Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
MICHAEL CLEMENT: Thank you. Is this positioned right? Okay. Today I’m going to be talking about maternal health totally in Arizona with some reference to national. The sources for this are Arizona Vital Records, Arizona Hospital DRGs, Records, and the National Vital Statistics System. In Arizona, there were a little over 88,000 live infants born in 2002. This slide shows the racial and ethnicity of women delivering in Arizona in 2002, and a couple things to note on this. First of all, our black population is quite small. The Native American is fairly extensive, being about 6.5 percent of deliveries. The Caucasian/Hispanics make up about 42 percent, and Caucasian/Non-Hispanics about 43. One thing to note is that the foreign born Hispanics--that green one--is extensive and makes up, now, about 25 percent of all live births in Arizona are to foreign born Hispanics, considerably more than U.S. Born. This has changed over the last 12 years, and you’ll note that the Hispanics now total 42 percent of all deliveries, and in 1990 it was 28 percent, and the increase is due primarily to the influx of immigrant Hispanic women who are delivering in the state. Access, which is the Arizona Medicaid program, in 2002 paid for about 50 percent, just under 50 percent of deliveries, which is up from 1989. The current level of eligibility is 140 percent of federal poverty level, and I believe it was the same in 2002.
Well, what are some of the Maternal Health indicators that I looked at? I looked at DRG records because there are more diagnoses and things shown on them than there are on birth records, and then I also used birth records because there’s a better ethnic breakdown on them than there is on the DRG records and I could also compare them to national data. This is a very busy slide and I apologize for that, but it is 22 morbid conditions that are found on the DRG records. And the first two on the left, if you add those together, those are infection, and you can see that about 3.6 percent, something like that, of women in Arizona--maternal women--end up with an infection. The next one is way high and that’s hypertension, which includes eclampsia, and that’s 77 per thousand or almost eight percent of women delivering in Arizona or hypertensive. Over a few points, you’ll find three that are hemorrhage antepartum, intrapartum, and postpartum, and they, again, make up a rather substantial number of women.
Then partway through the slide--I’m sorry I can’t point at both the screens, but over here is diabetes, and both women with diabetes non-pregnant and gestational diabetes. And again, added together, they are quite substantial. The next three columns, large columns, are other complications that are hard to classify where the woman was sick with something else prior to pregnancy and it is complicating the pregnancy, or there were problems at labor and delivery. And the last large column is inadequate prenatal care. On this, it’s about 56 per thousand; by birth certificates, it’s 68 per thousand. So there was more shown as inadequate on the birth certificate than on the DRG record. Now this slide shows mortality associated with those conditions, and I have lumped, on this slide, things together so there is one column for infection, for example. And on this slide you’ll note that hypertension, infection, and hemorrhage accounted for over 50 percent of the maternal deaths. And while those sound like they might be high, the incidents of these conditions is high, but the mortality rate is less than one per thousand, and there were also two associated with inadequate prenatal care, two deaths. On the other hand, pulmonary embolism, obstetric pulmonary embolism has a very low incidence of only two-tenths per thousand, but a very high mortality rate.
Now if you look at these by ethnicity, and this is again from DRG--I’m looking at those 22 conditions--what we see is that black women had the highest rate for 11 of those conditions, which indicates to me a high degree of poor maternal health in this group. Native Americans were highest in sixth, Caucasians, three, and Hispanics, only one. So I’m getting the impression that the Hispanic population, in terms of maternal health, is pretty healthy. If you look at this in terms of age, you have a classic “U” shape, and the sickest women, if you will, are the youngest and the oldest, and there’s no surprise there. Now I went to the birth certificates. Now the birth certificates, I looked at three things: maternal diabetes, hypertension, and anemia. And the incident rates on the birth certificates is less than on the DRG for all of these conditions, but the ethnic breakdown is better and I could compare them to national figures. Look at this in terms of Native Americans and diabetes: sky high, way high. None of the others are statistically significant one from another, but the Native Americans are off the chart, and there is one of the Arizona tribes that now over 50 percent of their adult members have diabetes, and this is growing in, I believe, all tribes in the state right now.
This is Arizona compared to national data, and you’ll see that we are lower overall and lower for the other ethnic groups with the exception of the Native Americans, where we’re higher. This is maternal hypertension, including eclampsia. And again, you’ll note that the Native Americans are highest and blacks and Caucasians are quite high, but look at the foreign born Hispanics--by far the lowest. They are statistically significantly lower than anybody else. If you look at hypertension compared nationally, we see that we are lower overall, not by a lot, except for the Native Americans. Maternal anemia is even more striking in terms of the foreign born Hispanics. They are way low compared to anybody else, and again, black and Native Americans are the highest. Nationally: we are lower across the board than the national averages. I would also say that maternal mortality in Arizona is higher in blacks and Native Americans. Their rate is higher than the other groups, and disproportionate to the population. So apparently, from this data, the best time to have a child is between ages 20 and 34, and if you’re a foreign born Hispanic, you may in fact be in the healthiest ethnic group in Arizona. Now what about pregnancy outcome and maternal health?
The ultimate outcome, of course, is mortality, and this slide shows infant mortality based on race and ethnicity. The red column is Caucasian women, non-Hispanic, ages 20 through 34 with 13 plus years of education. We have thought as epidemiologists that this was the gold standard that which we would all try to shoot for in terms of reducing infant mortality. Look at foreign born Hispanics right next to that: very, very close. And blacks are way high. Now this is 1998 data, but the current data is basically the same in terms of the relationships. The numbers are a little bit different, but the relationships are the same. Infant mortality is a broad time period, almost two years, in terms of when does risk occur and when does death occur because we’re talking about death for a year after the baby’s birth, and the risk may actually occur any time after conception. So in order to look at this more closely to find out when is the greatest period of risk, we do a--and I know many of you are familiar with this--a perinatal period of risk, and when we do that in Arizona, we find that the maternal health period of risk is, by far, the highest period of risk for these infants, which indicates that maternal health is indeed a major problem and probably the major problem contributing to infant morality.
Incidentally, if you break this down further, foreign born Hispanics again have a very low, lower than this, rate of maternal risk. The fetal death rate, another indication of poor maternal health, is climbing in Arizona, although we do have some problems with that database. Low birth weight has been climbing for over 20 years until the last three years, and so if you just look at this, you think, “Boy, we’re making wonderful improvements and this is good.” Well, not so fast. The low birth weight rate is lowest for foreign-born Hispanics and highest for blacks, as you see here. And remember, 25 percent of all births in the state now are foreign born Hispanics. This slide shows what’s happened with these ethnicities over time. The top line is blacks, and you can see that that’s basically unchanged in over 20 years. The next line is--can’t read that. In any event, the next three lines are Native Americans, U.S. born Hispanics, and Caucasian/Non-Hispanics, and they have all basically continued this up slide. But the bottom line is foreign born Hispanics and they have made flat and low for this entire period of time, and if you do the math, you’ll find that this drop in the last three years is totally due to the increasing numbers of foreign born Hispanics with their low rate of low birth weight rate. So we’re really not accomplishing much, and if we want to just look at statistics, we ought to open our borders a little wider so we can get this down more.
Now one of the questions is what is so different between the U.S. born women and their ethnic foreign-born counterparts? And reviewing the literature, I was able to find nine differences. The foreign born woman has better nutrition than her U.S. born counterpart, she smokes less, she uses drugs less-illegal drugs, she’s less likely to be unwed, she works less outside the home, she has better family support, she has less stress in her life, she uses alcohol less, and she has a greater degree of religiosity. Does this tell us something? Should we be looking at these factors more in terms of other women? In summary, immigration is having a very significant impact on maternal and child health in the state of Arizona. It is apparent that the healthiest mothers are having the best infant outcomes. And are there lessons to be learned from immigrant mothers? Are we fouling our nest? I wonder. Thank you.