Back to the Future: Perinatal Outcomes in Latinos Elena Fuentes-Afflick, MD, MPH San Francisco General Hospital University of California, San Francisco

Disclosures None

Objectives 1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos. 2. To identify areas for future research in perinatal outcomes in Latinos.

US population Census Bureau

Births in the US, National vital statistics reports, 2009

Latino births in the US (%), National vital statistics reports, 2009

US births (%), by ethnicity: 2006 National Center for Health Statistics, 2009

National Center for Health Statistics Infant mortality:

Infant mortality rate: National Center for Health Statistics

Neonatal mortality rate: Texas, Powell-Griner and Streck, Am J Public Health 1982

“We tentatively conclude from our study that the low neonatal mortality rates observed in Texas among the Spanish surname population are due in part to underreporting of neonatal deaths.” Powell-Griner and Streck, Am J Public Health 1982

Infant mortality: Harris County Texas, Selby et al, Am J Public Health 1984

“These consistently paradoxical findings lead us to conclude that the Spanish surname infant mortality rate is not a valid indicator of health status for the Mexican American population of Harris County, Texas.” Selby et al, Am J Public Health 1984

Infant mortality rate, by ethnicity: CA Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Odds of infant death, by ethnicity Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Causes of infant mortality Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Population-based indicators of health Low birth weight and prematurity are significant risk factors for infant mortality Low birth weight and prematurity are associated with neurologic impairment, cerebral palsy, learning differences

Low birth weight and prematurity: US, 2005 National Center for Health Statistics, 2008

Low birth weight in the US Healthy People 2010 goal

Low birth weight: CA, 1981 Williams et al, Am J Public Health 1986

Low birth weight: 32 studies Fuentes-Afflick E and Lurie P, Arch Pediatr Adolesc Med 1997

Low birth weight among Latina and White women in CA, 1992 Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999

Low birth weight: Latinas in CA, 1992 Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1999 * *

Perinatal Outcomes Behavioral Nutrition/ Diet Social Support Cultural Community Artifact Obstetric Reproductive Medical Healthy Immigrant

Behavioral factors Latina women have lower rates of behavioral risk factors (tobacco and alcohol use) than African American or White women Foreign-born women generally have lower rates of tobacco and alcohol use than US- born women

Healthy nutrition

Micronutrients

Nutrition - Obesity

Medical factors Are Latina women healthier than women of other ethnic groups? Are immigrant Latinas healthier than women in their population of origin? Are immigrant Latinas healthier than women in the receiving population?

Obstetric / Reproductive Interpregnancy interval? Do Latina women have a reproductive advantage?

Summary Latina women have low rates of infant mortality, low birth weight, and prematurity We do not understand why Latina women have such favorable perinatal outcomes

Objectives 1. To review perinatal statistics for infant mortality, low birth weight, and prematurity in Latinos. 2. To identify areas for future research in perinatal outcomes in Latinos.

Ethnicity ≠ Acculturation

Immigrants in the US

Acculturation “… the process by which immigrants adopt the attitudes, values, customs, beliefs and behaviors of a new culture.” Abraido-Lanza A et al, AJPH 2005

Last names in the US, 2009 #1Smith #2Johnson #3Williams #4Brown #5Jones #8Garcia #9Rodriguez Census Bureau

Foreign-born childbearing women: US, 2005 National Center for Health Statistics

Low birth weight, by birthplace: Latina women in CA, 1992 VLBW OR 0.92 ( ) MLBW* OR 0.91 ( ) Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1998

Infant mortality, by birthplace: Latina women CA, Unadjusted OR 1.08 ( )* Adjusted OR 0.88 ( )* Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

Two dimensions of the epidemiologic paradox Latina women have surprisingly favorable perinatal outcomes relative to African American and White women Foreign-born Latinas have surprisingly favorable perinatal outcomes relative to US-born women

Risk factor models – one size fits all? Interventions – tailored? Universal? Protective factors versus risk factors Implications of the epidemiologic paradox

Social support

Community factors “The paradox of Hispanic health represents a group-level correlation between ethnicity and mortality that cannot be explained in terms of an individual-level model.” Scribner R, Am J Public Health 1996

Lifecourse approach  Demographic risk factors  Medical/health status  Obstetric/reproductive factors

Promising areas Acculturation Prematurity Interpregnancy interval

Challenging areas Methodologic and challenges Body mass, maternal Paternal factors Community-level factors Acculturation ‘web’