1. Eliminating Racial Disparities in Birth Outcomes Conference on Ending Family Homelessness Workshop: Healthcare Matters: Providing Health Services to Diverse Populations February 7, 2008 February 7, 2008 Susan Barkan, Public Health Seattle & King County Melanie Whitfield, People of Color Against AIDS Network Maria Carlos, Public Health Seattle & King County

2. Acknowledgements Susan Barkan Kathy Carson Maria Carlos Eva Wong Doctoral Student, Department of Epidemiology, University of Washington Alice Park Mei Castor Urban Indian Health Institute Shira Rutman Jim La Roche Leslie RandallNorthwest Portland Area Indian Health Board Leah Henry Native American Women’s Dialog on Infant Tanner Mortality (NAWDIM) Jim GaudinoOregon State Department of Health Parent Child Health, Public Health-Seattle & King County

3. Infant Mortality Rates US, Washington State, King County, Seattle Three Year Rolling Average, 1981-2004

4. Contributions to the Overall Decline in Infant Mortality in King County First Steps First Steps: Maternity support and expansion of Medicaid coverage of prenatal services Safe Sleep: Safe Sleep: Back to Sleep Campaign Medical Advances: Medical Advances: Neonatal intensive care Behavioral: Behavioral: Decline in use of tobacco, alcohol, unintended pregnancies

5. Infant Mortality Rates by Race/Ethnicity, King County, Three Year Rolling Averages, 1985-2004

6. Perinatal Periods Of Risk (PPOR) Approach  A simple approach.  identify gaps in the community.  target resources for prevention activities.  mobilize the community to action.

7. PPOR guides strategies to improve birth outcomes Prematurity and low birthweight lead to infant mortality. Prematurity and low birthweight lead to infant mortality. PPOR method gives information that guides community strategies to help infants be born healthy. PPOR method gives information that guides community strategies to help infants be born healthy.

8. PPOR Findings WA State, 2000-2004 Infant Health is the highest contributor to preventable FIMR among American Indian/Alaska Natives Infant Health is the highest contributor to preventable FIMR among American Indian/Alaska Natives Maternal Health/Prematurity is the highest contributor among African Americans and the second highest contributor among AI/AN. Maternal Health/Prematurity is the highest contributor among African Americans and the second highest contributor among AI/AN. Maternal Care is the third highest contributor to among AI/AN. Maternal Care is the third highest contributor to among AI/AN. Newborn Care is consistently the lowest and is similar for all racial/ethnic groups. Newborn Care is consistently the lowest and is similar for all racial/ethnic groups.

9. Implications/”Opportunity Gaps” Maternal Health/ Prematurity Infant Health Preconception Health Health Behaviors Perinatal Care + EXPAND STRATEGIES to address social factors giving rise to disparities Sleep Position Breast Feeding Injury Prevention Medical Care for Infections and Chronic Conditions

10. Prevalence and Trends in Birth Risk Factors by Race, King County

11. How Stress Can Affect Health:  Increased cortisol (fight/flight hormones) results in increased cardiovascular function  Can lead to high blood pressure, depressed immune function with increased vulnerability to infection, and depression. All of these can contribute to risk of preterm delivery.  These stress responses are designed to help us deal with short term threats, but for many, the stressors don’t go away.  Long-term, chronic stress does not allow for system recovery and predisposes to adverse health effects

14. INSTITUTIONALIZED RACISM/ Historical Trauma Discrimination PovertyAbuse Internalized Racism Health CareHealth Care HousingHousing Legal SystemLegal System EmploymentEmployment Refused care over IHS statusRefused care over IHS status Affordable HousingAffordable Housing Moving frequentlyMoving frequently Adequate EducationAdequate Education EmploymentEmployment Access to Health CareAccess to Health Care Perceived as wealthyPerceived as wealthy STRESS Direct Effects: Endocrine System Response - Increased cortisol levels, decreased immune function, increased vulnerability to infection, trigger onset of labor Indirect Effects: Maternal Behaviors – Smoking, alcohol, substance use, poor nutrition, survival supersedes wellness DISPARITIES IN BIRTH OUTCOME InstitutionalInstitutional InterpersonalInterpersonal CyclesCycles SubstanceSubstance HopelessnessHopelessness Self-hatred and blameSelf-hatred and blame Inability to see family/ community as supportInability to see family/ community as support Ancestry seen as hindrance to life’s goalsAncestry seen as hindrance to life’s goals Mayet Dalila, IntraAfrikan Konnections

15. Indigenist model of trauma, coping, and health outcomes for American Indian women (Walters K. 2002)

16. What more needs to be done:  Continue support of pregnant women’s health care: prenatal care, MSS/ICM, outreach.  Find support for community mobilization efforts  Community collaboration around housing, income equity, access to quality education, access to culturally relevant, culturally appropriate health care...  Decrease the impact of inequalities and racism on women and families through community support.  NAWDIM & Brown Sugar Babies

17. What more needs to be done:  Continue the PPOR analysis and community engagement process to use the data to target prevention efforts and support the work of the community  Need for prevention to focus on preconceptional health, health behaviors, and specialized perinatal care services  Sustained need for early and continuous prenatal care services, referral of high-risk pregnancies and good medical management of medical problems  Continued need for programs that support infant health such as SIDS prevention, access to a medical home, and injury prevention

18. What You Can Do:   Work on adequate housing, income equity, quality education, access to culturally appropriate health & social services.   Provide culturally appropriate mental health services for people of color & low-income folks.   Get training on undoing institutionalized racism Undoing Institutionalized Racism, People’s Institute for Survival & Beyond Undoing Institutionalized Racism, People’s Institute for Survival & Beyond PBS Video: Race: The Power of Illusion PBS Video: Race: The Power of Illusion PBS Video: Unnatural Causes: Is Racism Making Us Sick? (March, 2008) PBS Video: Unnatural Causes: Is Racism Making Us Sick? (March, 2008)   Involve community members, clients, consumers in defining your work. “Injustice anywhere is a threat to justice everywhere.” Martin Luther King, Jr.

19. Thank you!