Prenatal Care and Birth Outcomes Among Latina Women: What Do We Know

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Prenatal Care and Birth Outcomes Among Latina
WomenWhat Do We Know?

• Oregon Latina Prenatal Summit
• Providence St. Vincents Hospital
• September 19, 2003
• Michael McGlade, PhD
• Western Oregon University
• Salem, Oregon
• Somnath Saha, MD, MPH
• Portland VA Medical Center
• Portland, Oregon

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Goal to examine data and research that suggest
paths towards the expansion of prenatal care for
Latinas, given the current fiscal environment
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BASIC DEMOGRAPHY OF OREGON LATINOS
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Why did the Latino population grow more rapidly
in Oregon than other PNW states?

• Oregons 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.

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Oregon Latinos

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

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Oregon Latinos (cont.)

• are growing more rapidly than any other major
  ethnic group in Oregon
• currently comprise nearly 9 of Oregons total
  population, but are 16 of total births
• births more than doubled in past decade
• are more youthful and have higher birth rates
  than the other major ethnic groups

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THE LATINA EXPERIENCE DURING PREGNANCY
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Disparities in 1st-trimester Prenatal Care
Oregon PRAMS 2000
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Barriers to Getting Prenatal Care

• Low income
• Lack of insurance
• Documented status related fears
• Low levels of formal education
• Lack of awareness of prenatal care or need for
  prenatal care
• Cultural differences
• Language
• Discrimination

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Lack of Insurance
At the time of your 1st pregnancy test, were you
insured for prenatal care?
Oregon PRAMS 2000
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Barriers to Early Prenatal Care
Oregon PRAMS 2000
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Lack of Perceived Need
Did you get prenatal care as early as you wanted?
Oregon PRAMS 2000
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Life Events Before/During Pregnancy
Oregon PRAMS 2000
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Life Events Before/During Pregnancy
Oregon PRAMS 2000
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Who Is Providing Prenatal Care?
Where did you go most of the time for prenatal
care?
Oregon PRAMS 2000
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Participation in WIC
How many weeks pregnant at time of 1st WIC visit?
Weeks
Oregon PRAMS 2000
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Discrimination in Prenatal Care
Do you think you were treated differently by
health care providers during prenatal care, labor
or delivery because of your
Oregon PRAMS 2000
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LATINA BIRTH OUTCOMES A MIXED PICTURE
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Maternal and Infant Outcomes

• 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

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BUT

• 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
• ANDwhen compared to African-American women with
  similar income, Latinos have
• Much lower rates of LBW
• Much lower rates of infant mortality

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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 did
• Prenatal 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. 200011243-257

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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 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 Gynecology2000182233-239

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Useful knowledge about the context of Latina
births
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Why Latinas overall do not have worse birthing
outcomes, given their high rates of poverty, lack
of access to prenatal care, and other
disadvantages

• Informal prenatal care systems
• Cultural protective factors

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What are informal prenatal care systems?

• Supportive grandmothers and other maternal
  figures
• Helpful extended family members and other
  community people
• Life partners
• Community-based parteras and health promoters
• Others outside of the wage economy who provide a
  context for healthy maternity

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Systems of Care and Support for Latina Mothers
INFORMAL
FORMAL
community health workers
immediate family
clinics
extended family
clinicians
promotores
friends
hospitals
parteras
trusted community members
birthing centers
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Informal Systems of Care Make a Difference

• 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)

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Informal systems of care combine with cultural
protective factors, including

• healthy dietary traditions
• strong cultural approval and support of maternity
• the expectation of self-sacrificing motherhood
  (marianismo)
• the cultural prohibition of unhealthy behaviors
  for mothers such as drinking and smoking

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The beneficial effects of cultural protective
factors and informal systems of care tend to
erode with acculturation to the descending limb
of US mass cultureBirthing outcomes worsen,
and the formal medical system ends up picking up
some of the costs.
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Negative Effects of Acculturation

• 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
  1994139184-192

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• 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.
• 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. 200111722-731

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CONCLUSIONS

• Formal and informal prenatal care improve
  birthing outcomes
• Acculturation 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!