JOGNN
RESEARCH
Birth Outcomes of Hispanic Women and Risks or Strengths Associated with Ethnicity and Texas Border Residence Lorraine O. Walker, Hsiu-Rong Cheng, and Adama Brown
Correspondence Lorraine O. Walker, RN, EdD, MPH, University of Texas at Austin, School of Nursing, 1710 Red River St., Austin, TX 78701. [email protected]
ABSTRACT
Keywords breastfeeding cesarean gestational weight gain Hispanic macrosomia Texas U.S.-Mexico border
Methods: We used adjusted odds ratios (AOR) in logistic regression analyses to test the association of Hispanic ethnicity, border residence, and their interaction with high GWG, cesarean birth, macrosomia, and breastfeeding status at discharge.
Objective: To assess Hispanic ethnicity, border residence, or their interaction for association with risk of high gestational weight gain (GWG) and related outcomes. Design: Retrospective analysis of 2009 birth data. Setting: Texas. Participants: Participants included 146,458 Hispanic and 104,399 non-Hispanic (NH) White women.
Results: After adjusting for covariates, risk of inadequate or excessive GWG was not associated with being a border resident, but Hispanic women compared to NH White women had an increased risk of inadequate GWG (AOR = 1.21, 99% confidence interval [CI] [1.17, 1.26]) and decreased risk of excessive GWG (AOR = 0.77, 99% CI [0.74, 0.79]). Risk of cesarean birth was increased for border residents (AOR = 1.22, 99% CI [1.05, 1.42]), and this risk was increased further among border residents who were Hispanic (AOR = 1.52, 99% CI [1.30, 1.77]). Conclusion: We found strengths and vulnerabilities among Hispanic and border-residing women. Hispanic women were at lower risk of excessive GWG than NH White women. Border-residing Hispanic women were at greater risk of cesarean birth than other women.
JOGNN, 43, 422-434; 2014. DOI: 10.1111/1552-6909.12467 Accepted March 2014
Lorraine O. Walker, RN, EdD, MPH, is a Luci B. Johnson Centennial Professor in Nursing in the School of Nursing, University of Texas at Austin, Austin, TX. Hsiu-Rong Cheng, RN, PhD, is an associate professor in the Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan. Adama Brown, PhD, is a research scientist in the School of Nursing, University of Texas at Austin, Austin, TX.
The authors report no conflict of interest or relevant financial relationships.
422
ispanic women had 918,129 live births in the United States in 2011 (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). They generally have similar or better birth outcomes than non-Hispanic (NH) White women for many traditional indictors, such as low birth weight and preterm birth (Brown, Chireau, Jallah, & Howard, 2007; Walker & Chesnut, 2010). The obesity epidemic, however, has triggered concern about an additional set of weight-related birth outcomes, such as excessive gestational weight gain (GWG) (Kolielat & Whaley, 2013), high infant birth weight or macrosomia (Kabali & Werler, 2007), cesarean birth (Stotland, Hopkins, & Caughey, 2004), and decreased breastfeeding (Kugyelka, Rasmussen, & Frongillo, 2004). Because Hispanic women are a diverse population varying by geography and cultural background, it is important to understand how subpopulations fare on these latter weightrelated birth outcomes to better meet their health
H
care needs. Thus, we examined birth outcomes among Hispanic women who live in the unique border region of Texas versus outside this region in comparison to NH White women in these regions. Note, we use the terms Hispanic and Latino interchangeably because each are used in health and demographic studies.
Background The Latino/Hispanic Paradox The concept of the Latino or Hispanic paradox was introduced to describe the phenomenon of unexpectedly positive health outcomes among Hispanic populations living in the context of low socioeconomic resources (Acevedo-Garcia & Bates, 2008). One manifestation of this paradox is favorable birth outcomes among Hispanic women and their infants that often match or exceed those of NH White women (Brown et al., 2007;
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
RESEARCH
Walker, L. O., Cheng, H.-R., and Brown, A.
Fuentes-Afflick, Hessol, & Perez-Stable, 1997). Poverty or low socioeconomic resources and related disadvantages are generally associated with poorer health and higher rates of mortality (Turrell, Lynch, Leite, Raghunathan, & Kaplan, 2007). Similarly, low socioeconomic resources and disadvantage generally are associated with increased risk of unfavorable birth outcomes, such as preterm birth or low birth weight (Kramer, Sequin, Lydon, & Goulet, 2000). Nonetheless, Hispanic women and infants often demonstrate the paradox of favorable birth outcomes in the context of low resources (McGlade, Saha, & Dahlstrom, 2004). Yet there are many facets to the Hispanic or Latino paradox that warrant further examination (Acevedo-Garcia & Bates, 2008), and in this article we address two of them. The first relates to birth outcomes among Hispanic subpopulations defined by place, such as the demographically and culturally unique Texas–Mexico border region. Despite areas of extensive poverty in this region, it also may imbue strengths favorable to health stemming from cultural values and traditions related to the density of Latinos in the region (Shaw, Pickett, & Wilkinson, 2010). The second concern regards whether the favorable birth outcomes generally seen in Hispanic populations also extend to weight-related outcomes, such as high GWG or its potential consequences. Because prior estimates (Walker, Hoke, & Brown, 2009; Wells, Schwalberg, Noonan, & Gabor, 2006) often were not based on revised GWG guidelines (Institute of Medicine [IOM], 2009), or included only low-income women (Headen, Davis, Mujahid, & Abrams, 2012), revisiting how Hispanic women fare on weight-related birth outcomes is warranted.
The Texas–Mexico Border Region and Latino Women Hispanic women are often treated as a single population, but variations by region and ethnic subpopulations may result in differing patterns of health and perinatal outcomes (Freeman, & Lethbridge-Cejku, 2006; McDonald, Suellentrop, Paulozzi, & Morrow, 2008; Zsembik & Fennell, 2005). For this reason, the Texas portion of the U.S.–Mexico border region is of special interest because of its unique demographic composition, scope of poverty, and health challenges. The 62-mile wide American side of the U. S.-Mexico border region has its longest segment, anchored at one end by the city of El Paso and at the other end by Brownsville—falls in 32 counties of Texas (United States-Mexico
JOGNN 2014; Vol. 43, Issue 4
Hispanic women are often treated as a single population, but variations by region and ethnic subpopulations may result in differing patterns of perinatal outcomes.
Border Health Commission, 2010a) that span more than 1200 miles (Beaver, 2006). In one half of the 32 counties in this region more than 80% of the population is Hispanic, and in 14 counties more than twice as many live in poverty compared to the national average (U.S. Census Bureau, 2011). The fertility rate for Hispanic women in this region is twice that of White women, and diabetes prevalence is 16.1% (United States-Mexico Border Health Commission, 2010a). Of the 405,554 Texas-resident births in 2008 (Martin, Hamilton, Sutton, Ventura, Matthews, & Osterman, 2010b), 51,975 births were to border-county residents with 48,702 (93.7%) of those to Hispanic women (Texas Department of State Health Services, 2011). Although obesity is an important health problem for the U.S.–Mexico border region (California Department of Public Health, 2011; Texas Department of State Health Services, n.d.; United States-Mexico Border Health Commission, ´ 2010b), excessive GWG is one aspect of this problem about which little is known for Hispanic women dwelling in the border region compared to women elsewhere. GWG includes not only fetal growth but also changes in maternal tissues including fat deposition (Hytten, 1991; Sohlstrom & Forsum, 1995), which if excessive may contribute to weight gain and obesity after pregnancy (Hernandez, 2012; Mamun et al., 2010; Walker, Fowles, & Sterling, 2011). If subsequent maternal obesity occurs, it may increase risk of obesityrelated morbidities over the life course, such as type-2 diabetes and cardiovascular disease in women (Field et al. 2001; Must et al., 1999). Excessive GWG is of particular concern for Hispanic women of Mexican ancestry because their obesity prevalence rose from 35.3% to 45.1% between 1988–1994 and 2007–2008, and they now rank second to African American women in obesity prevalence (Ogden & Carroll, 2010).
Weight-Related Birth Outcomes Excessive GWG may occur in as many as 40% of normal weight women with still higher percentages in overweight women (Chu, Callaghan, Bish, & D’Angelo, 2009). In general, low-income Hispanic women are reported to be a lower risk of excessive GWG than NH White women (43% vs. >50%)
423
RESEARCH
Birth Outcomes of Hispanic Women and Risks or Strengths Associated with Ethnicity and Texas Border Residence
(Headen et al., 2012). Still, evidence is sparse regarding excessive GWG among women in the U.S.–Mexico border region (Feldman & Pittman, 2008; Walker et al., 2009). A study in New Mexico showed that 35.7% of Hispanic women had high GWG (Walker et al., 2009). Hispanic border residents in this study were at reduced risk of high GWG than nonborder residents; however, this study was completed prior to 2009 changes in body mass index (BMI)-linked recommendations for GWG (Institute of Medicine, 2009). Investigators in a more recent study on the Mexican side of the border, which used the 2009 IOM guidelines, reported that 37.5% of Mexican women in Tijuana had excessive GWG (ZonanaNacach, Baldenebro-Preciado, & Ruiz-Dorado, 2010). Given these few studies of GWG in the border region, it is unclear if Hispanic women in the border region are at greater risk of excessive GWG than Hispanic women in other regions, or than NH White women in the border region. Analysis of perinatal data that clarifies these associations would aid in better understanding the maternal health needs in the border region. If Hispanic women have excessive GWG, particularly if accompanied by prepregnancy obesity, they or their infants may be at higher risk of other unfavorable outcomes. These include perinatal outcomes, such as, cesarean birth (Stotland et al., 2004) and infant macrosomia (Kabali & Werler, 2007; Walker et al., 2009). It is unclear if excessive GWG is associated with reduced breastfeeding initiation or continuation among Hispanic women (Hilson, Rasmussen, & Kjolhede, 2006; Walker et al., 2009), although maternal obesity is associated with reduced breastfeeding (Kugyelka et al., 2004).
Purpose To understand weight-related birth outcomes in the border region, it is important to know if women in this region generally are at higher risk of excessive GWG and obesity-related perinatal outcomes than women elsewhere, and if Hispanic women specifically, who are the majority population of this region, are at higher risk than Hispanic women elsewhere. In this paper we draw on Texas birth data to address these considerations.
424
of excessive (or inadequate) GWG among women giving birth in Texas in 2009. The second aim was to examine if border region residence, Hispanic ethnicity, or their interaction, as well as patterns of GWG, was associated with these perinatal outcomes: cesarean birth, infant macrosomia, and breastfeeding on discharge.
Methods Design and Sample This is a retrospective analysis of birth certificate data obtained from the Center for Health Statistics, Texas Department of State Health Services, for 2009 resident births. The authors’ university Institutional Review Board classified this study as exempt. Because of our study focus, we extracted cases for analysis that were Hispanic or non-Hispanic (NH)-white, with the latter serving as the reference population. Of the 401,599 resident births in the 2009 dataset, 336,299 met initial inclusion criteria: 201,042 Hispanic women (who designated only one Hispanic ethnic subgroup– Mexican, Puerto Rican, Cuban, or other Hispanic) and 135,257 NH White women (who designated a single race). From these, we sequentially excluded births that were plural; were to women aged
RESEARCH
Birth Outcomes of Hispanic Women and Risks or Strengths Associated with Ethnicity and Texas Border Residence Lorraine O. Walker, Hsiu-Rong Cheng, and Adama Brown
Correspondence Lorraine O. Walker, RN, EdD, MPH, University of Texas at Austin, School of Nursing, 1710 Red River St., Austin, TX 78701. [email protected]
ABSTRACT
Keywords breastfeeding cesarean gestational weight gain Hispanic macrosomia Texas U.S.-Mexico border
Methods: We used adjusted odds ratios (AOR) in logistic regression analyses to test the association of Hispanic ethnicity, border residence, and their interaction with high GWG, cesarean birth, macrosomia, and breastfeeding status at discharge.
Objective: To assess Hispanic ethnicity, border residence, or their interaction for association with risk of high gestational weight gain (GWG) and related outcomes. Design: Retrospective analysis of 2009 birth data. Setting: Texas. Participants: Participants included 146,458 Hispanic and 104,399 non-Hispanic (NH) White women.
Results: After adjusting for covariates, risk of inadequate or excessive GWG was not associated with being a border resident, but Hispanic women compared to NH White women had an increased risk of inadequate GWG (AOR = 1.21, 99% confidence interval [CI] [1.17, 1.26]) and decreased risk of excessive GWG (AOR = 0.77, 99% CI [0.74, 0.79]). Risk of cesarean birth was increased for border residents (AOR = 1.22, 99% CI [1.05, 1.42]), and this risk was increased further among border residents who were Hispanic (AOR = 1.52, 99% CI [1.30, 1.77]). Conclusion: We found strengths and vulnerabilities among Hispanic and border-residing women. Hispanic women were at lower risk of excessive GWG than NH White women. Border-residing Hispanic women were at greater risk of cesarean birth than other women.
JOGNN, 43, 422-434; 2014. DOI: 10.1111/1552-6909.12467 Accepted March 2014
Lorraine O. Walker, RN, EdD, MPH, is a Luci B. Johnson Centennial Professor in Nursing in the School of Nursing, University of Texas at Austin, Austin, TX. Hsiu-Rong Cheng, RN, PhD, is an associate professor in the Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan. Adama Brown, PhD, is a research scientist in the School of Nursing, University of Texas at Austin, Austin, TX.
The authors report no conflict of interest or relevant financial relationships.
422
ispanic women had 918,129 live births in the United States in 2011 (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). They generally have similar or better birth outcomes than non-Hispanic (NH) White women for many traditional indictors, such as low birth weight and preterm birth (Brown, Chireau, Jallah, & Howard, 2007; Walker & Chesnut, 2010). The obesity epidemic, however, has triggered concern about an additional set of weight-related birth outcomes, such as excessive gestational weight gain (GWG) (Kolielat & Whaley, 2013), high infant birth weight or macrosomia (Kabali & Werler, 2007), cesarean birth (Stotland, Hopkins, & Caughey, 2004), and decreased breastfeeding (Kugyelka, Rasmussen, & Frongillo, 2004). Because Hispanic women are a diverse population varying by geography and cultural background, it is important to understand how subpopulations fare on these latter weightrelated birth outcomes to better meet their health
H
care needs. Thus, we examined birth outcomes among Hispanic women who live in the unique border region of Texas versus outside this region in comparison to NH White women in these regions. Note, we use the terms Hispanic and Latino interchangeably because each are used in health and demographic studies.
Background The Latino/Hispanic Paradox The concept of the Latino or Hispanic paradox was introduced to describe the phenomenon of unexpectedly positive health outcomes among Hispanic populations living in the context of low socioeconomic resources (Acevedo-Garcia & Bates, 2008). One manifestation of this paradox is favorable birth outcomes among Hispanic women and their infants that often match or exceed those of NH White women (Brown et al., 2007;
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
RESEARCH
Walker, L. O., Cheng, H.-R., and Brown, A.
Fuentes-Afflick, Hessol, & Perez-Stable, 1997). Poverty or low socioeconomic resources and related disadvantages are generally associated with poorer health and higher rates of mortality (Turrell, Lynch, Leite, Raghunathan, & Kaplan, 2007). Similarly, low socioeconomic resources and disadvantage generally are associated with increased risk of unfavorable birth outcomes, such as preterm birth or low birth weight (Kramer, Sequin, Lydon, & Goulet, 2000). Nonetheless, Hispanic women and infants often demonstrate the paradox of favorable birth outcomes in the context of low resources (McGlade, Saha, & Dahlstrom, 2004). Yet there are many facets to the Hispanic or Latino paradox that warrant further examination (Acevedo-Garcia & Bates, 2008), and in this article we address two of them. The first relates to birth outcomes among Hispanic subpopulations defined by place, such as the demographically and culturally unique Texas–Mexico border region. Despite areas of extensive poverty in this region, it also may imbue strengths favorable to health stemming from cultural values and traditions related to the density of Latinos in the region (Shaw, Pickett, & Wilkinson, 2010). The second concern regards whether the favorable birth outcomes generally seen in Hispanic populations also extend to weight-related outcomes, such as high GWG or its potential consequences. Because prior estimates (Walker, Hoke, & Brown, 2009; Wells, Schwalberg, Noonan, & Gabor, 2006) often were not based on revised GWG guidelines (Institute of Medicine [IOM], 2009), or included only low-income women (Headen, Davis, Mujahid, & Abrams, 2012), revisiting how Hispanic women fare on weight-related birth outcomes is warranted.
The Texas–Mexico Border Region and Latino Women Hispanic women are often treated as a single population, but variations by region and ethnic subpopulations may result in differing patterns of health and perinatal outcomes (Freeman, & Lethbridge-Cejku, 2006; McDonald, Suellentrop, Paulozzi, & Morrow, 2008; Zsembik & Fennell, 2005). For this reason, the Texas portion of the U.S.–Mexico border region is of special interest because of its unique demographic composition, scope of poverty, and health challenges. The 62-mile wide American side of the U. S.-Mexico border region has its longest segment, anchored at one end by the city of El Paso and at the other end by Brownsville—falls in 32 counties of Texas (United States-Mexico
JOGNN 2014; Vol. 43, Issue 4
Hispanic women are often treated as a single population, but variations by region and ethnic subpopulations may result in differing patterns of perinatal outcomes.
Border Health Commission, 2010a) that span more than 1200 miles (Beaver, 2006). In one half of the 32 counties in this region more than 80% of the population is Hispanic, and in 14 counties more than twice as many live in poverty compared to the national average (U.S. Census Bureau, 2011). The fertility rate for Hispanic women in this region is twice that of White women, and diabetes prevalence is 16.1% (United States-Mexico Border Health Commission, 2010a). Of the 405,554 Texas-resident births in 2008 (Martin, Hamilton, Sutton, Ventura, Matthews, & Osterman, 2010b), 51,975 births were to border-county residents with 48,702 (93.7%) of those to Hispanic women (Texas Department of State Health Services, 2011). Although obesity is an important health problem for the U.S.–Mexico border region (California Department of Public Health, 2011; Texas Department of State Health Services, n.d.; United States-Mexico Border Health Commission, ´ 2010b), excessive GWG is one aspect of this problem about which little is known for Hispanic women dwelling in the border region compared to women elsewhere. GWG includes not only fetal growth but also changes in maternal tissues including fat deposition (Hytten, 1991; Sohlstrom & Forsum, 1995), which if excessive may contribute to weight gain and obesity after pregnancy (Hernandez, 2012; Mamun et al., 2010; Walker, Fowles, & Sterling, 2011). If subsequent maternal obesity occurs, it may increase risk of obesityrelated morbidities over the life course, such as type-2 diabetes and cardiovascular disease in women (Field et al. 2001; Must et al., 1999). Excessive GWG is of particular concern for Hispanic women of Mexican ancestry because their obesity prevalence rose from 35.3% to 45.1% between 1988–1994 and 2007–2008, and they now rank second to African American women in obesity prevalence (Ogden & Carroll, 2010).
Weight-Related Birth Outcomes Excessive GWG may occur in as many as 40% of normal weight women with still higher percentages in overweight women (Chu, Callaghan, Bish, & D’Angelo, 2009). In general, low-income Hispanic women are reported to be a lower risk of excessive GWG than NH White women (43% vs. >50%)
423
RESEARCH
Birth Outcomes of Hispanic Women and Risks or Strengths Associated with Ethnicity and Texas Border Residence
(Headen et al., 2012). Still, evidence is sparse regarding excessive GWG among women in the U.S.–Mexico border region (Feldman & Pittman, 2008; Walker et al., 2009). A study in New Mexico showed that 35.7% of Hispanic women had high GWG (Walker et al., 2009). Hispanic border residents in this study were at reduced risk of high GWG than nonborder residents; however, this study was completed prior to 2009 changes in body mass index (BMI)-linked recommendations for GWG (Institute of Medicine, 2009). Investigators in a more recent study on the Mexican side of the border, which used the 2009 IOM guidelines, reported that 37.5% of Mexican women in Tijuana had excessive GWG (ZonanaNacach, Baldenebro-Preciado, & Ruiz-Dorado, 2010). Given these few studies of GWG in the border region, it is unclear if Hispanic women in the border region are at greater risk of excessive GWG than Hispanic women in other regions, or than NH White women in the border region. Analysis of perinatal data that clarifies these associations would aid in better understanding the maternal health needs in the border region. If Hispanic women have excessive GWG, particularly if accompanied by prepregnancy obesity, they or their infants may be at higher risk of other unfavorable outcomes. These include perinatal outcomes, such as, cesarean birth (Stotland et al., 2004) and infant macrosomia (Kabali & Werler, 2007; Walker et al., 2009). It is unclear if excessive GWG is associated with reduced breastfeeding initiation or continuation among Hispanic women (Hilson, Rasmussen, & Kjolhede, 2006; Walker et al., 2009), although maternal obesity is associated with reduced breastfeeding (Kugyelka et al., 2004).
Purpose To understand weight-related birth outcomes in the border region, it is important to know if women in this region generally are at higher risk of excessive GWG and obesity-related perinatal outcomes than women elsewhere, and if Hispanic women specifically, who are the majority population of this region, are at higher risk than Hispanic women elsewhere. In this paper we draw on Texas birth data to address these considerations.
424
of excessive (or inadequate) GWG among women giving birth in Texas in 2009. The second aim was to examine if border region residence, Hispanic ethnicity, or their interaction, as well as patterns of GWG, was associated with these perinatal outcomes: cesarean birth, infant macrosomia, and breastfeeding on discharge.
Methods Design and Sample This is a retrospective analysis of birth certificate data obtained from the Center for Health Statistics, Texas Department of State Health Services, for 2009 resident births. The authors’ university Institutional Review Board classified this study as exempt. Because of our study focus, we extracted cases for analysis that were Hispanic or non-Hispanic (NH)-white, with the latter serving as the reference population. Of the 401,599 resident births in the 2009 dataset, 336,299 met initial inclusion criteria: 201,042 Hispanic women (who designated only one Hispanic ethnic subgroup– Mexican, Puerto Rican, Cuban, or other Hispanic) and 135,257 NH White women (who designated a single race). From these, we sequentially excluded births that were plural; were to women aged
