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1.  Hostility and anomie: Links to preterm delivery subtypes and ambulatory blood pressure at mid-pregnancy 
Social science & medicine (1982)  2008;66(6):1310-1321.
Underlying maternal vascular disease has been implicated as one of several pathways contributing to preterm delivery (PTD) and psychosocial factors such as hostility, anomie, effortful coping, and mastery may be associated with PTD by affecting maternal vascular health. Using data from the Pregnancy Outcomes and Community Health (POUCH) study, we included 2,018 non-Hispanic White and 743 African American women from 52 clinics in 5 Michigan, USA communities who were interviewed at 15−27 weeks’ gestation and followed to delivery. We found that relations between psychosocial factors and PTD subtypes (i.e. medically indicated, premature rupture of membranes, spontaneous labor) varied by race/ethnicity and socioeconomic position (Medicaid insurance status). Among African American women not insured by Medicaid, anomie levels in mid-pregnancy were positively associated with medically indicated PTD after adjusting for maternal age and education. Among all women not insured by Medicaid, hostility levels were positively associated with spontaneous PTD after adjusting for maternal race/ethnicity, age, and education. Failure to detect links between psychosocial factors and PTD risk in poorer women may be due to their excess risk in multiple PTD pathways and/or a more complex web of contributing risk factors.
In a subset of 395 women monitored for blood pressure, anomie scores were positively associated with systolic blood pressure and heart rate and hostility scores were positively associated with systolic and diastolic blood pressure, heart rate and mean arterial pressure in models that included time, awake/asleep, race/ethnicity, and age as covariates. Further adjustment for body mass index and smoking attenuated the anomie-vascular relations but had little effect on the hostility-vascular relations. Overall this study of pregnant women provides some physiologic evidence to support findings linking levels of anomie and hostility with risk of PTD.
PMCID: PMC2761822  PMID: 18179853
premature birth; hostility; anomie; social class; social environment; blood pressure; pregnancy; USA
2.  Validity of Health Plan and Birth Certificate Data for Pregnancy Research 
To evaluate the validity of health plan and birth certificate data for pregnancy research.
A retrospective study was conducted using administrative and claims data from 11 U.S. health plans, and corresponding birth certificate data from state health departments. Diagnoses, drug dispensings, and procedure codes were used to identify infant outcomes (cardiac defects, anencephaly, preterm birth, and neonatal intensive care unit [NICU] admission) and maternal diagnoses (asthma and systemic lupus erythematosus [SLE]) recorded in the health plan data for live born deliveries between January 2001 and December 2007. A random sample of medical charts (n = 802) was abstracted for infants and mothers identified with the specified outcomes. Information on newborn, maternal, and paternal characteristics (gestational age at birth, birth weight, previous pregnancies and live births, race/ethnicity) was also abstracted and compared to birth certificate data. Positive predictive values (PPVs) were calculated with documentation in the medical chart serving as the gold standard.
PPVs were 71% for cardiac defects, 37% for anencephaly, 87% for preterm birth, and 92% for NICU admission. PPVs for algorithms to identify maternal diagnoses of asthma and SLE were ≥ 93%. Our findings indicated considerable agreement (PPVs > 90%) between birth certificate and medical record data for measures related to birth weight, gestational age, prior obstetrical history, and race/ethnicity.
Health plan and birth certificate data can be useful to accurately identify some infant outcomes, maternal diagnoses, and newborn, maternal, and paternal characteristics. Other outcomes and variables may require medical record review for validation.
PMCID: PMC3492503  PMID: 22753079
administrative databases; birth certificate; positive predictive value; pregnancy; validation
3.  Racial discrepancies in the association between paternal vs. maternal educational level and risk of low birthweight in Washington State 
The role of paternal factors in determining the risk of adverse pregnancy outcomes has received less attention than maternal factors. Similarly, the interaction between the effects of race and socioeconomic status (SES) on pregnancy outcomes is not well known. Our objective was to assess the relative importance of paternal vs. maternal education in relation to risk of low birth weight (LBW) across different racial groups.
We conducted a retrospective population-based cohort study using Washington state birth certificate data from 1992 to 1996 (n = 264,789). We assessed the associations between maternal or paternal education and LBW, adjusting for demographic variables, health services factors, and maternal behavioral and obstetrical factors.
Paternal educational level was independently associated with LBW after adjustment for race, maternal education, demographic characteristics, health services factors; and other maternal factors. We found an interaction between the race and maternal education on risk of LBW. In whites, maternal education was independently associated with LBW. However, in the remainder of the sample, maternal education had a minimal effect on LBW.
The degree of association between maternal education and LBW delivery was different in whites than in members of other racial groups. Paternal education was associated with LBW in both whites and non-whites. Further studies are needed to understand why maternal education may impact pregnancy outcomes differently depending on race and why paternal education may play a more important role than maternal education in some racial categories.
PMCID: PMC446198  PMID: 15202949
4.  Maternal Diet and Risk of Childhood Acute Lymphoblastic Leukemia 
Public Health Reports  2009;124(4):503-514.
Intrauterine environmental factors, including maternal diet, may play an etiologic role in acute lymphoblastic leukemia (ALL), a common childhood cancer. Expanding on previous findings from phase 1 of the Northern California Childhood Leukemia Study (NCCLS), a population-based case-control study, we sought to further elucidate and replicate the relationships between maternal diet and ALL risk.
We matched 282 case-control sets of children (205 pairs and 77 triplets) from phases 1 and 2 of the NCCLS on sex, date of birth, mother's race, Hispanic racial/ethnic status, and county of residence at birth. We used an interviewer-administered food frequency questionnaire to obtain information on maternal dietary intake in the 12 months prior to pregnancy.
Risk of ALL was inversely associated with maternal consumption of vegetable (adjusted odds ratio [AOR] = 0.65, 95% confidence interval [CI] 0.50, 0.84); protein sources (AOR=0.55, 95% CI 0.32, 0.96); fruit (AOR=0.81, 95% CI 0.65, 1.00); and legume food groups (AOR=0.75, 95% CI 0.59, 0.95). The risk reduction was strongest for consumption of the protein sources and vegetable food groups, independent of the child's diet up to age 2 years, and consistent across phases 1 and 2 of data collection for vegetable consumption.
These data suggest that it may be prudent for women to consume a diet rich in vegetables and adequate in protein prior to and during pregnancy as a possible means of reducing childhood ALL risk in their offspring.
PMCID: PMC2693164  PMID: 19618787
5.  Children’s asthma hospitalizations and relative risk due to nitrogen dioxide (NO2): Effect modification by race, ethnicity and insurance status 
Environmental research  2009;110(2):178.
This study explores the role of race, ethnicity, and insurance-status in modifying the effects of air pollution on children’s asthma hospitalizations in Phoenix, Arizona (US) between 2001 and 2003. While controlling for weather, interactions between nitrous dioxide (NO2) and race, ethnicity, and insurance-status are used to predict relative risk for subgroups of children.
The generalized logit regression model for nominal categorical data within a multinomial likelihood framework was used. This model is specifically suited to small counts and the reporting of 95% confidence intervals for the odds–ratio of hospital admission for one group as compared to another. The odds ratio is known to approximate relative risk for rare events.
Several significant findings were found for race, ethnicity, and insurance-status as modulators for the effect of NO2 on children’s risk for asthma hospitalization: (1) Children without insurance have 1.4 (95% CI: 1.1–1.8) times higher risk of asthma admissions than those with private insurance at exceedances of .02 parts per million (ppm) of NO2 above the seasonal mean; the same finding holds for children without insurance as compared to those with Medicaid; (2) Black children have 2.1 (95% CI: 1.3 –3.3) times higher risk of hospitalization than Hispanic children at seasonal mean NO2 levels, but this disproportionate risk shrinks to 1.7 with exceedances of .02 ppm of NO2 above the seasonal mean. Specific to finding (1) among those children without health insurance, Hispanic children have 2.1 (95% CI: 1.1–3.8) times higher risk of hospitalization than white children. Among all Hispanic children, those without health insurance have 1.9 (95% CI: 1.3–3.0) times greater risk than those with private insurance; the same finding holds for Hispanic children without insurance as compared to Hispanic children with Medicaid. Specific to finding (2), among children with private insurance, the disproportionate risk of black children as compared to Hispanic children is magnified by a factor of 1.3 (95% CI: 1.0–1.8) for exceedances of .02 ppm of NO2 above the seasonal mean.
Although we cannot confirm a cause-effect relationship, this analysis suggests that increasing insurance enrollment for all children, and specifically Hispanic children, may reduce their disproportionate risk from exceedances of air pollution. There are few black children in Phoenix, so further studies are needed to investigate the increasing risk of black children with private insurance as compared to Hispanics at exceedances of NO2.
PMCID: PMC2819647  PMID: 19944410
Children’s asthma; air pollution; effect modification; race/ethnicity; health insurance status
6.  Disparities in exposure to air pollution during pregnancy. 
Environmental Health Perspectives  2003;111(7):942-946.
Previous research shows poorer birth outcomes for racial and ethnic minorities and for persons with low socioeconomic status (SES). We evaluated whether mothers in groups at higher risk for poor birth outcomes live in areas of higher air pollution and whether higher exposure to air pollution contributes to poor birth outcomes. An index representing long-term exposure to criteria air pollutants was matched with birth certificate data at the county level for the United States in 1998-1999. We used linear regression to estimate associations between the air pollution index and maternal race and educational attainment, a marker for SES of the mother, controlling for age, parity, marital status, and region of the country. Then we used logistic regression models both to estimate likelihood of living in counties with the highest levels of air pollution for different racial groups and by educational attainment, adjusting for other maternal risk factors, and to estimate the effect of living in counties with higher levels of air pollution on preterm delivery and births small for gestational age (SGA). Hispanic, African-American, and Asian/Pacific Islander mothers experienced higher mean levels of air pollution and were more than twice as likely to live in the most polluted counties compared with white mothers after controlling for maternal risk factors, region, and educational status [Hispanic mothers: adjusted odds ratio (AOR) = 4.66; 95% confidence interval (95% CI), 1.92-11.32; African-American mothers: AOR = 2.58; 95% CI, 1.00-6.62; Asian/Pacific Islander mothers: AOR = 2.82; 95% CI, 1.07-7.39]. Educational attainment was not associated with living in counties with highest levels of the air pollution index (AOR = 0.95; 95% CI, 0.40-2.26) after adjusting for maternal risk factors, region of the country, and race/ethnicity. There was a small increase in the odds of preterm delivery (AOR = 1.05; 95% CI, 0.99-1.12) but not SGA (AOR = 0.96; 95% CI, 0.86-1.07) in a county with high air pollution. Additional risk of residing in areas with poor air quality may exacerbate health problems of infants and children already at increased risk for poor health.
PMCID: PMC1241529  PMID: 12782496
7.  Differences in risk factors for children with special health care needs (CSHCN) receiving needed specialty care by socioeconomic status 
BMC Pediatrics  2009;9:48.
The purpose of this study is to identify factors affecting CSHCN's receiving needed specialty care among different socioeconomic levels. Previous literature has shown that Socioeconomic Status (SES) is a significant factor in CHSHCN receiving access to healthcare. Other literature has shown that factors of insurance, family size, race/ethnicity and sex also have effects on these children's receipt of care. However, this literature does not address whether other factors such as maternal education, geographic location, age, insurance type, severity of condition, or race/ethnicity have different effects on receiving needed specialty care for children in each SES level.
Data were obtained from the National Survey of Children with Special Health Care Needs, 2000–2002. The study analyzed the survey which studies whether CHSCN who needed specialty care received it. The analysis included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for SES levels defined by federal poverty level: < 199%; 200–299%; ≥ 300%.
For the poorest children (,199% FPL) being uninsured had a strong negative effect on receiving all needed specialty care. Being Hispanic was a protective factor. Having more than one adult in the household had a positive impact on receipt of needed specialty care but a larger number of children in the family had a negative impact. For the middle income group of children (200–299% of FPL severity of condition had a strong negative association with receipt of needed specialty care.
Children in highest income group (> 300% FPL) were positively impacted by living in the Midwest and were negatively impacted by the mother having only some college compared to a four-year degree.
Factors affecting CSHCN receiving all needed specialty care differed among socioeconomic groups. These differences should be addressed in policy and practice. Future research should explore the CSHCN population by income groups to better serve this population
PMCID: PMC2729735  PMID: 19646227
8.  Neonatal Short-Term Outcomes of Gestational Diabetes Mellitus in Saudi Mothers: A Retrospective Cohort Study 
Gestational diabetes mellitus (GDM) affects up to 10% of all pregnancies and results in significant maternal and neonatal morbidities.
Our main objective was to investigate retrospectively the rate of neonatal intensive care unit (NICU) admissions and significant neonatal complications in pregnant mothers with gestational diabetes.
Materials and Methods:
A retrospective cohort study was conducted. The medical records of King Khalid University Hospital (KKUH) were reviewed from January till December 2007. All pregnant women with GDM along with their offsprings were included and matched with healthy pregnant women. The primary outcome was the rate of NICU admission, hypoglycemia, birth weight and length of hospital stay.
A total of 766 mothers (419 GDM mothers and 347 controls) with their term babies were included. Infants born to GDM mothers had significantly higher risk of NICU admissions [OR 2.7 (95% CI 1.5, 4.9), P value 0.0004], longer hospital stay and higher rates of hypoglycemia. Newborns of GDM mothers had higher rates of perinatal distress and macrosomia; however, the difference did not reach statistical significance.
GDM remains a significant morbidity to newborns resulting in increased intensive care admission, prolongation of hospital stay and higher rates of neonatal hypoglycemia. More efforts to assure early recognition and strict sugar control during pregnancy are still needed.
PMCID: PMC3761990  PMID: 24027682
Gestational diabetes mellitus; hypoglycemia; large for gestational age; macrosomia; neonatal intensive care unit
9.  The Problem of Confounding in Studies of the Effect of Maternal Drug Use on Pregnancy Outcome 
In most epidemilogical studies, the problem of confounding adds to the uncertainty in conclusions drawn. This is also true for studies on the effect of maternal drug use on birth defect risks. This paper describes various types of such confounders and discusses methods to identify and adjust for them. Such confounders can be found in maternal characteristics like age, parity, smoking, use of alcohol, and body mass index, subfertility, and previous pregnancies including previous birth of a malformed child, socioeconomy, race/ethnicity, or country of birth. Confounding by concomitant maternal drug use may occur. A geographical or seasonal confounding can exist. In rare instances, infant sex and multiple birth can appear as confounders. The most difficult problem to solve is often confounding by indication. The problem of confounding is less important for congenital malformations than for many other pregnancy outcomes.
PMCID: PMC3236404  PMID: 22190949
10.  Racial/Ethnic Differences in the Percentage of Gestational Diabetes Mellitus Cases Attributable to Overweight and Obesity, Florida, 2004-2007 
Gestational diabetes mellitus (GDM) affects 3% to 7% of pregnant women in the United States, and Asian, black, American Indian, and Hispanic women are at increased risk. Florida, the fourth most populous US state, has a high level of racial/ethnic diversity, providing the opportunity to examine variations in the contribution of maternal body mass index (BMI) status to GDM risk. The objective of this study was to estimate the race/ethnicity-specific percentage of GDM attributable to overweight and obesity in Florida.
We analyzed linked birth certificate and maternal hospital discharge data for live, singleton deliveries in Florida from 2004 through 2007. We used logistic regression to assess the independent contributions of women's prepregnancy BMI status to their GDM risk, by race/ethnicity, while controlling for maternal age and parity. We then calculated the adjusted population-attributable fraction of GDM cases attributable to overweight and obesity.
The estimated GDM prevalence was 4.7% overall and ranged from 4.0% among non-Hispanic black women to 9.9% among Asian/Pacific Islander women. The probability of GDM increased with increasing BMI for all racial/ethnic groups. The fraction of GDM cases attributable to overweight and obesity was 41.1% overall, 15.1% among Asians/Pacific Islanders, 39.1% among Hispanics, 41.2% among non-Hispanic whites, 50.4% among non-Hispanic blacks, and 52.8% among American Indians.
Although non-Hispanic black and American Indian women may benefit the most from prepregnancy reduction in obesity, interventions other than obesity prevention may be needed for women from other racial/ethnic groups.
PMCID: PMC3406742  PMID: 22515970
11.  Vulnerability and Unmet Health Care Needs 
Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks.
To present a profile of risk factors for poor access based on income, insurance coverage, and having a regular source of care, and examine the association of the profiles with unmet health care needs due to cost. Relationships are examined by race/ethnicity.
Analysis of 32,374 adults from the 2000 National Health Interview Survey.
Reported unmet needs due to cost: missing/delaying needed medical care, and delaying obtaining prescriptions, mental health care, or dental care.
Controlling for personal demographic and community factors, individuals who were low income, uninsured, and had no regular source of care were more likely to miss or delay needed health care services due to cost. After controlling for these risk factors, whites were more likely than other racial/ethnic groups to report unmet needs. When presented as a risk profile, a clear gradient existed in the likelihood of having an unmet need according to the number of risk factors, regardless of racial/ethnic group.
Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group. Without attention to these co-occurring risk factors for poor access, it is unlikely that substantial reductions in disparities will be made in assuring access to needed health care services among vulnerable populations.
PMCID: PMC1490048  PMID: 15836548
race/ethnicity; SES; vulnerability; access to care; disparities
12.  Pregnancy Risk among Black, White, and Hispanic Teen Girls in New York City Public Schools 
Disparities in teen pregnancy rates are explained by different rates of sexual activity and contraceptive use. Identifying other components of risk such as race/ethnicity and neighborhood can inform strategies for teen pregnancy prevention. Data from the 2005 and 2007 New York City Youth Risk Behavior Surveys were used to model demographic differences in odds of recent sexual activity and birth control use among black, white, and Hispanic public high school girls. Overall pregnancy risk was calculated using pregnancy risk index (PRI) methodology, which estimates probability of pregnancy based on current sexual activity and birth control method at last intercourse. Factors of race/ethnicity, grade level, age, borough, and school neighborhood were assessed. Whites reported lower rates of current sexual activity (23.4%) than blacks (35.4%) or Hispanics (32.7%), and had lower predicted pregnancy risk (PRI = 5.4% vs. 9.0% and 10.5%, respectively). Among sexually active females, hormonal contraception use rates were low in all groups (11.6% among whites, 7.8% among blacks, and 7.5% among Hispanics). Compared to white teens, much of the difference in PRI was attributable to poorer contraceptive use (19% among blacks and 50% among Hispanics). Significant differences in contraceptive use were also observed by school neighborhood after adjusting for age group and race/ethnicity. Interventions to reduce teen pregnancy among diverse populations should include messages promoting delayed sexual activity, condom use and use of highly effective birth control methods. Access to long-acting contraceptive methods must be expanded for all sexually active high school students.
PMCID: PMC2871086  PMID: 20383750
Adolescents; Contraception; Sexual behavior
13.  Birth Anomalies and Obstetric History as Risks for Childhood Tumors of the Central Nervous System 
Pediatrics  2011;128(3):e652-e657.
The causes of childhood central nervous system (CNS) tumors are largely unknown. Birth characteristics have been examined as possible risk factors for childhood CNS tumors, although the studies have been underpowered and inconclusive. We hypothesized that birth anomalies and a mother's history of previous pregnancy losses, as a proxy for genetic defects, increase the risk for CNS tumors.
From the California Cancer Registry, we identified 3733 patients aged 0 to 14 years with CNS tumors, diagnosed from 1988 through 2006 and linked to a California birth certificate. Four controls were matched to each patient. We calculated odds ratios (ORs) for the reported presence of a birth defect and for history of pregnancy losses by using logistic regression, adjusted for race, Hispanic ethnicity, maternal age, birth weight, and birth order.
Offspring from mothers who had ≥2 fetal losses after 20 weeks' gestation had a threefold risk for CNS tumors (OR: 3.13 [95% confidence interval (CI): 1.32–7.41]) and a 14-fold risk for high-grade glioma (OR: 14.28 [95% CI: 1.56–130.65]). Birth defects increased risk for the CNS cancers medulloblastoma (OR: 1.70 [95% CI: 1.12–2.57]), primitive neuroectodermal tumor (OR: 3.64 [95% CI: 1.54–8.56]), and germ cell tumors (OR: 6.40 [95% CI: 2.09–19.56]).
Multiple pregnancy losses after 20 weeks' gestation and birth defects increase the risk of a childhood CNS tumor. Previous pregnancy losses and birth defects may be surrogate markers for gene defects in developmental pathways that lead to CNS tumorigenesis.
PMCID: PMC3164097  PMID: 21824884
childhood brain tumors; congenital anomalies; birth defects; central nervous system tumors
14.  U.S. Maternally Linked Birth Records May Be Biased for Hispanics and Other Population Groups 
Annals of epidemiology  2010;20(1):23.
To advance understanding of linkage error in U.S. maternally linked datasets, and how the error may affect results of studies based on the linked data.
North Carolina birth and fetal death records for 1988-1997 were maternally linked (n=1,030,029). The maternal set probability, defined as the probability that all records assigned to the same maternal set do in fact represent events to the same woman, was used to assess differential maternal linkage error across race/ethnic groups.
Maternal set probabilities were lower for records specifying Asian or Hispanic race/ethnicity, suggesting greater maternal linkage error. The lower probabilities for Hispanics were concentrated in women of Mexican origin who were not born in the United States.
Differential maternal linkage error may be a source of bias in studies using U.S. maternally linked datasets to make comparisons between Hispanics and other groups or among Hispanic subgroups. Methods to quantify and adjust for this potential bias are needed.
PMCID: PMC2818138  PMID: 20006273
Bias; epidemiologic; Birth certificates; Epidemiologic methods; Medical record linkage; Validation studies
15.  Advanced maternal age and risk perception: A qualitative study 
Advanced maternal age (AMA) is associated with several adverse pregnancy outcomes, hence these pregnancies are considered to be “high risk.” A review of the empirical literature suggests that it is not clear how women of AMA evaluate their pregnancy risk. This study aimed to address this gap by exploring the risk perception of pregnant women of AMA.
A qualitative descriptive study was undertaken to obtain a rich and detailed source of explanatory data regarding perceived pregnancy risk of 15 women of AMA. The sample was recruited from a variety of settings in Winnipeg, Canada. In-depth interviews were conducted with nulliparous women aged 35 years or older, in their third trimester, and with singleton pregnancies. Interviews were recorded and transcribed verbatim, and content analysis was used to identify themes and categories.
Four main themes emerged: definition of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk communication with health professionals.
Several factors may influence women's perception of pregnancy risk including medical risk, psychological elements, characteristics of the risk, stage of pregnancy, and health care provider’s opinion. Understanding these influential factors may help health professionals who care for pregnant women of AMA to gain insight into their perspectives on pregnancy risk and improve the effectiveness of risk communication strategies with this group.
PMCID: PMC3490979  PMID: 22988825
Advanced maternal age; Risk perception; Qualitative study
16.  Non-hispanic whites have higher risk for pulmonary impairment from pulmonary tuberculosis 
BMC Public Health  2012;12:119.
Disparities in outcomes associated with race and ethnicity are well documented for many diseases and patient populations. Tuberculosis (TB) disproportionately affects economically disadvantaged, racial and ethnic minority populations. Pulmonary impairment after tuberculosis (PIAT) contributes heavily to the societal burden of TB. Individual impacts associated with PIAT may vary by race/ethnicity or socioeconomic status.
We analyzed the pulmonary function of 320 prospectively identified patients with pulmonary tuberculosis who had completed at least 20 weeks standard anti-TB regimes by directly observed therapy. We compared frequency and severity of spirometry-defined PIAT in groups stratified by demographics, pulmonary risk factors, and race/ethnicity, and examined clinical correlates to pulmonary function deficits.
Pulmonary impairment after tuberculosis was identified in 71% of non-Hispanic Whites, 58% of non-Hispanic Blacks, 49% of Asians and 32% of Hispanics (p < 0.001). Predictors for PIAT varied between race/ethnicity. PIAT was evenly distributed across all levels of socioeconomic status suggesting that PIAT and socioeconomic status are not related. PIAT and its severity were significantly associated with abnormal chest x-ray, p < 0.0001. There was no association between race/ethnicity and time to beginning TB treatment, p = 0.978.
Despite controlling for cigarette smoking, socioeconomic status and time to beginning TB treatment, non-Hispanic White race/ethnicity remained an independent predictor for disproportionately frequent and severe pulmonary impairment after tuberculosis relative to other race/ethnic groups. Since race/ethnicity was self reported and that race is not a biological construct: these findings must be interpreted with caution. However, because race/ethnicity is a proxy for several other unmeasured host, pathogen or environment factors that may contribute to disparate health outcomes, these results are meant to suggest hypotheses for further research.
PMCID: PMC3305434  PMID: 22325005
17.  Maternal mortality in New York City: Excess mortality of black women 
To assess maternal mortality in New York City, birth certificates and mortality records for New York City from 1988 through 1994 were linked and examined. During these 7 years, maternal mortality in New York City (defined by the International Classification of Diseases, 9th edition [ICD-9], as 630–676) per 100,000 live births signicantly exceeded that of the country as a whole (20.2 vs. 8.2, respectively). Within New York City, an even greater variation of maternal mortality by race/ethnicity was noted, with the mortality ratio of whites, blacks, and Hispanics being 7.1, 39.5, and 14.4 per 100,000 live births, respectively. Socioeconomic characteristics such as educational attainment, marital status, and income influenced maternal mortality more in non-blacks than blacks. Analyses of cause-specific mortality revealed that, overall, ectopic pregnancy, embolism, and hypertension were the leading causes of death. However, the major factors explaining the excess maternal mortality among blacks were hypertension (mortality ratio of blacks to whites 5.57,95% confidence interval 2.30–13.39), ectopic pregnancy (4.78,95% confidence interval 2.40–9.51), and abortion (4.58, 95% confidence interval 1.72–12.22). These findings confirm a persisting gap in maternal death between black and white women. Indeed, if all New Yorkers who became pregnant enjoyed the survival of the city's non-Hispanic white residents, the difference in maternal mortality between the city and the nation would be eliminated.
PMCID: PMC3456768  PMID: 11194313
18.  Maternal Factors and Disparities Associated with Oral Clefts 
Ethnicity & disease  2010;20(1 Suppl 1):S1-146-9.
The epidemiology of oral clefts continually unfolds. Researchers have not reached consensus concerning the significance of maternal smoking, weight gain, diabetes, age, and education and the risk of oral clefts. The purpose of this study was to examine these factors associated with oral clefts in the US population.
The 2005 US Natality Data File was utilized for this study. Bivariate analyses compared the characteristics of mothers of infants with and without oral clefts. Multivariate analysis calculated adjusted odds ratios for various maternal characteristics overall and for each race/ethnic group.
Significant bivariate associations with oral clefts were found for maternal age, race/ethnicity, education, tobacco use, and pregnancy-associated hypertension. Multivariate models found maternal age (OR=0.98), race/ethnicity (OR=0.36) for non-Hispanic Blacks (OR=0.79 for Hispanics), and tobacco use (OR=1.66) significant after adjustment for covariates. Across all race/ethnic groups maternal age (OR=0.98) and smoking (OR=1.66) were significantly associated with increased risk for oral cleft (OC). Non-Hispanic Blacks and Hispanics were at lower risk for OC regardless of the presence or absence of pregnancy-associated hypertension.
Consistent with previous studies, maternal smoking was found to be associated with an increased risk of oral clefts. This association was significant for non-Hispanic Whites but not for non-Hispanic Blacks and Hispanics. A small inverse association was observed between maternal age, pregnancy-associated hypertension and the risk of oral clefts. This study confirms relationships found in previous studies but cannot establish causality. Further investigations of the risk factors for oral clefts would benefit from the study of gene-environment interactions.
PMCID: PMC2994716  PMID: 20521404
Oral Clefts; Maternal Smoking; Maternal Diabetes; Maternal Alcohol Consumption; Disparities; Birth Defects
19.  Comparison of Ischemic Stroke Outcomes and, Patient and Hospital Characteristics by Race/Ethnicity and Socioeconomic Status 
Background and Purpose
Current literature provides mixed evidence on disparities by race/ethnicity and socioeconomic status (SES) in discharge outcomes following hospitalization for acute ischemic stroke. Using comprehensive data from eight states, we sought to compare inpatient mortality and length of stay (LOS) by race/ethnicity and SES.
We examined all 2007 hospitalizations for acute ischemic stroke in all non-Federal acute care hospitals in AZ, CA, FL, MA, NJ, NY, PA and TX. Population was stratified by race/ethnicity (non-Hispanic Whites, non-Hispanic Blacks and Hispanics) and SES, measured by median income of patient zip code. For each stratum we estimated risk-adjusted rates of inpatient mortality and longer LOS (> median LOS). We also compared the hospitals where these subpopulations received care.
Hispanic and Black patients accounted for 14 and 12 percent of all ischemic stroke admissions (N=147,780) respectively and had lower crude inpatient mortality rates (Hispanic=4.5%, Blacks=4.4%; all p-values < 0.001) compared to White patients (5.8%). Hispanic and Black patients were younger and fewer had any form of atrial fibrillation. Adjusted for patient risk, inpatient mortality was similar by race/ethnicity, but was significantly higher for low area-income patients than that for high area-income patients (Odds Ratio=1.08, 95% confidence interval=[1.02, 1.15]). Risk-adjusted rates of longer LOS were higher among minority and low area-income populations.
Risk adjusted inpatient mortality was similar among patients by race/ethnicity but higher among patients from lower income areas. However, this pattern was not evident in sensitivity analyses including the use of mechanical ventilation as a partial surrogate for stroke severity.
PMCID: PMC3595403  PMID: 23306327
ischemic stroke; inpatient mortality; length of stay; race; ethnicity; socioeconomic status; risk factors
20.  Secondhand Smoke Risk in Infants Discharged from an NICU: Potential for Significant Health Disparities? 
Nicotine & Tobacco Research  2011;13(11):1015-1022.
Secondhand smoke exposure (SHSe) threatens fragile infants discharged from a neonatal intensive care unit (NICU). Smoking practices were examined in families with a high respiratory risk infant (born at very low birth weight; ventilated > 12 hr) in a Houston, Texas, NICU. Socioeconomic status, race, and mental health status were hypothesized to be related to SHSe and household smoking bans.
Data were collected as part of The Baby's Breath Project, a hospital-based SHSe intervention trial targeting parents with a high-risk infant in the NICU who reported a smoker in the household (N = 99). Measures of sociodemographics, smoking, home and car smoking bans, and depression were collected.
Overall, 26% of all families with a high-risk infant in the NICU reported a household smoker. Almost half of the families with a smoker reported an annual income of less than $25,000. 46.2% of families reported having a total smoking ban in place in both their homes and cars. Only 27.8% families earning less than $25,000 reported having a total smoking ban in place relative to almost 60% of families earning more (p < .01). African American and Caucasian families were less likely to have a smoking ban compared with Hispanics (p < .05). Mothers who reported no smoking ban were more depressed than those who had a household smoking ban (p < .02).
The most disadvantaged families were least likely to have protective health behaviors in place to reduce SHSe and, consequently, are most at-risk for tobacco exposure and subsequent tobacco-related health disparities. Innovative SHSe interventions for this vulnerable population are sorely needed.
PMCID: PMC3430443  PMID: 21669959
21.  Education and race-ethnicity differences in the lifetime risk of alcohol dependence 
While lower socioeconomic status (SES) is related to higher risk for alcohol dependence, minority race-ethnicity is often associated with lower risk. This study attempts to clarify the nature and extent of social inequalities in alcohol dependence by investigating the effects of SES and race-ethnicity on the development of alcohol dependence following first alcohol use.
Cross-sectional analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43 093). Survival analysis was used to model alcohol dependence onset according to education, race-ethnicity and their interaction.
United States, 2001–2.
Compared with non-Hispanic white people, age-adjusted and sex-adjusted risks of alcohol dependence were lower among black people (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.63 to 0.78), Asians (OR = 0.65, CI = 0.49 to 0.86) and Hispanics (OR = 0.68, CI = 0.58 to 0.79) and higher among American Indians (OR = 1.37, CI = 1.09 to 1.73). Individuals without a college degree had higher risks of alcohol dependence than individuals with a college degree or more; however, the magnitude of risk varied significantly by race-ethnicity (χ2 for the interaction between education and race-ethnicity = 19.7, df = 10, p = 0.03); odds ratios for less than a college degree were 1.12, 1.46, 2.24, 2.35 and 10.99 among Hispanics, white people, black people, Asians, and American Indians, respectively. There was no association between education and alcohol dependence among Hispanics.
Race-ethnicity differences in the magnitude of the association between education and alcohol dependence suggest that aspects of racial-ethnic group membership mitigate or exacerbate the effects of social adversity.
PMCID: PMC2748996  PMID: 18272737
22.  Maternal and infant characteristics associated with prone and lateral infant sleep positioning in Washington State, 1996-2002 
The Journal of pediatrics  2008;153(2):194-198.e3.
To identify factors predictive of either lateral or prone infant sleep positioning.
Study design
We used data for 11,340 mother-infant pairs from the Pregnancy Risk Assessment Monitoring System for infants born in Washington State, 1996–2002. We employed predictive modeling to identify statistically significant (p<0.05) predictors of lateral and prone sleep positioning.
Factors associated with both high-risk sleep positions included infant’s year-of-birth, maternal race and ethnicity, maternal county of residence, and maternal parity. Mother’s being US-born (vs. foreign-born) and male infant sex were predictive only of prone sleep positioning. Having Medicaid as primary insurance, receipt of government benefits, low infant gestational age, and low birth weight were predictive only of lateral sleep positioning.
Factors predictive of either high-risk sleep position should be considered when devising public health intervention strategies for the prevention of SIDS.
PMCID: PMC2570534  PMID: 18534224
Sudden Infant Death Syndrome (SIDS); Pregnancy Risk Assessment Monitoring (PRAMS)
23.  Should Gestational Weight Gain Recommendations be Tailored by Maternal Characteristics? 
American Journal of Epidemiology  2011;174(2):136-146.
The authors tested whether the relation between gestational weight gain (GWG) and 5 adverse pregnancy outcomes (small-for-gestational-age (SGA) birth, large-for-gestational-age (LGA) birth, spontaneous preterm birth, indicated preterm birth, and unplanned cesarean delivery) differed according to maternal race/ethnicity, smoking, parity, age, and/or height. They also evaluated whether GWG guidelines should be modified for special populations by studying GWG and risk of at least 1 adverse outcome within different subgroups. Data came from a cohort of 23,362 normal-weight mothers who delivered singletons at Magee-Womens Hospital in Pittsburgh, Pennsylvania (2003–2008). Adequacy of GWG was defined as observed GWG divided by recommended GWG. The synergy analysis found that the combination of smoking, black race/ethnicity, primiparity, or short height with poor GWG was associated with an excess risk of SGA birth, while high GWG combined with each of these characteristics diminished risk of LGA birth in comparison with the same GWG among the women's counterparts. Nevertheless, there were no significant or meaningful differences in the risk of at least 1 adverse outcome between the GWG recommended by the Institute of Medicine in 2009 and the GWG that minimized risk of the composite outcome. These findings do not support the tailoring of GWG guidelines on the basis of a mother's smoking status, race/ethnicity, parity, age, or height among normal-weight women.
PMCID: PMC3167680  PMID: 21633118
ethnic groups; gestational age; parity; practice guidelines as topic; pregnancy; smoking; weight gain
24.  Socio-economic and Ethnic Disparities in Cardiovascular Risk In the United States, 2001-2006 
Annals of epidemiology  2010;20(8):617-628.
To quantify socioeconomic status and ethnic differences in risk for coronary heart disease (CHD) accrued from major risk factors, in the United States (US).
Data came from the National Health and Nutrition Examination Survey 2001-2006. Outcomes examined were a) 10-year risk for CHD events as predicted by the National Cholesterol Education Program Adult Treatment Panel III 2004 Updated guidelines, and b) the prevalence of the metabolic syndrome and overt diabetes mellitus (a CHD risk-equivalent).
Strong inverse socioeconomic gradients with risk were present in all race/ethnicity groups except foreign-born Mexican American men, and were attenuated by controls for physical activity, smoking, and abdominal obesity. In contrast, race/ethnicity disparities were seen in some but not all socioeconomic strata, with some Non-Hispanic Blacks and US-born Mexican Americans having higher risk and some Foreign-born Mexican Americans having lower risk.
Disparities in cardiovascular risk in the United States are primarily related to SES, and less to race/ethnicity. Socioeconomically disadvantaged individuals should be targeted for lifestyle counseling and early screening for risk factors, regardless of race/ethnicity, to reduce social disparities in cardiovascular outcomes.
PMCID: PMC2901883  PMID: 20609342
Socioeconomic status; ethnic differences; Framingham risk score; metabolic syndrome
25.  The impact of advanced maternal age and parity on obstetric and perinatal outcomes in singleton gestations 
To investigate the effect of advanced maternal age (AMA) separately in nulliparous and multiparous women on obstetric and perinatal outcomes in singleton gestations.
Study design
A historical cohort study on data from 6,619 singleton pregnancies between 2004 and May 2007 was performed. AMA was defined as 35 years and older. Obstetric and perinatal outcomes in AMA versus women younger than 35 years (non-AMA) were compared for both nulli- and multiparae with Student’s t-test and Chi-square test in univariate analysis. Multiple logistic regression analysis was performed to examine the independent effect of AMA.
Out of 6,619 singleton pregnancies, the frequency of nulliparity was 42.7 and 33.4% of the parturients were of AMA. Among nulliparous women, AMA was significantly associated with a higher frequency of caesarean section both before labour (OR 2.26 with 95% CI 1.74–2.94), in labour (OR 1.44 with 95% CI 1.07–1.93), and more instrumental vaginal deliveries (ORs 1.49 with 95% CI 1.13–1.96). Among multiparous women, AMA was only significantly associated with a higher caesarean section rate before labour (ORs 1.42, 95% CI 1.19–1.69). There were no significant differences between the two age groups in the prevalence of other adverse obstetric outcomes and adverse perinatal outcomes.
Operative delivery is increased in AMA, including caesarean sections, as well as instrumental vaginal deliveries in nulliparous women. In multiparous women, however, only the rate of caesarean section before labour was increased. AMA had no significant effect on other adverse obstetric and perinatal outcomes irrespective of parity.
PMCID: PMC3112324  PMID: 20632182
Advanced maternal age (AMA); Parity; Obstetric outcome; Perinatal outcome

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