Title: Eliminating RacialEthnic Disparities in Preterm Births: Is MCH Up to the Challenge
1Eliminating Racial-Ethnic Disparities in Preterm
BirthsIs MCH Up to the Challenge?
- Michael C Lu, MD, MPH
- Assistant Professor
- Department of Obstetrics Gynecology
- Department of Community Health Sciences
- Center for Healthier Children, Families,
Communities - UCLA Schools of Medicine Public Health
2Preterm Birth
- A leading cause of infant mortality long-term
disabilities
3Racial Ethnic DisparitiesPreterm Births lt 37
Weeks
Percent of Live Births
17.6
10.8
Year 2010 Goal
NCHS 2003
4Racial Ethnic Disparities Very Preterm Births
lt 32 Weeks
Percent of Live Singleton Births
3.5
Year 2010 Goal
1.2
NCHS 2002
5Racial Ethnic DisparitiesInfant Mortality,
United States
Deaths Per 1,000 Live Births
13.5
Year 2010 Goal
5.7
NCHS 2003
6Racial Ethnic DisparitiesPreterm Births,
1965-1998
Percent
Black
White
Preterm is less than 37 weeks gestation Source
National Center for Health Statistics, final
natality data Prepared by March of Dimes
Perinatal Data Center, 2000
7Racial Ethnic DisparitiesPreterm Birth
Percent of Live Births
Year 2010 Goal
NCHS 2002
8Preterm Birth
- What causes preterm birth?
9Preterm Birth
10Society/Policy
Neighborhood/Community
Interpersonal
Individual
11Preterm Birth
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
12Racial and Ethnic Disparities Stress Preterm
Birth
Mother
Placenta
Fetus
Stress
Hypothalamus
Hypothalamus
CRH
CRH
CRH
Pituitary
Pituitary
ACTH
ACTH
Adrenal
Adrenal
Cortisol DS
Estriol
Cortisol Norepineprhine
Liver
16 alpha OH DS
Adapted from Hobel 1998
13Racial Ethnic DisparitiesStress and CRH in
Pregnancy
Levels of Corticotropin Releasing Hormone (CRH)
P lt0.001
14Preterm BirthInfection
Choriodecidual bacterial Colonization (endotoxins
and exotoxins)
Preterm Delivery
Goldenberg 1998
15Preterm Birth
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
16Preterm Birth
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
17Preterm Birth
Family
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
18Preterm Birth
Housing Instability
Social Capital
Neighborhood Violence
Residential Segregation
Lack of Social Services
Partner
Family
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
19Preterm Birth
Child Support
Employment Safeguards
Institutional Racism
Housing Instability
Social Capital
Neighborhood Violence
Residential Segregation
Lack of Social Services
Partner
Family
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
20Racial Ethnic DisparitiesVery Low Birth Weight
Racism
20
P lt 0.01
12
21Preterm Birth
Child Support
Employment Safeguards
Institutional Racism
Housing Instability
Social Capital
Neighborhood Violence
Residential Segregation
Lack of Social Services
Partner
Family
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
22Preventing Preterm Birth
- Clinical risk factors
- Cervical measurement
- Home uterine activity monitoring
- Biochemical markers
- Smoking cessation programs
- Nutritional interventions
- Preterm birth education programs
- Bedrest
- Hydration
- Cerclage
- Tocolysis
- Antibiotics
- Progesterone
- Psychosocial support
- Home visits
23Preventing Preterm Birth
- Most interventions designed to prevent preterm
birth do not work, and the few that do, are not
universally effective and are applicable to only
a small percentage of women at risk for preterm
birth. -
-
Goldenberg et al (1998)
24Preventing Preterm Birth
25Preventing Preterm Birth
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
26Preventing Preterm Birth
- Screen for infections
- STIs
- RTIs
- Asymptomatic bacteriuria
- Periodontal infections
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
27Preventing Preterm Birth
- Screen for infections
- STIs
- RTIs
- Asymptomatic bacteriuria
- Periodontal infections
- Screen for
- Maternal depression
- Intimate partner violence
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
28Preventing Preterm Birth
- Screen for
- Nutrition
- Maternal smoking
- Environmental smoking
- Substance use
- Screen for infections
- STIs
- RTIs
- Asymptomatic bacteriuria
- Periodontal infections
- Screen for
- Maternal depression
- Intimate partner violence
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
29The Breakthrough Series
30Unfair Treatmentin Prenatal Care
Percent reporting received advice about
P lt 0.001
17.6
Kogan 1994
31Preventing Preterm Birth
Male Involvement
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
32Racial and Ethnic DisparitiesBirths to Unmarried
Mothers
Percent of Live Births
Source NCHS 1999
33Preventing Preterm Birth
Family Resource Center
Family
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
34Preventing Preterm Birth
- One Hundred Intentional Acts of Kindness toward
Pregnant Women - Healthy African
American Families II
35Preventing Preterm Birth
Increase Social Capital
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
36Preventing Preterm Birth
Improve Community Infrastructure
Lack of Social Services
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
37Preventing Preterm Birth
- Healthy Births Learning Collaborative
- Los Angeles Best Babies Collaborative
38Preventing Preterm Birth
Build Cross-Sectoral Collaboration
Housing Instability
Residential Segregation
Lack of Social Services
Neighborhood Violence
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
39Preventing Preterm Birth
Policy Advocacy
Employment Safeguards
Child Support
Housing Instability
Residential Segregation
Lack of Social Services
Neighborhood Violence
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
40Preventing Preterm Birth
Undo Racism
Institutional Racism
Employment Safeguards
Child Support
Housing Instability
Residential Segregation
Lack of Social Services
Neighborhood Violence
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
41Preventing Preterm Birth
- Improve content quality of prenatal care
- Outreach case management
- Male involvement program
- Family resource center
- Increase social capital (e.g. One Hundred Acts)
- Improve community infrastructure
- Build cross-sectoral collaboration
- Policy advocacy
- Undo racism
42Preventing Preterm Birth
- Clinical risk factors
- Cervical measurement
- Home uterine activity monitoring
- Biochemical markers
- Smoking cessation programs
- Nutritional interventions
- Preterm birth education programs
- Bedrest
- Hydration
- Cerclage
- Tocolysis
- Antibiotics
- Progesterone
- Psychosocial support
- Home visits
43Life Course Perspective
White
Reproductive Potential
African American
Pregnancy
Age
Lu Halfon (2003)
44Life Course Perspective
White
Reproductive Potential
African American
Pregnancy
Age
Lu Halfon (2003)
45Life Course Perspective
White
Good Birth Outcome
African American
Poor Birth Outcome
0
5
Age
Puberty
Pregnancy
46Life Course Perspective
White
African American
Prenatal Care
Interconception Care
Preconception Care
0
5
Age
Pregnancy
Puberty
Lu Halfon 2003
47Preventing Preterm Birth
- Improve content quality of prenatal care
- Outreach case management
- Male involvement program
- Family resource center
- Increase social capital (e.g. One Hundred Acts)
- Improve community infrastructure
- Build cross-sectoral collaboration
- Policy advocacy
- Undo racism
- Preconception Care
- Interconception Care
48Preventing Preterm BirthA Life-Course Strategy
White
African American
Primary Care for Children
Early Intervention
Prenatal Care
Primary Care for Adolescents
Prenatal Care
Interconception Care
Preconception Care
Womens Health Care
0
5
Age
Pregnancy
Puberty
Lu Halfon 2003
49Preterm Birth
Child Support
Employment Safeguards
Institutional Racism
Housing Instability
Social Capital
Neighborhood Violence
Residential Segregation
Lack of Social Services
Partner
Family
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
50Eliminating Racial-Ethnic Disparities in Preterm
Births
- Is MCH Up to the Challenge?
51Eliminating Racial-Ethnic Disparities in Preterm
Births
Knowledge Base
Social Strategies
Political Will
Richmond Kotelchuck