1. Melissa VonderBrink, MPH Ohio Department of Health Center for Public Health Statistics and Informatics

2. Racial Disparities in the U.S. Racial/ethnic disparities in maternal and child health have existed for some time in the U.S. Unintended pregnancy and abortion rates highest among black women, followed by Hispanic 1 Even controlling for socioeconomic status, infant mortality twice as high among black infants as white infants 2 1 Cohen S. Abortion and Women of Color: The Bigger Picture (2008). Guttenmacher Policy Review. Vol. 11, No. 3. 2 Alio A., et. al. An Ecological Approach to Understanding Black-White Disparities in Perinatal Mortality. (2009). Matern Child Health J. DOI 10.1007/s10995-009-0495-9.

3. Objective Describe the differences in preconception health among Ohio women by race and ethnicity to identify those most in need of intervention

4. Ohio’s Population Population: 11,536,504 By race: 83% white 12% black 5% other or multiple races By ethnicity: 3% Hispanic

5. Development of Indicators In 2007, CDC’s Public Health Work Group developed 45 preconception health indicators that could be measured at the state level Ohio created a data book using the 37 indicators for which data were available 4 chosen from this data book to examine racial/ethnic disparities in Ohio

6. Indicators to Describe Racial and Ethnic Disparities in Preconception Health in Ohio IndicatorYears Examined Unintended pregnancy2006-2008 High pre-pregnancy BMI2006-2008 Diabetes2004-2008 STD diagnoses2006-2008

7. Background Unintended Pregnancy Associated with high risk maternal behaviors and late entry into prenatal care More than half of women in the U.S. have had an unintended pregnancy by age 45 3 Socioeconomic factors may explain some of racial/ethnic disparities seen among women with unintended pregnancies 4 3 Frost JJ, Darroch JE, Remez L. Improving Contraceptive Use in the United States. In Brief, New York: Guttmacher Institute, 2008, No. 1. 4 Cubbin C, et al. Socioeconomic and Racial/Ethnic Disparities in Unintended Pregnancy Among Postpartum Women in California. Matern Child Health J. 2002 Dec; 6(4): 237-46.

8. Background Pre-Pregnancy Obesity Obese women more likely to: Enter pregnancy with chronic medical conditions and have additional problems in following years Have baby with neural tube or heart defects at birth Racial/ethnic disparities seen among obese women, with non-Hispanic black women having the highest prevalence 5 5 Wang Y, Beydoun MA. The Obesity Epidemic in the United States – Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Johns Hopkins Bloomberg School of Public Health. Epidemiologic Reviews. Volume 29; 2007.

9. Background Diabetes and Gestational Diabetes Women with diabetes have higher risk for other health complications. Baby also at risk for neural tube defects. Gestational diabetes associated with macrosomia and cesarean delivery Mother has increased risk of developing Type 2 diabetes later in life Nationally, diabetes is the 4 th leading cause of death for non-white women 6 6 CDC. Diabetes and Pregnancy. 2009 Nov. Available at http://www.cdc.gov/Features/DiabetesPregnancy.

10. Background Sexually Transmitted Diseases Chlamydia 2.8 million cases in U.S. each year Can cause infertility, pelvic inflammatory disease and ectopic pregnancy if untreated Gonorrhea Concern about antibiotic-resistant strains Similar risks to chlamydia if untreated Syphilis 40% of pregnancies with untreated syphilis result in fetal death Transmission rate between mother and infant is high Risks to infant include brain damage, blindness, and bone deformities

11. Methods 4 indicators from Ohio’s preconception health data book were used Chose indicators with known racial/ethnic disparities nationally to see how Ohio compares Examined Ohio women ages 18 through 44 by race/ethnicity

12. Data Sources 1) Ohio Pregnancy Risk Assessment Monitoring System (PRAMS) Population-based survey that monitors maternal behaviors and experiences before, during and shortly after pregnancy 2) Ohio Behavioral Risk Factor Surveillance System (BRFSS) Random-digit dial telephone survey that tracks health and risk behaviors of adults 18 years and older 1) Ohio Pregnancy Risk Assessment Monitoring System (PRAMS) Population-based survey that monitors maternal behaviors and experiences before, during and shortly after pregnancy 2) Ohio Behavioral Risk Factor Surveillance System (BRFSS) Random-digit dial telephone survey that tracks health and risk behaviors of adults 18 years and older Descriptive statistics calculated as proportions and/or frequencies using weighted survey methods 95% confidence intervals calculated Data are self-reported

13. Data Sources (continued) 3) Ohio STD Surveillance Tracks syphilis, gonorrhea, and chlamydia in Ohio. Provides data used to help prevent the spread of STDs 3) Ohio STD Surveillance Tracks syphilis, gonorrhea, and chlamydia in Ohio. Provides data used to help prevent the spread of STDs Data collected from health care providers and testing sites Rates of diagnoses calculated per 100,000 women ages 18-44 using Census estimates

14. Results

15. Ohio Women Having a Live Birth Whose Pregnancy Was Unintended n=4252 CharacteristicPercent95% CI Mothers Age 18-4445.043.0-47.0 Race/Ethnicity Non-Hispanic White39.837.5-42.2 Non-Hispanic Black69.066.1-71.8 Hispanic54.942.9-66.3 Non-Hispanic Other46.336.9-56.1 Source: 2006-2008 Ohio Pregnancy Risk Assessment Monitoring System, Center for Public Health Statistics and Informatics, Ohio Department of Health, 2010.

16. *Based on self-reported height and weight. Overweight defined as having BMI ≥ 25 kg/m 2 but less than 30 kg/m 2. Obese defined as having BMI ≥ 30 kg/m 2. Error bars equal 95% confidence interval for each year Source: Ohio Pregnancy Risk Assessment Monitoring System, Center for Public Health Statistics and Informatics, Ohio Department of Health, 2010.

17. Ohio Women Who Were Overweight or Obese Prior to Pregnancy* n = 4308 *Based on self-reported height and weight. Overweight defined as having BMI ≥ 25 kg/m 2 but less than 30 kg/m 2. Obese defined as having BMI ≥ 30 kg/m 2. Source: 2006-2008 Ohio Pregnancy Risk Assessment Monitoring System, Center for Public Health Statistics and Informatics, Ohio Department of Health, 2010. CharacteristicPercent95% CI Mothers Age 18-4445.143.1-47.1 Race/Ethnicity Non-Hispanic White43.641.3-46.0 Non-Hispanic Black57.554.4-60.6 Hispanic45.834.2-57.8 Non-Hispanic Other30.222.1-39.6

18. Ohio Women Diagnosed with Diabetes (Including Gestational Diabetes)* *Women who have ever been told by a health care provider that they had diabetes, including gestational diabetes (self-reported) Source: 2004-2008 Ohio Behavioral Risk Factor Surveillance System, Center for Public Health Statistics and Informatics, Ohio Department of Health, 2010. CharacteristicPercent95% CI Women Age 18-445.64.8-6.4 Race/Ethnicity Non-Hispanic White5.14.3-5.9 Non-Hispanic Black8.56.0-11.0 Hispanic4.01.8-6.1 Non-Hispanic Other8.33.3-13.3 n = 8,548

19. *Rate per 100,000 women ages 18-44 calculated using U.S. Census estimates for that year. Source: 2006-2008 STD Surveillance, Ohio Department of Health. Data reported as of October 8, 2010.

20. *Rate per 100,000 women ages 18-44 calculated using U.S. Census estimates for that year. Source: 2006-2008 STD Surveillance, Ohio Department of Health. Data reported as of October 8, 2010.

21. *Rate per 100,000 women ages 18-44 calculated using U.S. Census estimates for that year. Source: 2006-2008 STD Surveillance, Ohio Department of Health. Data reported as of October 8, 2010.

22. Syphilis Diagnoses Among Young Women Age 18-24 By Race, Ohio, 2006-2008 *Rate per 100,000 women ages 18-24 calculated using U.S. Census estimates for that year. Source: 2006-2008 STD Surveillance, Ohio Department of Health. Data reported as of May 12, 2011.

23. Discussion Understanding how racial/ethnic disparities affect preconception health can help public health administrators effectively plan and implement programs and policies to target those most in need For the indicators studied, black and Hispanic women had generally poorer preconception health than white women But further studies needed to determine reasons for racial/ethnic disparities

24. Next Steps Created Ohio Gestational Diabetes Mellitus Team and the Ohio Collaborative to Prevent Infant Mortality to focus on improving health care Block Grant state performance measure designed to monitor and evaluate preconception health care efforts Share results with state programs (STD, diabetes prevention) to more effectively target high risk populations

25. Acknowledgements ODH Center for Public Health Statistics and Informatics Connie Geidenberger, PhD Carrie A. Hornbeck, MPH Brandi Bennett Holly Sobotka, MS ODH STD Surveillance Program Rhiannon Richman, MPH

26. Thank you! Melissa VonderBrink, MPH Ohio Department of Health Center for Public Health Statistics and Informatics 246 N. High St. Columbus, OH 43215 (614) 644-0190 missy.vonderbrink@odh.ohio.gov