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

2. Disclosures None

3. 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.

4. US population Census Bureau

5. Births in the US, 1990-2005 National vital statistics reports, 2009

6. Latino births in the US (%), 1990-2005 National vital statistics reports, 2009

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

8. National Center for Health Statistics Infant mortality: 1940-1995

9. Infant mortality rate: 1995-2005 National Center for Health Statistics

10. Neonatal mortality rate: Texas, 1970-9 Powell-Griner and Streck, Am J Public Health 1982

11. “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

12. Infant mortality: Harris County Texas, 1974-75 Selby et al, Am J Public Health 1984

13. “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

14. Infant mortality rate, by ethnicity: CA 1990-93 Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

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

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

18. 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

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

20. Low birth weight in the US www.nchs.gov Healthy People 2010 goal

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

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

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

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

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

28. 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

29. Healthy nutrition

30. Micronutrients

31. Nutrition - Obesity http://wellroundedmama.blogspot.com

32. 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?

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

34. 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

35. 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.

36. Ethnicity ≠ Acculturation

37. Immigrants in the US

38. 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

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

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

41. Low birth weight, by birthplace: Latina women in CA, 1992 VLBW OR 0.92 (0.80-1.07) MLBW* OR 0.91 (0.86-0.96) Fuentes-Afflick E, Hessol NA, Perez-Stable EJ, Arch Pediatr Adolesc Med 1998

42. Infant mortality, by birthplace: Latina women CA, 1990-93 Unadjusted OR 1.08 (1.03-1.13)* Adjusted OR 0.88 (0.80-0.97)* Hessol NA, Fuentes-Afflick E, Ann Epidemiol 2000

43. 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

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

45. Social support

47. 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

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

49. Promising areas Acculturation Prematurity Interpregnancy interval

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

51. www.harrycutting.com