A Common Problem – Uncommon Strategies

August 25, 2003CityMatCH

Vicki Alexander, M.D., MPHMCAH Director, City of Berkeley

Acknowledgements

Poki Namkung, M.D., MPH, Health OfficerJose Ducos, M.D., MPH, EpidemiologistDeborah Greene, M.D., MPH, EpidemiologistDeborah Arthur, MPH, Program ManagerMargaret Thomas, PHN, CPSP CoordinatorHeather Muhr, PA, Highland HospitalSheryl Walton, MPH, CCB CoordinatorKristin Tehrani, MPH, Health EducatorPrenatal Through Preschool Collaborative

Segregation Photo

Age Adjusted Mortality Rates by Race/EthnicityCity of Berkeley, 1998

381.5

353.3

944.8

414.7

431.7

666.6

471.7

450.4

690.9

All Races

White

African American

0.0 200.0 400.0 600.0 800.0 1000.0 1200.0

Rates per 100,000 population

Berkeley

California

U.S.

Source: Berkeley City Health Departmentt, Epidemiology and Health Statistics,Mortality Database, 1998, National Statistics Report, NCHS, July 24, 2000, CDHS.

Racial disparity through the lens of

Breastfeeding…

Consistent disparity in Berkeley WIC Program:-15% of African American

babies are breastfed.-60% of White babies are.

Racial disparity through the lens of immunization (% Up-To-Date at 2nd

birthdate, by race and year)

0

10

20

30

40

50

60

70

80

W H AA

1996

1999

What is Low Birth Weight?

Low Birth Weight (LBW) is defined as a birth weight less than 2,500 grams or 5 and ½ lbs.

Why is Low Birth Weight Important?

Impact on families is seriousCost to School Systems for Special EducationSome children are labeled “learning disabled” and tracked for life Health costs are high - average $50,000 per LBW baby just to get out of the hospital

Why is Low Birth Weight Important?

More likely to have Coronary Heart Disease, hypertension and Insulin Resistance Syndrome as an adultDecreased job skills as an adultIncreased encounters with the Criminal Justice SystemPREVENTABLE

4220

4221

4232

4222

4219

4231

4233 4234

42404239 4238

423742364235

4230 4229

4226

4228 4227

4216

42254224

4223

42184217

4214

4215

4211

42124213

0.2 0 0.2 0.4 Miles

N

EW

S

Census TractsBay

Berk_lin.shp

Low Birthweight0 %0 - 4.87 %4.87 - 6.84 %6.84 - 9.24 %9.24 - 13.66 %

Percent of Low Birthweight Infants by Census TractsCity of Berkeley, 1990-2001

0

2

4

6

8

10

12

14

1988 1990 1992 1994 1996 1998

Per

cent

White/Other African American

American Indian/Eskimo/Aleut Asian/Pacific IslanderHispanic

Percent of Low Birthweight BirthsPercent of Low Birthweight BirthsBy Race/Ethnicity, California 1990-1997By Race/Ethnicity, California 1990-1997

California Department of Health Services 1999

LBW: How does Berkeley compare to other US

cities?

Out of all cities sampled in the U.S. with populations greater than 100,000, Berkeley had the lowest percentage for white LBW babies - 4.16% (aggregate data for three years, 1993-1995)Out of these 162 cities, Berkeley’s African American community had 16.61% LBW, the third worst ranking for all of represented cities

Racial Disparities in LBW for US Cities - 1993-1995

Berkeley

DC

# of cities

Ratio of Black to White Low Birth Weight

4.003.75

3.503.25

3.002.75

2.502.25

2.001.75

1.501.25

40

30

20

10

0

Std. Dev = .33

Mean = 2.04

N = 165.00

Berkeley

DC

Used with permission from Deborah Greene,M.D.,MPH

WHY?

Is it due to more multiple births?

Exclude multiple births and Racial Disparity

Worsens

Black:White Ratio excluding twins and other multiple births =

4.88Blacks are almost five times as likely to have a LBW single birth as Whites

WHY?

Is it Genetic?

Genetics?Racial & Ethnic Disparities

Low Birth Weight & Nativity

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Odd

s of

LB

W

Foreign Born United States Born

African Americans

Cabral 1990

WHY?

Is it due to lack of access to prenatal

care?

Prenatal Care in First Trimester

788082

8486

8890

9294

9698

1997 2001

AALatinaWhite

WHY?

Teen Births?

TEENSBirth Rates Among Adolescent Mothers, 15 to 19 Years Old

City of Berkeley, 1994 - 2001

16.0

13.9

11.9

8.98.0

9.3 8.8 8.8

1994 1995 1996 1997 1998 1999 2000 2001

Year

0.0

5.0

10.0

15.0

20.0

Rates per 1000

Source: Berkeley City Health Department, Epidemiology and Health Statistics; Birth Records, 1994-2001.

Berkeley: 8.5Alameda County: 37.7California: 50.32010 National Objective: None Established

1998-2000:

WHY?

•Income?•Education?

Income and Education

Analyzed eight years of Berkeley birth dataFor the years 1990 through 1997, LBW disparity remains a constantControl for educational background and income accounted for 25% of the disparity

WHY?

•Medical Conditions?•Substance Abuse?

ABMC Medical Record Review

Review of 334 records Older African American women have LBW babies (consistent with national data)African American mothers of LBW babies had substantially higher rates of substance use (Nicotine, illicit drugs) White mothers of LBW babies had histories of selective reductions and multi-substance useControl for substance abuse and medical conditions – accounted for 25% of the disparity

WHY?

Stress?

STRESS

Stress and Preterm Birth

Safety

Preterm Birth

StressLowBirth

Weight

InfantMortality

IntrauterineGrowth

Retardation

Abuse

Health

Relations

Work

Money

Racism

WEATHERING HYPOTHESISThe effect of social inequality on the health of populations compounds with age, leading to growing gaps in health status that can affect fetal health

L B W & V L B W increa se w ith increasing age in b lacks but not in w hites

0

5

10

15

20

25

30

15-19 20-24 25-29 30-34

M ate rnal Age

Per

cen

t L

BW

& V

LB

W

Black White

G eron im us 1996

Racial and Ethnic Disparities

Role of InstitutionsChart reviews and patient surveys (n=334)Differential drug testing of African American women at deliveryDifferential referral of African American women to hospital classes on care of a babyDifferential treatment of African American women with DepoProvera shot as birth control (interferes with milk production)

Role of Prenatal Care Providers

Provider survey to determine what office practices/policies might contribute to LBW – post card, phone call, mailing of questionnaires with self-addressed stamped envelopN=17 responses to intensive questionsPrecursor to Grand Rounds

Provider Responses N = 55“Presentation was informative and educational (N = 39)“I will change my practice based on this presentation.” (Yes = 10)Information was of value in patient education and counseling. (Yes = 15)

Individual Interviews of WIC Clients

N = 16, 10 African American, 6 White1 – 2 hour interviews in the client’s home, monetary incentive givenInterview tool developed by California Pan-Ethnic Health NetworkPerceptions of discriminatory prenatal care in 4/10 African American women, 1/6 White womenCompares to other studies across the nation

What have we done in Berkeley?

Black Infant Health Program – June 2001Centering Pregnancy Program – Jan. 2001Substance abuse training – Jan. 2001Community Action Teams - April 2000

Have these efforts been effective in Berkeley?

Absolutely

Centering Pregnancy Results

Time period: 07/01/01 – 12/30/02Enrolled: 59 women in 6 groupsBerkeley Residents: 27 of 59AA Berkeley Residents: 18 of 27LBW of AA Berkeley Residents: 1 of 18Percent LBW among AA: 5.6%

Black Infant Health Results

Time period: 06/01/01 – 12/30/02Total enrolled and delivered: 39Total LBW: 3Spontaneous abortion: 1LBW % in BIH: 7.7% Overall African American LBW % for the year 2001: 9.4%

LBW in Berkeley – 1990-2001

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

1990-1992 1993-1995 1996-1998 1999-2001

Low Birth Weight Percentage by Race/Ethnicity

Proportion of Low Birthweight (Three Years Averaged) by Race/EthnicityCity of Berkeley, 1990-2001

15.0%16.0%

13.0%13.9%

4.2% 4.2%

5.8%

4.3%3.6%

5.4% 5.1%

4.0%

5.1% 4.9%5.9%

4.0%

1990-1992 1993-1995 1996-1998 1999-2001

0.0%

5.0%

10.0%

15.0%

20.0%

Percent Low Birthweight

African American White Latina Asian/PI

Source: Berkeley City Health Department, Epidemiology and Health Statistics; Birth Records, 1990-2001.

Individual Responsibility?????

Yes, BUT………If you blame Low Birth Weight babies on individual behavior, then you assume.…

Equal accessEqual informationEqual treatment

Does this equality exist?

Does Equality Exist? NO!!

Institute of Medicine Report – April 2002Racial and ethnic disparities in health care exist based on unequal treatment and, because this treatment is associated with worse outcomes in many cases, it is unacceptable

Where do we go from here?

Continue to work with Community Action TeamsContinue Low Birth Weight Team

Maintain existing programsFocus on inter-pregnancy healthIdentify institutional racismEarly identification of congenital abnormalities

Skills we need to apply for COURAGE

C = Commitment – we can do itO = Outspoken – we won’t be afraidU = Understanding and using good judgementR = Responsibility, doing what is right

A = Accountability, action and activistG = Goodness, love, mind, heart and soulE = Effort, willing to work hard and long

Courage to leave no one behind: Ensure Health and Equal Life

Expectancy for ALL