Minnesota Title V MCH Needs Assessment Fact Sheets

Pregnant Women, Mothers and Infants

Health Disparities in Mothers and Infants

Fall 2004

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Size of the Problem

Over 68,000 births annually are recorded in Minnesota. Twenty-two percent (22%) of these new mothers are racial/ethnic minorities- with 7% African-Americans, 6.8% Hispanic, 5.5% Asian/ Pacific Islanders, and 1.9% American Indian. This represents an estimated 30,000 mothers and babies [1].

Seriousness

People affected by health disparities. Healthy Minnesotans Public Health Improvement Goals 2004, specifies that Minnesota will eliminate the disparities in health outcomes and the health profile of populations of color [2]. Stark differences have been identified in the health status of maternal and infant populations of color. Specific health disparity indicators that are monitored for this age cohort include the following:

Infant Mortality Rates (IMR): Nearly 25% of the 2,000 infants who died during 1995-1999 in Minnesota were from racial and ethnic minorities. Yet minorities make up only 8.8% of the total population.

Minnesota Infant Mortality by Race, 1989-1993 and 1996-2000
  Infant Deaths/1,000 Births
  1989-1993 1996-2000
White
5.2
6.5
Hispanic
6.8
7.3
Asian
7
6.2
American Indian
12
16.5
African American
12.7
16.5
Source: MDH. Populations of Color in Minnesota- Health Status Report Update Summary. Fall 2003.

Neonatal Mortality Rates (NMR): The IMR combines both neonatal and post neonatal infant deaths. Neonatal refers to deaths that occur before the 28th day of life and are often attributed to endogenous causes of death related to the pregnancy such as prematurity and low birth weight (LBW). NMR disparities are especially great between African Americans and whites. The most recent state rates (1996-2000) for African Americans and whites respectively are 8.5 and 3.4 per 1000 live births. African American neonates are 2.5 times more likely to die in their first month than are white neonates. The American Indian NMR is 6.2 indicating that American Indian neonates are 1.8 times more likely to die than white neonates [3].

Low Birth Weight Births by Race/Ethnicity, Singleton Births Under 2500 Grams
  1989-1993 1997-2001
African American
11.5%
9.1%
American Indian
5.6%
5.8%
Asian/P.I.
5.6%
6.4%
Hispanic
4.9%
4.8%
White
3.8%
4%
Source: MDH. Populations of Color in Minnesota- Health Status Report Update Summary. Fall 2003.

Postneonatal Mortality Rates (PNMR): This refers to deaths that occur from 28 to 365 days of life and are likely to be classified as from exogenous or environmental causes such as Sudden Infant Death Syndrome, injuries, or infections. PNMRs are higher for American Indian infants (1996-2000) at 5.7 compared to the white PNMR of 1.7. American Indian infants die at a rate 3.4 times the white rate. The African American PNMR of 4.2 indicates African American infants are dying at 2.5 times the white rate [3].

Maternal Mortality Rates: A retrospective review of maternal mortality in Minnesota, 1990-1999, revealed that African American women died of pregnancy-associated deaths at a rate 2.4 times higher than the white rate. The American Indian women’s pregnancy-associated death rate was 2.8 times the white rate [3].

More uninsured: The Minnesota Health Access Survey of 2001 reported the percent of people of all ages who were uninsured by race/ethnicity for that year. They found that 4.6 percent of whites were uninsured compared to 15.6 percent of Blacks, 16.2 percent of American Indians, and 17.4% of Hispanics [4]. Although many low income women do become eligible for state Medicaid programs when they are pregnant, the lack of insurance coverage before and between pregnancies negatively impacts women’s health.

Higher rates of inadequate or no prenatal care: Minnesota birth certificate data for all births indicates that American Indian pregnant women are five times more likely than white pregnant women to receive late or no prenatal care. African American and Hispanic pregnant women are between 3 ½ to 4 times more likely to receive late or no prenatal care than white pregnant women [5].

Inadequate or No Prenatal Care in Minnesota by Race/Ethnicity, 1989-1993 and 1997-2001
  1989-1993 1997-2001
White
3.3%
3.2%
Hispanic
14.7%
11.2%
Asian
20.6%
9.8%
American Indian
27.2%
17.4%
African American
20.1%
12.4%
Source: MDH. Populations of Color in Minnesota- Health Status Report Update Summary. Fall 2003.

An additional health disparity monitored in Minnesota are rates of diabetes and gestational diabetes. These rates are three times higher among pregnant American Indian women than non-Hispanic white pregnant women in one Minnesota study [6].

Economic
Cost savings for early and adequate prenatal care as documented by the Centers for Disease Control and Prevention (CDC) are $14,755 per pregnant woman (in 1984 dollars) if all US women received adequate prenatal care [7].

The cost-effectiveness of intensive diabetes management preconceptionally and prenatally was found in one California study to save $5.19 for every dollar spent on the program (1990 dollars) [8].

Interventions

Interventions, recommended for pregnant women and infants of all races/ethnicities, have been identified by national and Minnesota experts:

  • The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have collaborated in preparing and publishing Guidelines for Perinatal Care which specifically addresses screening and intervention that should be done as a part of quality prenatal care [9].
  • Minnesota has also benefited from having local standards of prenatal care developed by the Institute for Clinical Systems Improvement [10]. These standards of prenatal care have a strong emphasis on early identification and treatment of medical complications found in pregnancy.
  • The Association of State and Territorial Health Officials issued a policy statement in 2003 that recommends, “expand access to prenatal care services through targeted outreach and intervention” [11].

Effectiveness of Interventions
The 2002 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health, recommended several potentially effective strategies to eliminate disparities in healthcare as follows:

  • Increase awareness of potential bias and stereotyping within the healthcare system and provide cross cultural education to healthcare professionals.
  • Support use of community health workers and multidisciplinary treatment/ preventive care teams;
  • Collect/monitor data on patients’ access and utilization of health care services by race, ethnicity, and primary language.
  • Increase the proportion of racial and ethnic minorities among health professionals to improve access to care and reduce cultural and linguistic barriers to care [12].

The federal Office of Minority Health has developed standards and recommendations for assuring cultural and linguistic appropriate services (CLAS) in health care [13].

Status

Minnesota Resources
Within MDH, the Maternal and Child Health Section (MCH), the Office of Minority and Multicultural Health (OMMH), and the Center for Health Statistics collaborate on a variety of strategies to address perinatal disparities.

  • Eliminating Health Disparities Initiative (EHDI) In 2001, the state legislature allocated $14 million for EHDI. This funded a statewide competitive grants process that succeeded in bringing new partners to the MDH. Many grantees are community-based organizations that serve populations of color and American Indians. Infant mortality and teen pregnancy prevention activities are two of the seven health focus areas that grantees are addressing with innovative and culturally specific solutions.
  • Twin Cities Healthy Start (TCHS) was first funded in 1999 by the federal Maternal and Child Health Bureau (MCHB) to eliminate the disparities in infant mortality experienced by African American and American Indian families in Minneapolis and St. Paul. TCHS’ data demonstrate that the program is having a positive impact on participating families.
  • Save 10 Committee In April, 2002, the CDC reported that of the 60 largest US cities, St. Paul had the 4th highest African American infant mortality and Minneapolis had the 2nd highest Hispanic infant mortality. The OMMH, Center for Health Statistics, and the MCH section of MDH and local public health, TCHS, the Department of Human Services, and the March of Dimes established the Save 10 Committee which has been addressing the issues through various strategies and actions including:
    • African American Infant Mortality Community Conferences held in February 2003 and January 2004 in St. Paul;
    • Development of the Save 10 Community Task Force;
    • Partnership with Minnesota State Colleges and Universities as they plan and implement a community health worker curriculum to provide both an academic and career ladder to increase minority populations’ entry into health professions.
  • Maternity Case Management Project A qualitative survey of the perinatal delivery system in Hennepin and Ramsey counties done in 1999, found that few low income pregnant women were receiving coordinated care and support during pregnancy. The ensuing report concluded that women of color and American Indians were most impacted by these circumstances [14]. The Maternity Case Management Project, led by the Minneapolis Department of Health and Family Support (MDHFS), has a goal to create model care coordination programs within smaller systems of care that serve pregnant women.
  • State Perinatal Plan/Perinatal Health Team In 2003, MDH created an interdivisional Perinatal Health Team and a Perinatal Health Plan which describes perinatal health as part of the continuum of women’s health. The plan focuses on promotion of effective physical and mental health strategies that are population-based, science-based, asset-based, and rooted in cultural common sense.

Community Awareness
The OMMH is hosting a conference in December, 2004, to highlight results from the EHDI.

The Save 10 Community Task Force is attempting to increase awareness in the Twin Cities metro area through participation in community events.

A study of barriers and motivators for prenatal care conducted among low income women in Minneapolis in the late 1980’s determined that the primary reason women delay getting care is their ambivalence about their pregnancy. Other barriers included not being insured and the need for transportation and child care [15].

The current Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) for 2002 will provide more current information on barriers and motivators for pregnant women by their racial/ethnic origin.

In greater Minnesota, a shortage of prenatal providers, long distances to travel, a reluctance to apply for state-funded insurance (even when eligible) have all been identified as barriers [16].

References

1. Minnesota Center for Health Statistics. 2003
2. MDH. Healthy Minnesotans: Public Health Improvement Goals 2004. September 1998.
3. MDH. MN Center for Health Statistics. MCH requested data analysis. 2003.
4. MDH. 2001 Minnesota Health Access Survey. Health Economics Program.
5. MDH. Center for Health Statistics. Populations of color in MN Health status report. Update summary, fall, 2003.
6. MDH. Diabetes among American Indians in Minnesota. January 2001.
7. CDC. An ounce of prevention: what are the returns? October 1999.
8. Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: The cost-effectiveness of the California diabetes and pregnancy program. Am J of Public Health 82(2):168-175.1992.
9. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG). 2002. Guidelines for Prenatal Care. Washington, DC.
10. Institute for Clinical System Improvement. Routine Prenatal Care. 2003. www.ICSI.org Attn: Non-MDH Link
11. Association of State and Territorial Health Officials. State Policy options to Improve Birth Outcomes. October 2003.
12. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. March 2002. National Academy Press. www.nap.edu. Attn: Non-MDH Link
13. US Dept. of Health & Human Services. OMH. Assuring cultural competence in health care. www.omhrc.gov/clas/. Accessed 9-04.
14. MDH & MDHFS. (2002): Falling through the Cracks: An Analysis of Care Coordination for Low Income Pregnant Women in Hennepin and Ramsey Counties.
15. Lia-Hoberg B. et al. Barriers and motivators to prenatal care: experiences of low income women. August 1988.
16. Reports of the St. Louis County (1999) and SE Minnesota (1997-98) Fetal and Infant Mortality Review (FIMR) projects. Available from MDH, MCH Section.