1. Prenatal Care and Birth Outcomes Among Latina Women: What Do We Know? Oregon Latina Prenatal Summit Providence St. Vincent’s Hospital September 19, 2003 Michael McGlade, PhD Western Oregon University Salem, Oregon Somnath Saha, MD, MPH Portland VA Medical Center Portland, Oregon

2. Goal: to examine data and research that suggest paths towards the expansion of prenatal care for Latinas, given the current fiscal environment

3. BASIC DEMOGRAPHY OF OREGON LATINOS

5. Why did the Latino population grow more rapidly in Oregon than other PNW states? Oregon’s growth was concentrated in the northern Willamette Valley and Portland Metro counties, where a high demand for farm worker labor happened to be near the Portland and Salem labor markets.Oregon’s growth was concentrated in the northern Willamette Valley and Portland Metro counties, where a high demand for farm worker labor happened to be near the Portland and Salem labor markets. The geographic proximity of labor intensive agriculture and cities resulted in farm worker labor networks feeding urban labor markets. Idaho and Washington did not experience this process to such a degree.The geographic proximity of labor intensive agriculture and cities resulted in farm worker labor networks feeding urban labor markets. Idaho and Washington did not experience this process to such a degree.

6. Oregon Latinos 4 of 5 are of Mexican origin4 of 5 are of Mexican origin poverty rates are among highest in the USpoverty rates are among highest in the US over half have less than a high school educationover half have less than a high school education most have family roots in rural Mexican communitiesmost have family roots in rural Mexican communities worldview and lifeways in rapid transition from collectivism (Latin American) to individualismworldview and lifeways in rapid transition from collectivism (Latin American) to individualism

7. Oregon Latinos (cont.) are growing more rapidly than any other major ethnic group in Oregonare growing more rapidly than any other major ethnic group in Oregon currently comprise nearly 9% of Oregon’s total population, but are 16% of total birthscurrently comprise nearly 9% of Oregon’s total population, but are 16% of total births births more than doubled in past decadebirths more than doubled in past decade are more youthful and have higher birth rates than the other major ethnic groupsare more youthful and have higher birth rates than the other major ethnic groups

8. THE LATINA EXPERIENCE DURING PREGNANCY

9. Disparities in 1st-trimester Prenatal Care Oregon PRAMS 2000

10. Barriers to Getting Prenatal Care Low incomeLow income Lack of insuranceLack of insurance Documented status & related fearsDocumented status & related fears Low levels of formal educationLow levels of formal education Lack of awareness of prenatal care or need for prenatal careLack of awareness of prenatal care or need for prenatal care Cultural differencesCultural differences LanguageLanguage DiscriminationDiscrimination

11. Lack of Insurance At the time of your 1st pregnancy test, were you insured for prenatal care? Oregon PRAMS 2000

12. Barriers to Early Prenatal Care ReasonLatinas Non- Latinas Couldn’t get an appointment 23.6%13.3% Lack of money to pay for visits 8.4%8.5% Lack of insurance 5.5%13.0% Didn’t know I was pregnant 9.2%10.4% Oregon PRAMS 2000

13. Lack of Perceived Need Did you get prenatal care as early as you wanted? Oregon PRAMS 2000

14. Life Events Before/During Pregnancy EventLatinas Non- Latinas Separated/divorced from partner 9.4%9.3% Moved to a new address 42.2%42.1% Homeless7.9%2.1% Lost job 19.9%15.1% Partner lost job 21.9%10.2% Oregon PRAMS 2000

15. Life Events Before/During Pregnancy EventLatinas Non- Latinas Partner did not want pregnancy 6.1%7.4% Unable to pay bills 31.0%27.9% Involved in physical fight 4.4%2.3% In jail or partner in jail 4.2%3.1% Oregon PRAMS 2000

16. Who Is Providing Prenatal Care? Where did you go most of the time for prenatal care? Oregon PRAMS 2000

17. Participation in WIC How many weeks pregnant at time of 1 st WIC visit? Weeks Oregon PRAMS 2000

18. Discrimination in Prenatal Care Latinas Non- Latinas Race4.3%1.0% Culture4.8%1.3% Ability to speak/understand English 11.9%1.4% Do you think you were treated differently by health care providers during prenatal care, labor or delivery because of your : Oregon PRAMS 2000

19. LATINA BIRTH OUTCOMES: A MIXED PICTURE

20. Compared with non-Latina white women, Latinas in the U.S. have:Compared with non-Latina white women, Latinas in the U.S. have:  34% higher rate of maternity-related deaths  3-fold higher rate of gestational diabetes  Slightly higher rate of preterm delivery Maternal and Infant Outcomes

21. BUT… Despite lower income and less prenatal care than non-Latino whites, Latinos have:Despite lower income and less prenatal care than non-Latino whites, Latinos have:  Similar rates of low birth weight (LBW)  Similar rates of infant mortality AND…when compared to African-American women with similar income, Latinos have:AND…when compared to African-American women with similar income, Latinos have:  Much lower rates of LBW  Much lower rates of infant mortality

22. Does Prenatal Care Make a Difference in Latino Birth Outcomes? A national study of 1.1 million Mexican-American births found that infant mortality rates were 2.5 times greater for those who did not get prenatal care vs. those who didA national study of 1.1 million Mexican-American births found that infant mortality rates were 2.5 times greater for those who did not get prenatal care vs. those who did Prenatal care matters most for U.S.-born LatinasPrenatal care matters most for U.S.-born Latinas Zukevas, A, Wells BL, Lefkowitz B. Mexican American infant mortality rate: implications for public policy. Journal of Health Care for the Poor and Underserved. 2000;11:243-257

23. Prenatal Care Makes Economic Sense A California study showed that for every dollar cut from prenatal care for undocumented women, $3.33 in postnatal costs were accruedA California study showed that for every dollar cut from prenatal care for undocumented women, $3.33 in postnatal costs were accrued Lu MC, Lin YG, Prietto, NM, Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis. American Journal of Obstetrics and Gynecology;2000;182:233-239

24. Useful knowledge about the context of Latina births

25. Why Latinas overall do not have worse birthing outcomes, given their high rates of poverty, lack of access to prenatal care, and other disadvantages: 1.Informal prenatal care systems 2.Cultural protective factors

26. What are informal prenatal care systems? Supportive grandmothers and other maternal figuresSupportive grandmothers and other maternal figures Helpful extended family members and other community peopleHelpful extended family members and other community people Life partnersLife partners Community-based parteras and health promotersCommunity-based parteras and health promoters Others outside of the wage economy who provide a context for healthy maternityOthers outside of the wage economy who provide a context for healthy maternity

27. INFORMAL FORMAL clinics clinicians immediate family friends trusted community members community health workers extended family Systems of Care and Support for Latina Mothers promotores hospitalsparteras birthing centers

29. Informal Systems of Care Make a Difference A growing body of evidence suggests that social support is the missing element in understanding why:A growing body of evidence suggests that social support is the missing element in understanding why: –N. Europe has lower infant mortality than the US –Immigrant women have better birthing outcomes than their US born coethnics (Latinas & African origin women)

30. Informal systems of care combine with cultural protective factors, including: healthy dietary traditionshealthy dietary traditions strong cultural approval and support of maternitystrong cultural approval and support of maternity the expectation of self-sacrificing motherhood (marianismo)the expectation of self-sacrificing motherhood (marianismo) the cultural prohibition of unhealthy behaviors for mothers such as drinking and smokingthe cultural prohibition of unhealthy behaviors for mothers such as drinking and smoking

31. The beneficial effects of cultural protective factors and informal systems of care tend to erode with acculturation to the “descending limb” of US mass culture… Birthing outcomes worsen, and the formal medical system ends up picking up some of the costs.

32. Negative Effects of Acculturation In a study of 22,872 Mexican American births in Illinois:In a study of 22,872 Mexican American births in Illinois: –Mexican immigrant women in low income census tracts had low birth weight rates of 3% –US born women of Mexican ancestry in the same census tracts had low birth weight rates of 14% Collins JW, Shay, DK. Prevalence of Low Birth Weight among Hispanic infants with Unites States-born and foreign-born mothers: the effect of urban poverty. Am J Epidemiol 1994;139:184-192

33. Indirect yet strong evidence of the positive role of a supportive Latino community, and the protective effects of Mexican culture, comes from a study of over 1 million Southwest US Mexican-American infants: Mortality ranged from 4.3 in counties with high proportions of Mexican births, to 5.5 in counties with low proportions of Mexican births.Mortality ranged from 4.3 in counties with high proportions of Mexican births, to 5.5 in counties with low proportions of Mexican births. However, this community context association was limited to US-born Mexican mothers, whose rates ranged from 7.0 in low concentration counties to 4.4 in high concentration counties. For births to Mexico- born mothers, there was no association between community context and mortality.However, this community context association was limited to US-born Mexican mothers, whose rates ranged from 7.0 in low concentration counties to 4.4 in high concentration counties. For births to Mexico- born mothers, there was no association between community context and mortality. Jenny AM, Schoendorf KC, Parker JD. The association between community context and mortality among Mexican-American infants. Ethnicity and Disease. 2001;11:722-731

34. CONCLUSIONS Formal and informal prenatal care improve birthing outcomesFormal and informal prenatal care improve birthing outcomes Acculturation erodes informal systems of care and cultural protective factorsAcculturation erodes informal systems of care and cultural protective factors Health systems that integrate some components of the informal systems of care might save lives & money!Health systems that integrate some components of the informal systems of care might save lives & money!