I Caceres and B Cohen Division of Research and Epidemiology Bureau of Health Information, Statistics, Research and Evaluation Massachusetts Department of Public Health Inequalities in Infant Mortality: The Interaction of Race and Socioeconomic Status Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6 th – June 10 th, 2010

Source of Disparities Influencing Adverse Outcomes

Outline Study Questions Methods Background Results Summary

Study Questions  Do Race/Ethnicity differences in IMR persist after accounting for SES?  Does the difference depend on SES measures used (Birth certificate education vs Census poverty level)?  Is there race variation in infant mortality by education?  Is there ethnicity variation in infant mortality by education?  Is there race variation in infant mortality by level of poverty?  Is there ethnicity variation in infant mortality by level of poverty?

Methods Data sources: MA Births Census 2000 Study Outcome Infant mortality rate (IMR) Number of deaths within first year of live in a given period per 1000 live births in the same period

Methods Race: White non-Hispanic (reference group) Hispanics Black non-Hispanics Asian non-Hispanics Ethnicity: 21 ethnicity groups, Euro-American (reference group) Education: Less than high school (<HS) High school (HS) Associated Degree/Some college (Assoc/some college) College or graduate (Coll+) (reference group: most educated)

Methods Area of residence: 11-digit census tract Neighborhood poverty level is the percent of population in census tract below the Census 2000 federally-defined poverty line, four categories are defined: < 5% (reference: least poor neighborhood) % % %

Methods Disparities are measured using ratio of rates for each group to that of the reference group Race Disparities (ref: WNH) Ethnicity Disparities (ref: Euro-American) Education disparities (ref: most educated) Poverty Disparities: (ref: least poor neighborhood) 95% Confidence intervals of ratios are used to identify significant disparities (or excess of risk) compared with that of the reference group

BACKGROUND

Maternal Race: Births vs. Infant Deaths 21% 34%

Maternal Ethnicity: Births vs. Infant Deaths

Infant Mortality Rate (IMR) Massachusetts: * Statistically Significant (p ≤.05) APC = Annual Percentage Change -5.4%* APC 1996

IMR by Race & Hispanic Ethnicity Massachusetts:

Race Disparities in IMR by Race * * ** * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Ratio of rates in excess to 1 (relative to NH Whites) Reference: White non- Hispanics

IMR by Ethnicity Massachusetts Births Infant deaths per 1000 live births

Ethnicity Disparities in IMR * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Reference: Euro- American Ratio of rates in excess to 1 (relative to Euro-American) * * * * * * **

Education, Race, and Infant Mortality

Maternal Education: Births vs. Infant Deaths 50%

Disparities in IMR by Education * * * * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Ratio of rates in excess to 1 (relative to most educated: Coll+) Reference: Coll+

Education Disparities in IMR by Race * * * * Excess risk * * Reference: Coll+ * * RATIO Statistically higher than 1 (p<.05) Ratio of rates in excess to 1 (relative to most educated: Coll+)

Ratio of rates in excess to 1 (relative to NH Whites) Disparities in IMR by Race and Education * * * ** * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk * * Reference: White non-Hispanics

Education, Ethnicity, and Infant Mortality

Births by Education and Ethnicity % of Total Births (61%)(6%) (2%) (3%) (1%) Most Educated Least Educated

Births by Education and Ethnicity Most Educated Least Educated (4%)(2%) (1%) (2%) (2%) % of Total Births

Infant Deaths by Education and Ethnicity % of Total Infant deaths (51%)(10%) (3%) (2%) (2%) Most Educated Least Educated

Infant Deaths by Education and Ethnicity Most Educated Least Educated (9%)(3%) (3%) (1%) (1%) % of Total Infant deaths

Disparities in IMR by Ethnicity and Education * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Reference: Euro-American Ratio of rates in excess to 1 (relative to Euro-American) * * * * * * * * *

Poverty, Race, Ethnicity and Infant Mortality

Percent of Population in Census Tract Below Poverty Level 1 Least poor Most poor 1. Categories of ‘below poverty level’ in census tracts (or in neighborhood areas) are based on percent of population in these areas below the Census 2000 federally-defined poverty line.

IMR by Neighborhood Poverty Level Infant deaths per 1000 live births

IMR by Neighborhood Poverty Level * * * Excess risk Ratio of rates in excess to 1 (relative to least poor neighborhood) Reference: neighborhoods with <5% in poverty * RATIO Statistically higher than 1 (p<.05)

47% Least poor Most poor Distribution of Neighborhood Poverty Level Births vs. Infant Deaths

51% Least poor Most poor Births by Neighborhood Poverty Level and Race (70%) (7%) (8%)(13%) * Non-Hispanic. % of Total Births

68% Least poor Most poor Infant Deaths by Neighborhood Poverty Level and Race (59%) (4%) (17%)(17%) * Non-Hispanic. % of Total Infant deaths

IMR by Neighborhood Poverty Level and Race * Excess risk * * Ratio of rates in excess to 1 (most poor to least poor neighborhood) Reference: neighborhoods with <5% in poverty * RATIO Statistically higher than 1 (p<.05)

* * ** * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Reference: White non- Hispanics * * Ratio of rates in excess to 1 (relative to NH Whites) ** Race Disparities in IMR by Neighborhood Poverty Level

Least poor Most poor Births by Neighborhood Poverty Level by Ethnicity % of Total Births (61%)(6%) (2%) (3%) (1%)

Least poor Most poor Births by Neighborhood Poverty Level by Ethnicity % of Total Births (4%)(2%) (1%) (2%) (2%)

Least poor Most poor Infant Deaths by Neighborhood Poverty Level and Ethnicity % of Total Infant deaths (51%)(10%) (3%) (2%) (2%)

Least poor Most poor Infant Deaths by Neighborhood Poverty Level and Ethnicity % of Total Infant deaths (9%)(3%) (3%) (1%) (1%)

Ethnicity Disparities in IMR by Neighborhood Poverty Level * RATIO Statistically higher than 1 (p<.05) ** RATIO Statistically lower than 1 (p<.05) Excess risk Reference: Euro- American Ratio of rates in excess to 1 (relative to Euro-American) * * * * * * * *

Summary

One out of 2 infant deaths are to mothers with high school education or less One out of 4 infant deaths are to mothers living in poor neighborhoods, however 2 out 3 infant deaths to Hispanic mothers are to those living in poor neighborhoods

Race and neighborhood poverty disparities are more influential in excess of risk of infant mortality among Black non-Hispanic mothers More educated BNH mothers have equal risk of IMR than their least educated counterparts For White non-Hispanic and Hispanic mothers, increasing levels of educational attainment diminishes their risk of IMR

BNH, Hispanics, and WNH mothers living in poor neighborhoods have an excess risk of IMR compared to those living in most affluent neighborhoods Asian mothers have a lower risk in IMR compared with WNH mothers. However, Asian mothers with less than high school education have an excess risk of IMR than that of their counterparts with college or more education

Public Health Implications Clearly, IMR reduction strategies need to focus on lower SES families whether defined by individual education or areal poverty More needs to be done to understand the mechanisms that drive excess of risk in IMR across all levels of education and across all levels of neighborhood affluence particularly among BNH mothers, compared with that of WNH mothers

Public Health Implications We need to further explore the interaction of race and poverty to better target perinatal programs We need to collect more detailed ethnicity data to better understand patterns obscured by broad race groups