resident births Analysis by domains Potential duplicates in combined years

47 NM PRAMS Contacts Susan Nalder MCH Epidemiology Program Manager & NM PRAMS Director Tel NM PRAMS Coordinator (S. Weng) Tel Ssu Weng, Epidemiologist Tel MCH Epidemiology Program Family Health Bureau NM Department of Health 2040 South Pacheco St. Santa Fe, NM