Acculturation and maternal health behaviors: findings from the Massachusetts birth certificate Bruce B. Cohen, PhD Massachusetts Department of Public Health Collaborators: Summer Sherburne Hawkins, PhD Boston College Matthew W. Gillman, MD Harvard Medical School and Harvard Pilgrim Health Care Institute Emily F. Shafer, PhD RAND

Background: maternal race/ethnicity Most studies use the standard OMB race/ethnicity categories to identify disparities in maternal health behaviors Vital Statistics uses NCHS categories from Census that include “sub-race” groups that roll up into broad OMB categories White and Hispanic mothers are more likely to start and continue breastfeeding than black mothers White mothers are more likely to smoke during pregnancy than black and Hispanic mothers Mothers from other ethnic groups are usually either combined into an ‘Other’ category or excluded from analyses

Background: acculturation Maternal health behaviors vary by mothers’ country of birth, duration of residence in the US, and language preference Proxies of acculturation: adoption of cultural elements and health-related norms and behaviors of the new dominant culture Foreign-born mothers are less likely to smoke during pregnancy and more likely to start breastfeeding than their native-born counterparts or US born white mothers Duration in the US among foreign-born mothers or preference for English has been associated with poorer health behaviors Most studies have focused on Hispanic mothers and less is known about other ethnic groups, particularly those from new immigrant populations

Demographic shift Similar shift in the characteristics of mothers giving birth in the US and Massachusetts From 1998-2009, a 70% increase in the proportion of births to Asian mothers and 40% increase in the proportion of births to black and Hispanic mothers Percentage of births to foreign-born mothers also increased from 18% to 27%

Proportion of births by maternal ethnicity in Massachusetts, 1996-2009

Research aims To examine the associations of proxies of acculturation with maternal smoking during pregnancy and breastfeeding initiation for each major ethnic group in Massachusetts To demonstrate the value of collecting detailed ethnicity data on birth certificates

Methods All live births from the Registry of Vital Records and Statistics (1996-2009) Standard Certificate of Live Birth Parent Worksheet: Maternal ethnicity, age, marital status, educational attainment Outcome: Maternal smoking during pregnancy (yes/no) Hospital Worksheet: Plurality of birth, parity, delivery source of payment Outcome: “Is mother breastfeeding?” as indicator for breastfeeding initiation (yes/no)

Proxy of acculturation Mothers report their state/country of birth and language preference for health-related materials 3-category proxy for acculturation: US born, foreign-born English speaking, foreign-born non-English speaking 2-category proxy for ethnic groups with fewer than 125 mothers in the foreign born non-English speaking category: US born, foreign born

Maternal ethnicity N=1,067,375 births by mothers from 31 ethnic groups Mothers indicate their ancestry or ethnic heritage from 39 options Mothers from the 8 categories with 1,800 mothers or fewer were included in the relevant ‘Other’ category Race recorded as black and ethnicity as American were recoded as African American ethnicity Mothers who were not African American or Native American were coded as Other American N=1,067,375 births by mothers from 31 ethnic groups

Methods For each ethnic group, logistic regression models examined the association between acculturation and each maternal health behavior Foreign-born English speaking mothers and foreign-born non-English speaking mothers were separately compared with US born mothers (reference group) Models adjusted for the following socio-demographic characteristics: maternal education, age, marital status, plurality, parity, delivery source of payment, year of birth

Maternal socio-demographic characteristics by acculturation

Adjusted ORs of maternal smoking by an indicator of acculturation Reference group: US born * * * *NS

Adjusted ORs of breastfeeding initiation by an indicator of acculturation Reference group: US born * * * * * * * * *NS

Adjusted ORs of breastfeeding initiation by an indicator of acculturation Reference group: US born * * 0.77 (0.64-0.92) * 0.73 (0.56-0.96) * * * * *NS

Discussion and implications Maternal smoking and breastfeeding initiation varied widely across 31 ethnic groups, which would be impossible to see using standard OMB race/ethnicity categories Regardless of mothers’ ethnic identity, acculturation in the US results in poorer maternal health behaviors Public health efforts need to both support the preservation of these positive health-related norms and behaviors from mothers’ original cultures and improve health-related norms in the US

Discussion and implications Collecting detailed ethnicity information on birth (and death) certificates can be a valuable source of data for research, planning, and targeting public health interventions The vital statistics community should continue to expand the use of the data we collect to examine maternal and infant outcomes, behaviors and chronic disease