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Racial Disparity in Infant Mortality Among African American Women in Florida: A Comparative Study
Fran T. Close, Ph.D.Florida A&M University College of Pharmacy
Institute of Public Health9th Annual Summer Public Health
Videoconference on Minority Health
Outline Introduction Background Theoretical Foundation Methodology Results Discussion Conclusions Acknowledgements
Introduction
Infant Mortality Number of deaths within the first 12
months of life
One of the leading measures of the health and social conditions of a community
Affects families across all racial and ethnic groups
Infant Mortality In US African American babies die
2-3 times more often
Large disparity between overall and cause specific rates
Leading causes of infant deaths Congenital malformation
Low birth weight
Sudden Infant Death Syndrome
Maternal complications
Respiratory distress
National Vital Statistics Report, Vol.50, No.4 January 30, 2002
Infant Mortality Rates by Race and Ethnicity
7.014.1
5.8
0
10
20
30
40
50
60
70
80
90 United States
Black/Non-Hispanic
White/Non-Hispanic
Infant Mortality African American infant mortality
rate is four times higher from low birth weight
Respiratory distress and maternal complications are highest among African Americans
BACKGROUND
Reach 2010 Priority Areas Breast and Cervical Cancer Cardiovascular Disease Child and/or Adult Immunizations Infant Mortality Diabetes HIV/AIDS
Florida REACH 2010PURPOSE
To examine the root causes of the disparity in infant mortality rates between African American populations and white populations in Gadsden and Hillsborough Counties
Florida REACH 2010Goal
To involve the African American health care and related communities in planning, developing and implementing interventions to reduce or eliminate disparity in infant mortality rates in Florida
Gadsden County Rural county in Northern Florida
Panhandle
Population (2000): 45,087
African American- 57%
White Population- 39%
Hillsborough County Urban, semi-tropical county on the Gulf
Coast of Florida
Population (2000): 988,948
African American- 15%
White Population- 75%
Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis
Infant Mortality Rates
0
5
10
15
20
25
1999 2000 2001
Florida
GadsdenCounty
HillsboroughCounty
Florida Department of Health, Office of Planning, Evaluation and Data Analysis May 2003
Infant Mortality Rates 1999
7.35.57
13.410.42
28.57
6.51
16.37
0
5
10
15
20
25
30 Florida
Florida White
Florida Black
GadsdenWhiteGadsdenBlackHillsboroughWhiteHillsboroughBlack
Florida Department of Health, Office of Planning, Evaluation and Data Analysis
Infant Mortality Rates 2000
7.05.4
12.6 11.11
20.69
5.56
17.1
0
5
10
15
20
25
30 Florida
FloridaWhiteFloridaBlackGadsdenWhiteGadsdenBlackHillsboroughWhiteHillsboroughBlack
Florida Department of Health, Office of Planning, Evaluation and Data Analysis, May 2003
Infant Mortality Rates 2001
7.35.53
13.511.32
13.86
6.29
17.63
0
5
10
15
20
25
30 Florida
FloridaWhiteFloridaBlackGadsdenWhiteGadsdenBlackHillsboroughWhiteHillsboroughBlack
Infant Mortality Rates (African American)
Hillsborough County: 3 times higher
Gadsden County: 4 times higher
THEORETICAL FOUNDATION
Periods of Risk Model
Total Fetal/Infant Deaths per 1000 Live Births + Late Fetal Deaths = New Measure of Maternal and Infant Health
Maternal Health
Infections Before & During PregnancyNutritionFamily Planning, Birth IntervalsTobacco/Alcohol/Drug UsePrevious Pregnancy OutcomeStress & WorkGeneral State of Mother’s HealthDomestic ViolenceInjuries
Maternal Care
Screening, Risk AssessmentNutrition During PregnancyTobacco/Alcohol/Drug UseLate/Inadequate CareMom’s Ability to Recognize ProblemsRequiring CareRx of InfectionsRecognition/Management of Early Labor
Newborn CareHospital Care, CapabilitiesOB ExpertiseNICU CareRegular Newborn CarePediatric ExpertiseMom’s Ability to care for BabyBreastfeeding, Feeding Issues
Infant CarePrevention & Rx of InfectionsRecognition of Birth DefectsRecognition of Developmental AnomaliesSIDS PreventionFailure to Obtain Well-Child CareFailure to Obtain Follow-up of IllnessPrevention & Rx of Injuries
Fetal and Infant Death Rates by Period of Risk
Late Fetal Death (Gestation > 27 Weeks)
Early Neonatal Death (< 7 Days)
Late Neonatal Death (7-27 Days)
Post-neonatal Death (28-364 Days)
Very Low Birth Weight (<1500 gms)
Maternal Health
Low Birth Weight (1500-2499 grams)
MaternityCare
Newborn Care
Infant Care
Normal Birth Weight (2500+ grams
BWPRate=(Number of deaths in a given weight group)/(Total live births late fetal deaths in all weight groups) X 1000
METHODOLOGY
Florida REACH 2010Partners Florida Department of Health
Gadsden Citizens for Healthy Babies
Healthy Start of Hillsborough County
Central Healthy Start of Hillsborough
Florida State University Center for Prevention and Early Intervention Policy
Florida REACH 2010Partners The Lawton and Rhea Chiles
Center at University of South Florida
Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health
Florida REACH 2010Phase I: Strategies Conduct a targeted community-
specific assessment to examine the disparity
Initiate a community awareness/education campaign
Develop a Phase II Community Action Plan
Community Sites Project Site Manager
Florida A&M University Graduate Research Assistant
Housed at local Healthy Start Coalition Offices
Local Taskforce
Florida REACH 2010 Activities Quantitative data collection
Qualitative data collection
Consumer and Provider Marketing Campaign Plan
Sample African American Women 15-44
Gadsden County- Surveys: 467 Focus groups: 13
Hillsborough County- Surveys: 430 Focus Groups: 14
Instruments
Behavioral
Psychosocial
Socioeconomic/Political
RESULTS
Quantitative Data
Gadsden County Findings
Age of Respondents
19%
19%
20%
15%
26%
0% Under 1818-2122-2526-3031-3536-44over 44
What grade did you complete?
4046.7
8.35
0
10
20
30
40
50
60
70
Per
cen
t
Less than 12thgradeHigh schooldiploma or GEDSome College
Graduated 4years of college
What is your yearly income level?
42.6
31.1
13.1
6.53.7 1.3 1.8
0
10
20
30
40
50
60
70
Per
cen
t
Less than$15,000$15,000-$25,000$26,000-$30,000$31,000-$35,000$36,000-$40,000$41,000-$50,000More than$50,000
Age at First Pregnancy
4.8
18.9
40.5
22.313.2
0
10
20
30
40
50
60
70
80
90
Per
cen
t
> 15 yearsold
15-17years old
18-21years old
< 21 yearsold
neverbeenpregnant
Who is the person you go to most often to get advice about your general health?
69.1
15.1
3.1 5.3
0
10
20
30
40
50
60
70
80
90
Per
cen
t
Doctor
Mother
Grandmother
Friends
Whose advice do you trust most to have a healthy baby?
77.7
13.9
3.4 1 1.9
0
10
20
30
40
50
60
70
80
90
Per
cen
t
Doctor
Mother
Grandmother
Friends
Other
About how often would you say that you use a douche?
24.827.5
11.4
24.1
12.2
0
5
10
15
20
25
30
Per
cen
t
Once a month2 times a month4 times a monthonce in a whilenever
Have you ever experienced discrimination at:
32.1
38.6
16.5
10.6
12.711.3
10.8
28.3
4.1
0
10
20
30
40
Per
cen
t
Work
Store
Bank
Doctor's office
School
Place of recreation
All of the above
None of the above
Other
How much stress in your life has been caused by your experience
with racism?
13.6
21
27.9
36.5
0
5
10
15
20
25
30
35
40
Per
cent
A lot of stressSome stressVery little stressNo Stress
Have you ever had a baby that was born too soon or weighed less than 5 pounds?
17.0
82.0
0
102030
405060
7080
90
Per
cen
t
Yes
No
My relationship with my baby’s father makes me feel:
39.6
20.5 19.9
5.6
14.3
0
10
20
30
40
Per
cen
t
Supported andcared forStressed and notsupportedIt doesn't affectme at allOther
I do not havechildren
Are there any special foods or herbs or homemade medicines that you or other women you know take because you/they think it’s good
for you when you are pregnant?
10.20%
89.80%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Per
cen
t
YesNo
Why do you think that Black babies die in your community at more than 2.5 times the rate of
White infants?(Respondents chose top 3 reasons)
54
31.624.5
6.611.4
61.1
54.8
35.4
4.5
0
10
20
30
40
50
60
70
Per
cent
Lack of Education
Lack of financial support
Lack of emotional support
Stress of discrimination
Stress at work
Poor nutrition
Drug/Alcohol abuse
Lack of health insurance
Other
Is the financial support you get from your baby’s or children’s father?…
27.8 25.3
12.319.8
14.8
0
10
20
30
40
50
60
70
Per
cen
t
A lot
Some
Very little
None
I do not havechildren
Hillsborough County Findings
Age of Respondents
1%17%
16%
17%16%
32%
1%
Under 1818-2122-2526-3031-3536-44over 44
What grade did you complete?
18.8 18.8
31.223.0
8.1
0
10
20
30
40
50
60
70
Per
cen
t
>12th grade12th gradesome college4 year degreegraduate degree
What is your yearly income level?
8.74.8 2.6
10.110.3
30.233.3
0
10
20
30
40
50
60
70
Per
cen
t
>$50,000
$41,000-$50,000$36,000-$40,000$31,000-$35,000$26,000-$30,000$15,000-$25,000<$15,000
Age at First Pregnancy
4.7
22.828
23.8 20.7
0
10
20
30
40
50
60
70
80
90
Per
cen
t
> 15 yearsold
15-17years old
18-21years old
< 21 yearsold
neverbeenpregnant
Who is the person you go to most often to get advice about your general health?
68.9
16.5
2.1
18.6
0
10
20
30
40
50
60
70
80
90
Per
cen
t
Doctor
Mother
Grandmother
Friends
Whose advice do you trust most?
68.9
16.5
2.15.0
0.2 2.4 5.0
0
10
20
30
40
50
60
70
80
Per
cent
Doctor
Mother
Grandmother
Friends
TV/Radio
Books/Magazines
Other
About how often would you say you use a douche?
21.2 19.8
6.7
24.627.7
0
10
20
30
40
50
60
70
80
90
Per
cen
t
1 x amonth2 x amonth4 x amonthOnce in awhileNever
Have you ever experienced discrimination at:
38.1
48.7
14.612.3
27.6
12.516.9
20.6
6
0
10
20
30
40
50
Per
cen
t
WorkStoreBankDoctor's officeSchoolPlace of recreationAll of the aboveNone of the aboveOther
How much stress in your life has been caused by your experience with racism?
6.1
31.933.9
28.1
05
101520253035
Per
cen
t A lot of stressSome stressVery little stressNo Stress
Have you ever had a baby that was born too soon
or weighed less than 5 pounds?
18.8
81.2
0
10
20
30
40
50
60
70
80
90
Per
cent Yes
No
Why do you think that Black babies die in your community at more than 2.5 times the rate of
White infants?(Respondents chose top 3 reasons)
54.3
3225.8
4.97.7
52.7
42.936
3.2
0
10
20
30
40
50
60
Per
cen
t
Lack of Education
Lack of financial support
Lack of emotionalsupportStress of discrimination
Stress at work
Poor nutrition
Drug/Alcohol abuse
Lack of health insurance
Other
Qualitative Data
Gadsden County
Behavioral Douching:
“I douche after my cycle. I started when I was 16 years old.”
“I seen my sister doing it, so I just tried it.”
Behavioral Periodontal Disease
“Every time I was pregnant I had to get a tooth pulled. The first one was a wisdom tooth and the second was a cavity…”
“The dentist would not pull my teeth because I was pregnant.”
Behavioral Home remedies:
“Grandma knows more than the doctor.”
“I would go to my grandmother or mother for a home remedy to prevent using antibiotics during pregnancy.”
Psychosocial Discrimination
“Sometimes at the doctor’s office. I have sat there like 30 minutes and other people come in and they wait on them. So I have just gotten up and left.”
“You don’t get any respect if you do not have insurance or are on Medicaid.”
Psychosocial Stress
“…It is a stress everyday even though I do provide for my children to have what I couldn’t have…”
“Men. They give us a hard time.”
Socio-economics
“ I feel safe in a way and in a way I don’t. Cause it’s so much going on out here.”
“Half the time you have to beg somebody to take you somewhere and you paying them.”
Qualitative Data
Hillsborough County
Behavioral Douching:
“What did [your mom] tell you about douching?” She said to keep your body clean.”
“It keeps women having vaginal discharges and give’ em yeast. So I use douches only periodically.”
Psychosocial Stress
“…If you’re on Medicaid or any kind of assistance for medical procedures they don’t really care.”
“…I know that you’re in pain but do you have your Medicaid number, Medicaid card…”
Psychosocial Stress
“It seems like the stress levels for Black women doubles that of the stress level for any other race. We have a lot more stress to deal with.”
“Because me and my significant other…are so young and we are both trying to start out in life, it put like a lot of stress on the relationship.”
Socio-economics
“ …Sometimes we have to get up financially and hit the pavement running; some that might be able to jump into their cars, but others they might have to walk four blocks and take two buses.”
Socio-economics
“…I think welfare holds you down in a way because say you get a check and then decide to go and get a little part-time job…it doesn’t matter they cut the little money off that you need…you really need that money
Discussion
Contributing Factors Pre-term births and low birth weights (LBW)
Maternal infections
Nutrition factors
Maternal stress
Low socioeconomic status
Pre-term births and Low birth weights Influenced by maternal infections,
maternal age and smoking (Von Der Pool, 1998)
Non-white women (2000:FDOH Office of
Evaluation) Gadsden County: 2-3 times LBW Hillsborough County: 2 times LBW
Maternal Infections-Douching High percentage of the women douche at
least once per month
Learned habit from female family members
Habit formed in adolescence or early teens
Increases risk of Bacterial Vaginosis and Pelvic Inflammatory Disease (Kirshner, 2000)
Maternal Infections- Periodontal Disease Disease of the supporting structures of the
teeth
More common among socio-economically disadvantaged groups
Increase risk of pre-term delivery or low birth weight by 7 times
A risk factor for pre-term LBW and pre-term delivery
Nutrition Anemia higher among African
American women (CDC, 1996)
African American women more likely to be diabetic, hypertensive and obese
Pica
Maternal Stress Increases levels of corticotropin releasing
hormone (Smith, 1999)
Increases the risk of adverse pregnancy outcomes
No variation in reaction or stress type by SES or education status
Discrimination, racism and baby’s father relationship perceived as stressful
Socio-economic Status High SES
higher risk of infant mortality
Low SES poor access to care exposure to environmental hazards poor nutrition high stress
Conclusions
Community Action Plan Primary data sources
Survey data Focus group data
Secondary data sources Florida Vital Statistics Fetal and Infant Mortality Review
(FIMR) Periods of Risk Data
Community Action Plan-Gadsden Peer Support Networks
Consumer Education Program
Environmental Health
Community Action Plan-Hillsborough Research into Black Infant
Mortality
Consumer Education
Stress Reduction Strategies
Florida REACH Consumer and Provider Marketing Campaign Provide awareness
Establish linkages with community leaders, public officials and funders
Develop culturally sensitive materials
Acknowledgements Florida REACH Coalition
Florida Department of Health Gadsden Citizens for Healthy Babies Healthy Start Coalition of Hillsborough
County Central Hillsborough Healthy Start FSU Center for Prevention and Early
Intervention Policy Lawton and Rhea Chiles Center for Healthy
Mothers and Babies FSU Center for Health Equity
Acknowledgements Florida REACH Site Managers Community Taskforces Florida A&M University COPPS/IPH
Dr. C. Perry Brown Dr. Adrienne L. Hollis Dr. Cynthia Harris Ms. Vanisha Brown Mrs. Nichole Jefferson FAMU REACH Graduate Research Assistants
Acknowledgements
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