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Eliminating RacialEthnic Disparities in Preterm Births: Is MCH Up to the Challenge

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Male Involvement. Racial and Ethnic Disparities. Births to Unmarried Mothers ... Puberty. Interconception. Care. Primary Care. for Adolescents. Early ... – PowerPoint PPT presentation

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Title: Eliminating RacialEthnic Disparities in Preterm Births: Is MCH Up to the Challenge


1
Eliminating 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

2
Preterm Birth
  • A leading cause of infant mortality long-term
    disabilities

3
Racial Ethnic DisparitiesPreterm Births lt 37
Weeks
Percent of Live Births
17.6
10.8
Year 2010 Goal
NCHS 2003
4
Racial Ethnic Disparities Very Preterm Births
lt 32 Weeks
Percent of Live Singleton Births
3.5
Year 2010 Goal
1.2
NCHS 2002
5
Racial Ethnic DisparitiesInfant Mortality,
United States
Deaths Per 1,000 Live Births
13.5
Year 2010 Goal
5.7
NCHS 2003
6
Racial 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
7
Racial Ethnic DisparitiesPreterm Birth
Percent of Live Births
Year 2010 Goal
NCHS 2002
8
Preterm Birth
  • What causes preterm birth?

9
Preterm Birth
  • Multifactorial

10
Society/Policy
Neighborhood/Community
Interpersonal
Individual
11
Preterm Birth
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
12
Racial 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
13
Racial Ethnic DisparitiesStress and CRH in
Pregnancy
Levels of Corticotropin Releasing Hormone (CRH)
P lt0.001
14
Preterm BirthInfection
Choriodecidual bacterial Colonization (endotoxins
and exotoxins)
Preterm Delivery
Goldenberg 1998
15
Preterm Birth
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
16
Preterm Birth
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
17
Preterm Birth
Family
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
18
Preterm Birth
Housing Instability
Social Capital
Neighborhood Violence
Residential Segregation
Lack of Social Services
Partner
Family
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
19
Preterm 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
20
Racial Ethnic DisparitiesVery Low Birth Weight
Racism
20
P lt 0.01
12
21
Preterm 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
22
Preventing 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

23
Preventing 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)

24
Preventing Preterm Birth
  • A multi-level approach

25
Preventing Preterm Birth
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
26
Preventing Preterm Birth
  • Screen for infections
  • STIs
  • RTIs
  • Asymptomatic bacteriuria
  • Periodontal infections

Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
27
Preventing Preterm Birth
  • Screen for infections
  • STIs
  • RTIs
  • Asymptomatic bacteriuria
  • Periodontal infections
  • Screen for
  • Maternal depression
  • Intimate partner violence

Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
28
Preventing 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
29
The Breakthrough Series
30
Unfair Treatmentin Prenatal Care
Percent reporting received advice about
P lt 0.001
17.6
Kogan 1994
31
Preventing Preterm Birth
Male Involvement
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
32
Racial and Ethnic DisparitiesBirths to Unmarried
Mothers
Percent of Live Births
Source NCHS 1999
33
Preventing Preterm Birth
Family Resource Center
Family
Partner
Infectious/ Immunologic
Neuroendocrine
Behavioral
Preterm Birth
34
Preventing Preterm Birth
  • One Hundred Intentional Acts of Kindness toward
    Pregnant Women
  • Healthy African
    American Families II

35
Preventing Preterm Birth
Increase Social Capital
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
36
Preventing Preterm Birth
Improve Community Infrastructure
Lack of Social Services
Social Capital
Partner
Family
Neuroendocrine
Infectious/ Immunologic
Behavioral
Preterm Birth
37
Preventing Preterm Birth
  • Healthy Births Learning Collaborative
  • Los Angeles Best Babies Collaborative

38
Preventing 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
39
Preventing 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
40
Preventing 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
41
Preventing 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

42
Preventing 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

43
Life Course Perspective
White
Reproductive Potential
African American
Pregnancy
Age
Lu Halfon (2003)
44
Life Course Perspective
White
Reproductive Potential
African American
Pregnancy
Age
Lu Halfon (2003)
45
Life Course Perspective
White
Good Birth Outcome
African American
Poor Birth Outcome
0
5
Age
Puberty
Pregnancy
46
Life Course Perspective
White
African American
Prenatal Care
Interconception Care
Preconception Care
0
5
Age
Pregnancy
Puberty
Lu Halfon 2003
47
Preventing 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

48
Preventing 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
49
Preterm 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
50
Eliminating Racial-Ethnic Disparities in Preterm
Births
  • Is MCH Up to the Challenge?

51
Eliminating Racial-Ethnic Disparities in Preterm
Births
Knowledge Base
Social Strategies
Political Will
Richmond Kotelchuck
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