1. 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

2. 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

3. 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

4. Demographic shift
Similar shift in the characteristics of mothers giving birth in the US and Massachusetts
From , 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%

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

6. 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

7. Methods
All live births from the Registry of Vital Records and Statistics ( )
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)

8. 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

9. 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

10. 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

11. Maternal socio-demographic characteristics by acculturation

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

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

14. Adjusted ORs of breastfeeding initiation by an indicator of acculturation
Reference group: US born * *
0.77 ( ) *
0.73 ( ) * * * *
*NS

15. 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

16. 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