I Caceres and B Cohen Division of Research and Epidemiology Bureau of Health Information, Statistics, Research and Evaluation Massachusetts Department

I Caceres and B Cohen

Division of Research and EpidemiologyBureau of Health Information, Statistics,

Research and Evaluation

Massachusetts Department of Public Health

Inequalities in Infant Mortality: The Interaction of Race and

Socioeconomic Status

Gateway to the Future:Improving the National Vital Statistics System

St. Louis, MO June 6th – June 10th, 2010

Source of Disparities Influencing Adverse Outcomes

Individual SE status

NeighborhoodAffluence

Race/ethnicityDisparities

AdverseOutcome

Outline

• Study Questions

• Methods

• Background

• Results

• Summary

Study Questions

Do Race/Ethnicity differences in IMR persist after accounting for SES?

Does the difference depend on SES measures used (Birth certificate education vs Census poverty level)?

Is there race variation in infant mortality by education?

Is there ethnicity variation in infant mortality by education?

Is there race variation in infant mortality by level of poverty?

Is there ethnicity variation in infant mortality by level of poverty?

MethodsData sources:

MA Births 2004-2007Census 2000

Study Outcome Infant mortality rate (IMR) Number of deaths within first year of live in a given period per 1000 live births in the same period

MethodsRace: White non-Hispanic (reference group)

HispanicsBlack non-HispanicsAsian non-Hispanics

Ethnicity: 21 ethnicity groups, Euro-American (reference group)Education:

Less than high school (<HS) High school (HS)Associated Degree/Some college (Assoc/some

college) College or graduate (Coll+) (reference group: most educated)

Methods

Area of residence: 11-digit census tractNeighborhood poverty level is the percent of population in census tract below the Census 2000 federally-defined poverty line, four categories are defined:

< 5% (reference: least poor neighborhood) 5- 9.9%10-19.9%20-100%

MethodsDisparities are measured using ratio of rates

for each group to that of the reference group Race Disparities (ref: WNH) Ethnicity Disparities (ref: Euro-American) Education disparities (ref: most educated) Poverty Disparities: (ref: least poor neighborhood)

95% Confidence intervals of ratios are used to identify significant disparities (or excess of risk) compared with that of the reference group

BACKGROUND

Maternal Race: Births vs. Infant Deaths

2% 3%7% 4%

8% 17%

13%

17%

70%59%

Birth Population Infant Deaths

White NH

Hispanic

Black NH

Asian

Other21%

34%

6%

61%

4% 3%2%3%3%

10%

51%

9%

0%

10%

20%

30%

40%

50%

60%

Birth Population

Infant Deaths

Maternal Ethnicity: Births vs. Infant Deaths

5.0

7.0

3.5

4.5

5.5

6.5

7.5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

IMR

(#

dea

ths/

1,0

00 li

ve

bir

ths)

Infant Mortality Rate (IMR)Massachusetts: 1990-2008

* Statistically Significant (p ≤.05) APC = Annual Percentage Change

-5.4%* APC

1996

3.7

6.1

11.7

13.7

7.9

9.1

0

2

4

6

8

10

12

14

16

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

IMR

(#

dea

ths/

1,00

0 liv

e b

irth

s)

White Black Hispanic

IMR by Race & Hispanic Ethnicity Massachusetts: 1990-2008

1.6

0.7

2.5

0 1 2 3 4

Black non-Hispanic

Hispanic

Asian

Race Disparities in IMR by Race

*

*

** * RATIO Statistically higher than 1 (p<.05)

** RATIO Statistically lower than 1 (p<.05)

Excess risk

Ratio of rates in excess to 1(relative to NH Whites)

Reference: White non-Hispanics

12.2

9.0

8.3

8.3

7.1

6.8

6.1

6.0

5.8

4.7

4.1

4.0

3.9

3.7

3.2

2.2

2.2

1.8

4.9

0 2 4 6 8 10 12 14

African Amer

Haitian

Puerto Rican

African

West Indian/Caribean

Cape Verdean

Cambodian

Dominican

Oth Central Amer

All

Portuguese

Euro-American

Salvadoran

Oth Hispanic

Brazilian

Other Asian

Vietnamese

Asian Indian

Chinese

IMR by Ethnicity Massachusetts BirthsInfant deaths per 1000 live births

0 1 2 3 4 5

African Amer

Haitian

Puerto Rican

African

West Indian/Caribean

Cape Verdean

Cambodian

Dominican

Oth Central Amer

Native Amer

Portuguese

Salvadoran

Oth Hispanic

Brazilian

Other Asian

Vietnamese

Asian Indian

Chinese

Middle Eastern

Ethnicity Disparities in IMR

* RATIO Statistically higher than 1 (p<.05)** RATIO Statistically lower than 1 (p<.05)

Excess risk

Reference: Euro-American

Ratio of rates in excess to 1(relative to Euro-American)

**

**

*

*

****

Education, Race, and Infant Mortality

Maternal Education: Births vs. Infant Deaths

10% 17%

25%

33%

22%

21%

42%29%


Coll+

Assoc

HS

<HS50%

2.4

2.0

1.4

0 1 2 3 4

<HS

HS

Assoc

Disparities in IMR by Education

*

*

* * RATIO Statistically higher than 1 (p<.05)

** RATIO Statistically lower than 1 (p<.05)

Excess risk

Ratio of rates in excess to 1(relative to most educated: Coll+)Reference: Coll+

0 1 2 3 4 5

Hispanic

White non-Hispanic

Black non-Hispanic

Asian

<HS

HS

Assoc

Education Disparities in IMR by Race

*

**

*

Excess risk

*

*

Reference: Coll+

*

* RATIO Statistically higher than 1 (p<.05)

Ratio of rates in excess to 1(relative to most educated: Coll+)

0 1 2 3 4

Hispanic

Black non-Hispanic

Asian

<HS

HS

Assoc

Coll+


Disparities in IMR by Race and Education

*

**

** * RATIO Statistically higher than 1 (p<.05)** RATIO Statistically lower than 1 (p<.05)

Excess risk

*

*


Education, Ethnicity, and Infant Mortality

Births by Education and Ethnicity

4%

35%

19% 22% 27%20%

41%

49%52% 41%

22%

18%23% 14% 23%

53%

6% 9% 12% 9%

Euro-American Puerto Rican Dominican Brazilian Cape Verdean

<HS HS Assoc Coll+

% of Total Births (61%) (6%) (2%) (3%) (1%)

Most Educated

Least Educated

Births by Education and Ethnicity

17%10% 9% 8%

1%

40%

33% 35%

15%

6%

28%

27%39%

11%

7%

15%29%

17%

66%

86%

AfricanAmerican

African Haitian Chinese Asian Indian

<HS HS Assoc Coll+

Most Educated

Least Educated

(4%) (2%) (1%) (2%) (2%)% of Total

Births

Infant Deaths by Education and Ethnicity

8%

47%33% 35% 39%

29%

36%52% 43% 33%

21%

17% 12%17%

17%42%

1% 3% 4%11%


<HS HS Assoc Coll+

% of Total Infant deaths

(51%) (10%) (3%) (2%) (2%)

Most Educated

Least Educated

Infant Deaths by Education and Ethnicity

18% 19% 14% 13%0%

35%45%

31% 38%

13%

34% 13%

28%

0%

0%

13%23% 28%

50%

88%

AfricanAmerican


<HS HS Assoc Coll+

Most Educated

Least Educated

(9%) (3%) (3%) (1%) (1%)% of Total

Infant deaths

0 1 2 3 4 5

Puerto Rican

Dominican

Chinese

Cape Verdean

Haitian

African Amer

African

Native Amer

<HS

HS

Assoc

Coll+

Disparities in IMR by Ethnicity and Education


Excess risk



**

*** **

*

*

Poverty, Race, Ethnicity and

Infant Mortality

%Below Poverty in Census Tract

< 5%

5 - 9.9 %

10 - 19.9 %

20 - 100 %

Percent of Population in Census Tract Below Poverty Level1

Least poor

Most poor

1. Categories of ‘below poverty level’ in census tracts (or in neighborhood areas) are based on percent of population in these areas below the Census 2000 federally-defined poverty line.

7.8

5.5

4.9

4.7

3.4

0 1 2 3 4 5 6 7 8 9

20-100 %

10-19.9%

All

5- 9.9%

0- 4.9%

IMR by Neighborhood Poverty LevelInfant deaths per 1000 live births

2.3

1.6

1.4

0 1 2 3 4

20-100 %

10-19.9%

5- 9.9%

IMR by Neighborhood Poverty Level

*

*

*

Excess risk

Ratio of rates in excess to 1(relative to least poor neighborhood)

Reference: neighborhoods with

<5% in poverty


17%26%

19%

21%

27%

27%

37%26%


0- 4.9%

5- 9.9%

10-19.9%

20-100 %

47%

Least poor

Most poor

Distribution of Neighborhood Poverty Level Births vs. Infant Deaths

7%16%

36%

51%

15%

21%

35%

27%

31%

28%

19%14%

47%35%

10% 8%

White* Asian* Black* Hispanic

20-100 % 10-19.9% 5- 9.9% 0- 4.9%

51%

Least poor

Most poor

Births by Neighborhood Poverty Level and Race

(70%) (7%) (8%) (13%)* Non-Hispanic.

% of Total Births

9%21%

43%

68%

18%

40%

29%

19%

33%

16%

23%

8%

40%

23%

5% 4%

White* Asian* Black* Hispanic

20-100 % 10-19.9% 5- 9.9% 0- 4.9%

68%

Least poor

Most poor

Infant Deaths by Neighborhood Poverty Level and Race

(59%) (4%) (17%) (17%)* Non-Hispanic.


2.5

1.5

2.4

2.0

0 1 2 3 4

Hispanic

White non-Hispanic

Black non-Hispanic

Asian

IMR by Neighborhood Poverty Level and Race

*

Excess risk

*

*

Ratio of rates in excess to 1(most poor to least poor neighborhood)

Reference: neighborhoods with

<5% in poverty


0 1 2 3 4

Hispanic

Black non-Hispanic

Asian

20-100 %

10-19.9%

5- 9.9%

0- 4.9%

**

** * RATIO Statistically higher than 1 (p<.05)** RATIO Statistically lower than 1 (p<.05)

Excess risk


*

*


**

Race Disparities in IMR by Neighborhood Poverty Level

7%

60% 60%

15%

43%

14%

23% 24%

30%

32%

31%

11% 12%

36%

17%

48%

6% 4%

19%8%


20-100 % 10-19.9% 5- 9.9% 0- 4.9%

Least poor

Most poor

Births by Neighborhood Poverty Level by Ethnicity

% of Total Births (61%) (6%) (2%) (3%) (1%)

43%

28% 22%15%

4%

34%

34%39%

14%

11%

15%

23% 26%

29%

34%

8%15% 12%

42%51%

AfricanAmerican


20-100 % 10-19.9% 5- 9.9% 0- 4.9%

Least poor

Most poor

Births by Neighborhood Poverty Level by Ethnicity

% of Total Births (4%) (2%) (1%) (2%) (2%)

10%

74% 79%

0%

29%16%

18%15%

39%

29%32%

6% 3%

43%

41%41%

3% 3%

17%

0%


20-100 % 10-19.9% 5- 9.9% 0- 4.9%

Least poor

Most poor

Infant Deaths by Neighborhood Poverty Level and Ethnicity


(51%) (10%) (3%) (2%) (2%)

49%37%

27%14%

0%

30%

33%

27%

14% 38%

14% 27%

40%

14%

25%

7% 3% 7%

57%

38%

AfricanAmerican


20-100 % 10-19.9% 5- 9.9% 0- 4.9%

Least poor

Most poor

Infant Deaths by Neighborhood Poverty Level and Ethnicity


(9%) (3%) (3%) (1%) (1%)

0 1 2 3 4 5

Puerto Rican

Cape Verdean

Haitian

African Amer

African

20-100 %

10-19.9%

5- 9.9%

0- 4.9%

Ethnicity Disparities in IMR by Neighborhood Poverty Level


Excess risk



*

*

*

***

*

*

Summary

One out of 2 infant deaths are to mothers with high school education or less

One out of 4 infant deaths are to mothers living in poor neighborhoods, however 2 out 3 infant deaths to Hispanic mothers are to those living in poor neighborhoods

Race and neighborhood poverty disparities are more influential in excess of risk of infant mortality among Black non-Hispanic mothers

More educated BNH mothers have equal risk of IMR than their least educated counterparts

For White non-Hispanic and Hispanic mothers, increasing levels of educational attainment diminishes their risk of IMR

BNH, Hispanics, and WNH mothers living in poor neighborhoods have an excess risk of IMR compared to those living in most affluent neighborhoods

Asian mothers have a lower risk in IMR compared with WNH mothers. However, Asian mothers with less than high school education have an excess risk of IMR than that of their counterparts with college or more education

Public Health Implications

Clearly, IMR reduction strategies need to focus on lower SES families whether defined by individual education or areal poverty

More needs to be done to understand the mechanisms that drive excess of risk in IMR across all levels of education and across all levels of neighborhood affluence particularly among BNH mothers, compared with that of WNH mothers

Public Health Implications

We need to further explore the interaction of race and poverty to better target perinatal programs

We need to collect more detailed ethnicity data to better understand patterns obscured by broad race groups

Documents

I Caceres and B Cohen Division of Research and Epidemiology Bureau of Health Information, Statistics, Research and Evaluation Massachusetts Department