Excess infant mortality among Native Hawaiians: identifying determinants for preventive action

Explaining the Link Between Paternal Socioeconomic Position and Small for Gestational Age Birth: The Effect of Maternal Unhealthy Behaviors

OBJECTIVE

To determine the proportion of small for gestational age (weight < 10th percentile, SGA) births among fathers with lifelong low (compared to high) socioeconomic position (SEP) attributable to white and African-American women's unhealthy pregnancy-related behaviors.

METHODS

Oaxaca-Blinder decomposition methods were conducted on the Illinois transgenerational dataset of infants (1989-1991) and their Chicago-born parents (1956-1976) with appended US census income data. The neighborhood income of father's residence at the time of his birth and at the time of his infant's birth were used to estimate his lifetime SEP. Maternal unhealthy pregnancy-related behaviors were defined as cigarette smoking, inadequate prenatal care, and/or low weight gain during pregnancy.

RESULTS

Among African-American women, births (n = 4426) to fathers with lifetime low SEP had an SGA rate of 14.8% compared to 12.1% for those (n = 365) born to fathers with lifetime high SEP (p < 0.0001). Among white women, births (n = 1430) to fathers with lifetime low SEP had an SGA rate of 9.8% compared to 6.2% for those (n = 9141) born to fathers with lifetime high SEP (p < 0.0001). Adjusting for maternal age, marital status, education, and parity, African-American and white women's unhealthy pregnancy behaviors accounted for 25% and 33%, respectively, of the disparity in SGA rates among infants of lifetime low (compared to high) SEP fathers.

CONCLUSION

A significant proportion of the disparity in SGA rates between fathers with lifelong low (compared to high) SEP is explained in both races by maternal unhealthy pregnancy behaviors.

Data Equity for Asian American and Native Hawaiian and Other Pacific Islander People in Reproductive Health Research

Though racial and ethnic disparities in sexual and reproductive health outcomes are receiving greater interest and research funding, the experiences of Asian American and Native Hawaiian and Other Pacific Islander (NHPI) people are often combined with those of other racial and ethnic minority groups or excluded from data collection altogether. Such treatment is often rationalized because Asian American and NHPI groups comprise a smaller demographic proportion than other racial or ethnic groups, and the model minority stereotype assumes that these groups have minimal sexual and reproductive health needs. However, Asian American and NHPI people represent the fastest-growing racial-ethnic groups in the United States, and they face disparities in sexual and reproductive health access, quality of care, and outcomes compared with those of other races and ethnicities. Disaggregating further by ethnicity, people from certain Asian American and NHPI subgroups face disproportionately poor reproductive health outcomes that suggest the need for culturally targeted exploration of the unique drivers of these inequities. This commentary highlights the evidence for sexual and reproductive health disparities both in and between Asian American and NHPI groups. We also examine the failures of national data sets and clinical studies to recruit Asian American and NHPI people in proportion to their share of the U.S. population or to consider how the cultural and experiential diversity of Asian American and NHPI people influence sexual and reproductive health. Lastly, we provide recommendations for the equitable inclusion of Asian American and NHPI people to promote and systematize the study and reporting of sexual and reproductive health behaviors and outcomes in these culturally, religiously, and historically diverse groups.

Global prevalence of preterm birth among Pacific Islanders: A systematic review and meta-analysis

The epidemiology of preterm birth among Pacific Islanders is minimally understood. The purpose of this study was to estimate pooled prevalence of preterm birth among Pacific Islanders and to estimate their risk of preterm birth compared to White/European women. We searched MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Library, CINAHL, Global Health, and two regional journals in March 2023. Observational studies were included if they reported preterm birth-related outcomes among Pacific Islanders. Random-effects models were used to estimate the pooled prevalence of preterm birth with 95% confidence interval (CI). Bayes meta-analysis was conducted to estimate pooled odds ratios (OR) with 95% highest posterior density intervals (HPDI). The Joanna Briggs Institute checklists were used for risk of bias assessment. We estimated preterm birth prevalence among Pacific Islanders in the United States (US, 11.8%, sample size [SS] = 209,930, 95% CI 10.8%-12.8%), the US-Affiliated Pacific Islands (USAPI, SS = 29,036, 6.7%, 95% CI 4.9%-9.0%), New Zealand (SS = 252,162, 7.7%, 95% CI 7.1%-8.3%), Australia (SS = 20,225, 6.1%, 95% CI 4.2%-8.7%), and Papua New Guinea (SS = 2,647, 7.0%, 95% CI 5.6%-8.8%). Pacific Islanders resident in the US were more likely to experience preterm birth compared to White women (OR = 1.45, 95% HPDI 1.32-1.58), but in New Zealand their risk was similar (OR = 1.00, 95% HPDI 0.83-1.16) to European women. Existing literature indicates that Pacific Islanders in the US had a higher prevalence of preterm birth and experienced health inequities. Learning from New Zealand's culturally-sensitive approach to health care provision may provide a starting point for addressing disparities. The limited number of studies identified may contribute to higher risk of bias and the heterogeneity in our estimates; more data is needed to understand the true burden of preterm birth in the Pacific region.

Preterm birth among Pacific Islanders in the United States and the US-affiliated Pacific Islands: A systematic review and meta-analysis

OBJECTIVE

To better understand the epidemiology of preterm birth among Pacific Islanders in the United States and the US-Affiliated Pacific Islands.

METHODS

Systematic searches of MEDLINE, Embase, CINAHL, PsycINFO, two nonindexed regional journals, and gray literature were conducted and finalized in September 2021. Observational studies published since January 2010 that documented preterm birth outcomes among Pacific Islanders in the United States and the US-Affiliated Pacific Islands were eligible for inclusion. Outcomes of interest included preterm birth prevalence, risk compared with white women, and risk factors for preterm birth among Pacific Islanders.

RESULTS

Fourteen of the 3183 screened articles were included in meta-analyses. Random-effects models were used for pooled estimates with 95% confidence intervals. The pooled prevalence of preterm birth among Pacific Islanders was 11.2%, 95% CI: 9.3%-13.6%. Marshallese women had the highest pooled prevalence (20.7%, 95% CI 18.6%-23.0%) among Pacific Islander subgroups. Compared with white women, Pacific Islander women had higher odds of experiencing preterm birth (OR = 1.40, 95% CI: 1.28-1.53). Four risk factors for preterm birth could be explored with the data available: hypertension, diabetes, smoking, and pre-pregnancy body mass index; hypertension and diabetes significantly increased the odds of preterm birth.

CONCLUSIONS

Existing literature suggests that United States Pacific Islanders were more likely to experience preterm birth than white women, although the pooled prevalence varied by Pacific Islander subgroup. Data support the need for disaggregation of Pacific Islanders in future research and argue for examination of subgroup-specific outcomes to address perinatal health disparities.

Implicit Racial Attitudes and Associations Among Obstetricians in Hawai'i: a Pilot Study

INTRODUCTION

Pacific Islanders living in Hawai'i with ancestral ties to islands in the western Pacific region of Micronesia are common targets of uninhibited forms of prejudice in multiple sectors, including healthcare. Whether the explicit societal-level attitudes toward this group are reflected in implicit attitudes among healthcare providers is unknown; therefore, we designed a pilot study to investigate this question. Our study measures implicit racial bias toward Pacific Islanders from Micronesia among Obstetrician-Gynecologists (OB-GYNs) in Hawai'i.

METHODS

We developed 4 new implicit association tests (IATs) to measure implicit attitudes and associations (i.e., stereotypes) toward Pacific Islanders from Micronesia in 2 conditions: (1) Micronesians vs. Whites and (2) Micronesians vs. Japanese Americans. Participants were practicing OB-GYNs in Hawai'i. The study was conducted online and included survey questions on demographic and physician practice characteristics in addition to IATs. The primary outcome was the mean IAT D score. Associations between IAT D scores and demographic and practice characteristics were also analyzed.

RESULTS

Of the 49 OB-GYNs, 38 (77.6%) were female, mean age was 40 years, 29.5% were Japanese, 22.7% were White, and none were from a Micronesian ethnic group. The mean IAT D score in the Micronesian vs. White condition (N = 29) was 0.181, (SD: 0.465, p < 0.05) for the Attitude IAT and 0.197 (SD: 0.427; p < 0.05) for the Stereotype IAT.

CONCLUSION

The findings from this pilot suggest a slight degree of implicit bias favoring Whites over Micronesians within this sample of OB-GYNs and warrant a larger investigation into implicit biases toward this unique and understudied Pacific Islander population.

Holistic antenatal education class interventions: a systematic review of the prioritisation and involvement of Indigenous Peoples' of Aotearoa New Zealand, Australia, Canada and the United States over a 10-year period 2008 to 2018

BACKGROUND

Research into the effectiveness of antenatal education classes is crucial for Indigenous Peoples from Aotearoa New Zealand, Australia, Canada and the United States who experience poorer maternal and infant health outcomes compared to non-Indigenous populations. Our systematic review questions were intended to determine the extent of Indigenous Peoples prioritisation and involvement in antenatal education classes, and to understand the experience of Indigenous Peoples from these countries in antenatal education classes.

METHODS

Using a standardised protocol, we systematically searched five electronic databases for primary research papers on antenatal education classes within the four countries noted and identified 17 papers that met the criteria. We undertook a qualitative meta-synthesis using a socio-critical lens.

RESULTS

Systematic review of the academic literature demonstrates that Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States are not prioritised in antenatal education classes with only two of 17 studies identifying Indigenous participants. Within these two studies, Indigenous Peoples were underrepresented. As a result of poor engagement and low participation numbers of Indigenous Peoples in these antenatal education classes, it was not possible to understand the experiences of Indigenous Peoples.

CONCLUSION

Given that Indigenous Peoples were absent from the majority of studies examined in this review, it is clear little consideration is afforded to the antenatal health needs and aspirations of Indigenous Peoples of Aotearoa New Zealand, Australia, Canada and the United States. To address the stark antenatal health inequities of Indigenous Peoples, targeted Indigenous interventions that consider culture, language, and wider aspects of holistic health must be privileged.

TRIAL REGISTRATION

PROSPERO Registration ID: CRD4202017658.

Pregnancy health and perinatal outcomes among Pacific Islander women in the United States and US Affiliated Pacific Islands: Protocol for a scoping review

This scoping review examines the literature on pregnancy and perinatal outcomes among Pacific Islander women in the United States (U.S.) and U.S.-affiliated Pacific Islands. Our aim was to identify research that disaggregated Pacific Islanders from other population groups. We conducted a systematic search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid) databases and a hand-search of grey literature. Forty-eight articles published between January 2010 and June 2020 were included. The majority of studies were conducted in Hawaii and utilized clinical record data. Infant outcomes were more commonly reported than maternal outcomes. We highlighted several limitations of the existing literature that included aggregation of Pacific Islanders with Asian American and other ethnic groups; limited comparison between Pacific Islander sub-groups; inadequate definitions of the nationality and ethnic composition of Pacific Islander groups; a lack of hypothesis-driven primary data collection and clinical trials; and underrepresentation of Pacific Islanders in population-based studies. Researchers should address these limitations to improve pregnancy and perinatal outcomes among Pacific Islanders, who comprise the second fastest growing ethnic minority in the U.S.

The Role of Danger Associated Molecular Patterns in Human Fetal Membrane Weakening

The idea that cellular stress (including that precipitated by stretch), plays a significant role in the mechanisms initiating parturition, has gained considerable traction over the last decade. One key consequence of this cellular stress is the increased production of Danger Associated Molecular Patterns (DAMPs). This diverse family of molecules are known to initiate inflammation through their interaction with Pattern Recognition Receptors (PRRs) including, Toll-like receptors (TLRs). TLRs are the key innate immune system surveillance receptors that detect Pathogen Associated Molecular Patterns (PAMPs) during bacterial and viral infection. This is also seen during Chorioamnionitis. The activation of TLR commonly results in the activation of the pro-inflammatory transcription factor Nuclear Factor Kappa-B (NF-kB) and the downstream production of pro-inflammatory cytokines. It is thought that in the human fetal membranes both DAMPs and PAMPs are able, perhaps via their interaction with PRRs and the induction of their downstream inflammatory cascades, to lead to both tissue remodeling and weakening. Due to the high incidence of infection-driven Pre-Term Birth (PTB), including those that have preterm Premature Rupture of the Membranes (pPROM), the role of TLR in fetal membranes with Chorioamnionitis has been the subject of considerable study. Most of the work in this field has focused on the effect of PAMPs on whole pieces of fetal membrane and the resultant inflammatory cascade. This is important to understand, in order to develop novel prevention, detection, and therapeutic approaches, which aim to reduce the high number of mothers suffering from infection driven PTB, including those with pPROM. Studying the role of sterile inflammation driven by these endogenous ligands (DAMPs) activating PRRs system in the mesenchymal and epithelial cells in the amnion is important. These cells are key for the maintenance of the integrity and strength of the human fetal membranes. This review aims to (1) summarize the knowledge to date pertinent to the role of DAMPs and PRRs in fetal membrane weakening and (2) discuss the clinical potential brought by a better understanding of these pathways by pathway manipulation strategies.

Multi-level Drivers of Disparities in Hispanic Cesarean Delivery Rates in US-Mexico Border States

BACKGROUND

Hispanic women living along the US-Mexico border have higher cesarean delivery rates than non-Hispanic white women, African American women, and other Hispanic women in the USA. Their rates also exceed those of other Hispanic women in states that border Mexico and non-Hispanic white women along the border. Our objective was to determine the causes of the disparities in border Hispanic cesarean rates.

METHODS

Using the 2015 birth certificate file and other sources, we performed a twofold Oaxaca-Blinder decomposition analysis of the disparities in low-risk primary and repeat cesarean rates between Hispanic and non-Hispanic white women in the US-Mexico border counties and Hispanic women residing in nonborder counties of border states.

RESULTS

Rates of low-risk primary cesarean among border Hispanic, nonborder Hispanic, and border non-Hispanic white women were 21.1%, 15.0%, and 16.5%, respectively. Higher Hispanic concentration in county of residence, a larger proportion of for-profit hospital beds, and greater poverty accounted for 24.7%, 22.1%, and 11.1% of the border-nonborder Hispanic difference, respectively. No other variable explained more than 5% of the difference. Higher Hispanic concentration, more for-profit beds, less attendance by an MD, higher BMI, and greater poverty explained 60.6%, 42.4%, 42.4%, 27.4%, and 21.3%, respectively, of the Hispanic-non-Hispanic white difference. Hispanic concentration and for-profit beds were also important explanatory variables for low-risk repeat cesareans.

CONCLUSION

Efforts to address potentially unnecessary cesareans among Hispanic women on the border should recognize that community demographic and health delivery system characteristics are more influential than maternal medical risk factors.

Disparities in Adverse Perinatal Outcomes Among Pacific Islanders in the Commonwealth of the Northern Mariana Islands

Introduction

Although other studies have found evidence for perinatal health disparities among Pacific Islanders in other regions, no studies have evaluated racial/ethnic disparities in adverse perinatal health outcomes in the small US island territory of the Commonwealth of the Northern Mariana Islands (CNMI).

Methods

We used retrospective cohort data on 8,427 singleton births from 2007 to 2014 at the Commonwealth Healthcare Corporation (CHCC), the only hospital in the CNMI. We used multivariate logistic regression to estimate risk for preterm birth (<37 weeks) and macrosomia (>4,000 g) among the racial/ethnic groups in the CNMI.

Results

Indigenous CNMI mothers (Chamorros and Carolinians, hereinafter Chamorro/Carolinian) and other Pacific Islander mothers were significantly more likely to have a preterm birth than Chinese mothers (adjusted odds ratio [AOR] = 2.7; 95% confidence interval [CI], 2.0–3.6 for Chamorro/Carolinians and AOR = 2.9; 95% CI, 2.1–4.1 for other Pacific Islanders). Additionally, Chamorro/Carolinian mothers and other Pacific Islander mothers were also significantly more likely to deliver babies with macrosomia (AOR = 2.4; 95% CI, 1.7–3.5 and 2.3; 95% CI 1.4–3.6 respectively) than Filipino mothers.

Conclusion

Although underlying causes for these disparities are still unknown, these findings add to the limited knowledge on maternal and neonatal health among Pacific Islanders and provide support for further research and intervention development to aid in reducing racial/ethnic disparities of perinatal health in the CNMI.

Deconstructing a disparity: explaining excess preterm birth among U.S.-born black women

PURPOSE

To determine components of excess preterm birth (PTB) rates for U.S.-born black women relative to both foreign-born black women and U.S.-born white women attributable to differences in observed sociodemographic, behavioral, and medical risk factors.

METHODS

Using the 2013 U.S. natality files, we used Oaxaca-Blinder decomposition on the absolute scale to estimate the contribution of the group differences in the prevalence of PTB predictors between U.S.- and foreign-born black women and U.S.-born black and U.S.-born white women.

RESULTS

U.S.-born blacks had a 3.2 (95% confidence interval: 3.0-3.5) and 4.4 (95% confidence interval: 4.3-4.5) percentage point higher risk of PTB than foreign-born blacks and U.S.-born whites, respectively. The variables in the models explained between 18% and 27% of the PTB disparities. Differences in paternal acknowledgment (about 12%), maternal hypertension (about 7%-11%), and maternal education (about 6%-10%) explained the largest proportion of these disparities.

CONCLUSIONS

Programs and policies that address both distal and proximate factors, including the social determinants of health and the prevention and management of hypertension, may reduce the higher rates of PTB among U.S.-born black women compared to foreign-born black women and U.S.-born white women.

Connecting culturally and spiritually to healthy eating: A community assessment with Native Hawaiians

Many of the chronic illnesses disproportionately experienced by Native Hawaiians are directly related to poor diets and long-standing obesity beginning in childhood. We report on the findings of in-depth key informant interviews (N=14) that took place in two Native Hawaiian communities as part of a larger, community-based participatory research study that included a community assessment through individual interviews and focused group discussions, and a pilot intervention targeting pregnant women, their infants, and families. Four categories emerged from the qualitative analysis of interview transcripts that described an understanding of "healthy eating": family roles and responsibilities, aspects of community and physical environment, deeper spiritual meaning of food, and ways of operationalizing personal eating choices. The findings revealed previously undocumented intergenerational influences on healthy eating patterns and informed the design of the next study phases and are of significance in targeting nutritional interventions for Native Hawaiians.

Early Childhood Vision Screening in Hawai'i Utilizing a Hand-Held Screener

The goal of early childhood vision screening is to detect subnormal vision and amblyopic risk factors that threaten visual development so that treatment can be initiated early to yield the highest benefit. Hand-held, portable, instrument-based vision screening devices can be used in children as young as 6 months of age. We assessed the feasibility of hand-held photoscreeners to screen for vision disorders in pre-school children in Hawai'i. A total of 137 preschool children on O'ahu in the "Tutu and Me"/Partners in Development program were screened at 6 different locations using the Plusoptix S12 hand-held photoscreener. Once technical issues were resolved, screening was fast and well tolerated. Possible vision abnormalities were found in 11 of the 137 children (8%). Poor compliance for follow-up with formal vision examination limited our ability to confirm these abnormalities. We conclude that photoscreening has the potential to facilitate early childhood vision screening in Hawai'i. The optimal referral criteria for use in Hawai'i will need to be determined after considering the age of the screening population and the available medical resources in Hawai'i. Early detection of treatable eye disorders has far-reaching benefits for the visual development and long term health and well-being of children. A comprehensive early childhood vision screening program in Hawai'i utilizing automated hand-held photoscreeners may have public health value. Such a program should integrate referral to an eye care professional for confirmation and management of vision disorders of at-risk children found on screening.

Social determinants and the classification of disease: descriptive epidemiology of selected socially mediated disease constellations

BACKGROUND

Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal.

METHODS AND FINDINGS

Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates--(n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor.

CONCLUSIONS

Between 1999 and 2006, deaths classified as "assault" and "lung cancer", as well as "infant mortality" formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations.

Social determinants and the classification of disease: descriptive epidemiology of selected socially mediated disease constellations

BACKGROUND

Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal.

METHODS AND FINDINGS

Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates--(n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor.

CONCLUSIONS

Between 1999 and 2006, deaths classified as "assault" and "lung cancer", as well as "infant mortality" formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations.