Maternal & Child Health Data by Southern Plains Tribal Health Board

MATERNAL

& CHILD HEALTH DATA

Suggested Citation Akbaran, M., Tayarachakul, S., AI/AN Maternal and Child Health Data: Southern Plains Tribal Health Board Oklahoma Area Tribal Epidemiology Center 2011-2015. Kunnel, B., Patrick, P.H., Maternal and Child Health Assessment, Oklahoma State Department of Health. September 2020.

Acknowledgments The Southern Plains Tribal Health Board (SPTHB) Oklahoma Area Tribal Epidemiology Center (OKTEC) would like to thank and acknowledge the following for providing data for this report. Maternal and Child Health Assessment, Oklahoma State Department of Health. The Maternal & Child Health Data was designed by the Creative Services Department staff, Alex Smith and Chris Reed, at the Southern Plains Tribal Health Board.

CONTENTS CHAPTER 1 | POPULATION CHARACTERISTICS �� 1 Population Composition �� 1-2 Regional Distribution �� 3-4 Women Who Delivered a Live Birth ��5-6

CHAPTER 2 | REPRODUCTIVE HEALTH ��7 Birth Rate �� 7-8 Fertility Rate ��9-10 Postpartum Birth Control and Family Planning ��11-12 Intended Pregnancy ��13-14 Mistimed, Unwanted Pregnancies and Barriers of Using Birth Control �� 15-16

CHAPTER 3 | INFANT MORTALITY AND ADVERSE BIRTH OUTCOMES �� 17 Infant Mortality ��17-18 Age of Infant Death �� 19-20 Birth Defects �� 21-22 Preterm Birth �� 23-24 Low Birth weight �� 25-26 Sudden Unexpected Infant Death �� 27-28

CHAPTER 4 | PRENATAL CARE ��29 Prenatal Care Visits �� 29-30 Mother’s Health Insurance and WIC Participation ��31-32 HIV Testing and Flu/Tdap Vaccination ��33-34 Multivitamin or Prenatal Vitamin �� 35-36

CHAPTER 5 | PRENATAL SUBSTANCE USE �� 37 Prenatal Harmful Substances Use ��37-38 Prenatal Cigarette Use �� 39-40 Prenatal Alcohol Use ��41-42

CHAPTER 6 | MATERNAL HEALTH �� 43 Pre-pregnancy Body Mass Index (BMI) ��43-44 Prior to Pregnancy �� 45-46 Life Stressors ��47-48 Emotional & Physical Abuse �� 49-50 Prenatal Oral Health �� 51-52 Health-Related Discussions with Healthcare Providers �� 53-54 Maternity Leave �� 55

CHAPTER 7 | INFANT HEALTH ��56 Barriers to Breastfeeding �� 56 Breastfeeding �� 57-58 Safe Infant Sleep ��59-60 Infant Sleep Environment �� 61-62

INTRODUCTION

THIS DATA REPORT IS FUNDED BY THE SOUTHERN PLAINS TRIBAL HEALTH BOARD OKLAHOMA AREA TRIBAL EPIDEMIOLOGY CENTERâ&#x20AC;&#x2122;S COOPERATIVE AGREEMENT WITH INDIAN HEALTH SERVICE U1B1IHS0009-16-02. The Oklahoma Area Tribal Epidemiology Center (OKTEC) is a division of the Southern Plains Tribal Health Board (SPTHB). The OKTEC receives core funding from the Indian Health Service (IHS) Cooperative Agreement with IHS Division of Epidemiology and Disease Prevention. OKTEC coverage area includes Kansas, Oklahoma, and Texas and serves the 44 federally recognized tribes within that area. As a public health authority, the OKTEC works with area tribes, state agencies, tribal organizations, academic institutions, non-profits, and many other agencies to provide a wide range of resources. The SPTHB and OKTEC promote healthy communities while strengthening tribal nations. The following data provides information related to American Indian & Alaska Native Maternal and Child Health. It contains data related to women before preconception, prenatal, and postnatal care in-order to ensure a positive quality of life and to reduce morbidity and mortality in children.

Chapter 1 | population characteristics

POPULATION COMPOSITION In 2015, the total population in Oklahoma was estimated to be 3,849,733, which made up 1.2% of the total population in the United States.1 • Figure 1 indicates maternal and child health populations as a percent of the total population by AI/AN versus non-AI/AN in Oklahoma in 2015. Among AI/ANs, adult women ages 20-44 years old were 17%, followed by children ages 5-9 years old (10%), and adolescents ages 10-14 years old (9%). Compared to non-AI/ANs, adult women ages 20-44 were 16%, followed by children ages 5-9 years old (7%), and adolescents ages 10-14 years old (6%). • Figure 1 shows that approximately 1 in 5 women in Oklahoma were women of childbearing age, 15-44 years old, for both AI/ANs and non-AI/ANs. • Table 1 indicates a population composition by maternal and child health (MCH) groupings and AI/AN status in Oklahoma in 2015.

Table 1: Population Composition by Maternal and Child Health Groupings and American Indian/Alaska Native Status, Oklahoma, 2015 Data Source: National Vital Statistics, Oklahoma Vital Statistics Population Estimate Population Group

Age in Years

Non-American Indian/ Alaska Native

American Indian/Alaska Native

Infants

47,040

6,092

Children

1-4

170,597

41,991

Children

5-9

217,899

49,353

Adolescents

10-14

213,137

48,512

Women of Childbearing Age

15-44

644,024

109,778

Teen Women

15-19

102,353

21,985

Adult Women

20-44

541,671

87,793

Total MCH Population

1,292,697

255,726

Others

2,044,546

256,764

Total Oklahoma Population

3,337,243

512,490

Endnotes- Chapter 1: Population Characteristics 1 U.S. Census Bureau, 2011-2015 American Community Survey 5-Year Estimates.

Chapter 1 | population characteristics

Figure 1: Maternal and Child Health Populations as a Percent of Total Population by American Indian/Alaska Native Status Vs. Non-American Indian/Alaska Native, Oklahoma, 2015 Data Source: National Vital Statistics, Oklahoma Vital Statistics

1% 5%

1% 8%

Infant <1

7% 6% 3%

Children 1-4 Years Adolescent 10-14 Years Teen Women 15-19 Years

61% 16%

10%

Children 5-9 Years

50%

Adult Women 20-44 Years

Others 17%

Non-AI/AN

AI/AN

Chapter 1 | population characteristics

REGIONAL DISTRIBUTION To present the population distribution of AI/AN status in Oklahoma, Indian Health Service (IHS) Oklahoma Area Office Service Units were used in this data book. There are nine Indian Health Service Units in Oklahoma: Ada Service Unit, Claremore Service Unit, Clinton Service Unit, Lawton Service Unit, Pawnee Service Unit, Shawnee Service Unit, Tahlequah Service Unit, Talihina Service Unit, and Wewoka Service Unit. See Figure 2. â&#x20AC;˘ In 2015, Claremore Service Unit had the highest percentage of AI/ANs (33.0%), followed by the Shawnee Service Unit (19.0%), and the Tahlequah Service Unit (13.2%). See Table 2. â&#x20AC;˘ According to Table 2, Shawnee Service Unit had the highest percentage of non-AI/ANs (32.2%), followed by the Claremore Service Unit (28.0%), and the Clinton Service Unit (8.7%).

Table 2: Population by Indian Health Service (IHS)-Oklahoma Area Office Service Unit and American Indian/Alaska Native Status, Oklahoma, 2015 Data Source: National Vital Statistics (Census)

Non-American Indian/Alaska Native

American Indian/Alaska Native

Population Size (N)

% of total

Population Size (N)

% of total

Ada

208,951

6.3

41,760

8.1

250,711

Claremore

932,943

28.0

168,988

33.0

1,101,931

Clinton

288,799

8.7

22,013

4.3

310,812

Lawton

278,661

8.4

33,167

6.5

311,828

Pawnee

236,394

7.1

31,384

6.1

267,778

Shawnee

1,075,840

32.2

97,387

19.0

1,173,227

Tahlequah

134,542

4.0

67,759

13.2

202,301

Talihina

151,452

4.5

40,427

7.9

191,879

Wewoka

29,661

9,605

1.9

39,266

3,337,243

100

512,490

100

3,849,733

IHS Service Unit

Total

Chapter 1 | population characteristics

Figure 2: Indian Health Service (IHS)-Oklahoma Area Office Service Unit Regions Data Source: Healthcare Information, Oklahoma State Department of Health

Ada Claremore Clinton Lawton Pawnee Shawnee Tahlequah Talihina Wewoka

Chapter 1 | population characteristics

WOMEN WHO DELIVERED A LIVE BIRTH In 2016, there were 52,607 live births in Oklahoma. Among those live births, 11.8% were AI/AN mothers, and 88.2% were non-AI/AN mothers (see Table 3). Those without known maternal race were excluded in this section. • According to Table 3, among AI/AN births, 11.4% were to mothers of age 15-19 years old, and 33.5% were to mothers 20-24 years old. Among non-AI/AN births, 7.6% were to mothers 15-19 years old, and 26.3% were from mothers 20-24 years old. There was a higher percentage of births from non-AI/ANs 35 years or older, compared to AI/ANs. • AI/AN mothers were less likely to have more than 12 or more years of education than non-AI/AN mothers (44.0% vs. 55.4%, respectively). See Table 3. • According to Table 3, more AI/AN mothers were unmarried, compared to non-AI/ANs (54.3% vs. 40.7%, respectively).

Chapter 1 | population characteristics

Table 3: Characteristics of Women Who Delivered a Live Birth by American Indian/Alaska Native Status, Oklahoma, 2016 Data Source: Oklahoma Vital Statistics (OK2SHARE)

Non-American Indian/Alaska Native

American Indian/Alaska Native

Population Size (N)

Percent

Population Size (N)

Percent

15-19 years

3,538

7.6

708

11.4

20-24 years

12,182

26.3

2,073

33.5

25-34 years

25,513

55.0

2,973

48.0

5,121

11.1

435

7.0

<12 years

7,594

16.4

1,203

19.5

12 years

13,061

28.2

2,260

36.6

>12 years

25,637

55.4

2,717

44.0

Married

27,539

59.4

2,833

45.7

Unmarried

18,861

40.7

3,366

54.3

Ada Service Unit

2,659

5.7

665

10.8

Claremore Service Unit

13,372

28.9

1,824

29.5

Clinton Service Unit

3,994

8.6

273

4.4

Lawton Service Unit

3,717

8.0

384

6.2

Pawnee Service Unit

2,879

6.2

345

5.6

Shawnee Service Unit

15,908

34.4

1,054

17.0

Tahlequah Service Unit

1,623

3.5

915

14.8

Talihina Service Unit

1,827

3.9

557

9.0

Wewoka Service Unit

338

0.7

169

2.7

46,406

88.2

6,201

11.8

Maternal Age

35 years or older Maternal Education

Marital Status

Maternal Residence (IHS Service Unit)

Overall

Chapter 2 | Reproductive health

BIRTH RATE Since the early 1990s, the population in Oklahoma has seen a natural increase, which describes a situation where there are more births than deaths in the population.1 The crude birth rate is the number of live births per total number of people in the population. The teen birth rate is the number of live births to teenagers, 15-19 years old, among the total population of females 15-19 years old.2 Preterm births and low birth weight infants are more likely among teens who are often less prepared than older women for pregnancy and parenthood and with limited resources. Therefore, teen birth rate is considered as an indicator for the public health status of maternal and child health (MCH) populations.2 • In 2015, Oklahoma’s crude birth rate of 13.6 live births per 1,000 population (data not shown) was 9.7% higher than the crude birth rate of all women in the U.S. (12.4 per 1,000 population).3 • When compared with the national rate in 2015, the American Indian/Alaska Native (AI/AN) population in Oklahoma had a much higher crude birth rate (14.8 per 1,000) than that of the AI/AN population nationwide (9.7 per 1,000).3 • According to Figure 1, the Oklahoma AI/AN crude birth rate dropped from 16.9 to 14.8 per 1,000 population between 2005 to 2015. This rate was consistently higher than the Oklahoma non-American Indian/Alaska Native (non-AI/AN) rate, which was 14.3 per 1,000 in 2005 and 13.4 per 1,000 in 2015. • The Oklahoma teen birth rate in 2015 was 34.8 births per 1,000 female teens 15-19 years old, 56.1% higher than the teen birth rate of women (all races combined) in the U.S. (22.3 per 1,000).3 • In 2015, the Oklahoma AI/AN teen birth rate (38.5 per 1,000 population) was higher than the Oklahoma non-AI/AN teen birth rate (34.2 per 1,000 population). See Figure 2.

Chapter 2 | Reproductive health

Figure 2: Teen Birth Rate (per 1,000) Trend by American Indian/ Alaska Native Status, Oklahoma and U.S., 2005-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Endnotes- Chapter 2: Reproductive Health 1 Census. Natural increase. https://factfinder.census.gov/help/en/natural_increase.htm. Accessed January 25, 2017 2 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 3 Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final Data for 2015. National Vital Statistics Reports; Vol 66 No 1. Hyattsville, MD: National Center for Health Statistics. 2017.

Chapter 2 | Reproductive health

FERTILITY RATE The general fertility rate (GFR), referred to as fertility rate in charts, of a population is defined as the number of births that occur during a given time period per 1,000 women, 15-44 years old.2 The size of the population of women of childbearing age is considered in GFR, unlike the crude birth rate.2 In 2015, the GFR for the United States was 62.5 per 1,000, while Oklahoma had a higher fertility rate at 69.0 per 1,000.3 • According to Figure 3, fertility rates decreased for Oklahoma women from 71.5 to 69.0 per 1,000 women of childbearing age during 2005 to 2015. A similar trend can be seen for non-AI/AN women (70.9 to 69.2 per 1,000). However, AI/AN women in Oklahoma had a bigger drop in fertility rates (76.4 to 68.0 per 1,000) than the state’s fertility rate and non-AI/AN women’s fertility rate. • AI/ANs in Oklahoma had the highest fertility rates among women 25-29 years old at 127.7 per 1,000 women. This fertility rate was higher than non-AI/AN women (123.0 per 1,000 women), and all women in the U.S. (104.3 per 1,000 women). See Figure 4. • According to Figure 4, AI/AN women in Oklahoma had higher fertility rates in younger age groups (15-29 years old) than non-AI/AN women in Oklahoma, whose fertility rates were higher in older age groups (3044 years old) than AI/ANs. • In 2015, the Oklahoma AI/AN teen birth rate was higher among women 18-19 years old than 15-17 years old (70.3 vs. 19.0 per 1,000). The similar trend, but at much lower rates, can be seen in the rates of women (all races combined) in the U.S., 40.7 per 1,000 population ages 18-19 and 9.9 per 1,000 population ages 15-17.3

Figure 3: Fertility Rate (per 1,000) Trend by American Indian/Alaska Native Status, Oklahoma and U.S., 2005-2015 Data Source: Vital Statistics, OK2SHARE

Chapter 2 | Reproductive health

Figure 4: Fertility Rate (per 1,000) by American Indian/Alaska Native Status and Age Group, Oklahoma and U.S., 2015 Data Source: Vital Statistics, OK2SHARE

Chapter 2 | Reproductive health

POSTPARTUM BIRTH CONTROL AND FAMILY PLANNING One method of increasing the time interval between births is to use birth control shortly after giving birth (the postpartum period) .2 As soon as four to six weeks after giving birth, most women are physiologically able to get pregnant.2 The healthiest pregnancy outcomes are associated with birth-topregnancy intervals of at least two years.2 The risk of negative outcomes for the mother and the baby such as infant mortality, low birth weight, preterm birth, stillbirth, miscarriage, and maternal morbidity can increase in shorter (less than 18 months) and long inter-pregnancy intervals (greater than 59 months).2,9 In 2011-2013, according to the data from National Survey of Family Growth, 61.7% of women, 15-44 years old, nationwide, were currently using contraception.4 The most common contraceptive methods were the oral contraceptive pill (16.0%), followed by female sterilization (15.5%), male condoms (9.4%), and long-acting reversible contraceptives (7.2%).4 If the birth control method fails or if a sexually active, fertile woman does not use birth control or uses birth control inconsistently or incorrectly, she may become pregnant.2 • According to Figure 5, in 2013, the rate of postpartum birth-control uses among non-AI/AN and AI/AN women in Oklahoma was very similar, 83.4% and 83.3%, respectively. • National PRAMS data in 2011 showed that among all women in the U.S. who recently delivered a live birth, 83.7% reported using birth control after delivery, which was lower than the state’s rate (85.6%) (data not shown).5 • According to Oklahoma PRAMS data of 2004-2013, among Oklahoma overall races women who delivered a live birth in 2013, 41.8% indicated that they were using birth control at the time they got pregnant. There was a slight decrease in the prevalence of women who had a live birth despite the use of birth control during the period 2004-2013, from 45.9% to 41.8%. • In 2013, 32.5% of AI/AN women and 42.7% of non-AI/AN women in Oklahoma had a live birth despite the use of birth control. See Figure 6.

Endnotes- Chapter 2: Reproductive Health 2 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 5 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Pregnancy Risk Assessment Monitoring System [online]. 2014. [accessed Jan 31, 2017]. URL: https://nccd.cdc.gov/ pramstat/ 9 Hamley, GE., Hutcheon, JA., Kinniburg, BA. et al. Inter-pregnancy Interval and Adverse Pregnancy Outcomes. The American College of Obstetricians and Gynecologists; Vol 129 No3. https://beforeandbeyond.org/wp-content/uploads/2017/01/SIPI-and-LongitudinalAdverse-Preg-Outcomes-Hanley-2017.pdf

Chapter 2 | Reproductive health

Figure 5: Postpartum Birth Control Use (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2013 Data Source: Oklahoma Pregnancy Risk Assessment Monitoring System (PRAMS), Oklahoma State Department of Health, Maternal and Child Health Division

Figure 6: Live Births Despite the Use of Birth Control (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2013

Percent of Live Births Despite the Use of Birth Control

Data Source: Oklahoma PRAMS, Oklahoma State Department of Health, Maternal and Child Health Division

45.8 41.7

42.7

32.5

Chapter 2 | Reproductive health

INTENDED PREGNANCY A pregnancy is considered intended if the mother wanted to be pregnant at the time of conception.6 Unintended pregnancy is a pregnancy that is unwanted or mistimed, which mainly results from not using contraception, or incorrect use of contraceptive methods.7 A study that combined intended and unintended births from 1982-2010 in the United States showed that women who were unmarried, with less income and education, had disproportionately higher number of unintentional births.8 There are many risks to maternal and infant health associated with unintended pregnancy; therefore, it is crucial to plan a pregnancy before conception to achieve optimal health for both the mother and the baby.7 • According to Oklahoma PRAMS data of 2004-2013, the overall prevalence of intended pregnancy among Oklahoma women delivering a live birth slightly increased from 48.0% in 2004 to 49.3% in 2013. • The prevalence of intended pregnancy among women in Oklahoma in 2011 (53.5%) was lower than among all women in the U.S. (60.0%).5 • Among AI/AN women in Oklahoma who delivered a live birth, the prevalence of intended pregnancy increased from 42.3% in 2004 to 47.7% in 2013. Among non-AI/AN women in Oklahoma, the prevalence of intended pregnancy slightly increased from 48.6% in 2004 to 49.4% in 2013. See Figure 7. • According to Figure 8, AI/AN women in Oklahoma in 2012-2013 were less likely to have intended pregnancy when compared to overall state and national rates. For the age group 20-24 years old, the intended pregnancy rate for AI/AN women was 31.8%, while the non-AI/ANs was 40.7%, and 43.0% for women (all other races combined) in the U.S. For the age group of 25-34 years old, the intended pregnancy rate for AI/AN women was 44.4%, while for non-AI/ANs it was 59.3%, and 67.3% for women (all other races combined) in the U.S.

Chapter 2 | Reproductive health

Figure 7: Intended Pregnancy (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004- 2013 Data Source: Oklahoma PRAMS, Oklahoma State Department of Health, Maternal and Child Health Division

Figure 8: Intended Pregnancy (%) by American Indian/Alaska Native Status and Age Group, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS, Oklahoma State Department of Health, Maternal and Child Health Division

Chapter 2 | Reproductive health

MISTIMED, UNWANTED PREGNANCIES AND BARRIERS OF USING BIRTH CONTROL As mentioned in the previous section, unintended pregnancies can lead to adverse health outcomes for mothers and babies. Lower likelihood of breastfeeding, adverse birth outcomes, such as preterm delivery, low birth weight, birth defects, and delayed prenatal care are associated with unintended pregnancies.2 Poorer mental and physical health during childhood lower educational attainment and behavioral issues as teenagers can occur in children from unintended pregnancies.2 Lower selfconfidence, less social support, and greater levels of depression and perceived stress occur in women with unwanted pregnancies.2 Nationally, 60.0% of pregnancies in 2011 were intended (wanted to be pregnant then or sooner), 30.4% were mistimed (wanted pregnancy later), and 9.6% were unwanted.5 • According to Figure 9, among AI/AN women in Oklahoma, who delivered a live birth in 2012-2013, 10.6% reported that they did not want to be pregnant at all. • In 2012-2013, the prevalence of mistimed pregnancies was higher among AI/ANs compared to non-AI/AN mothers (32.1% vs. 25.0%, respectively). See Figure 9. • In 2011-2013, the most common reason for not using birth control among women who delivered live births in Oklahoma was that they didn’t mind if they got pregnant (41.3%), followed by they thought they could not get pregnant at that time (28.0%), and the third most common reason was that their husband or partner didn’t want to use anything to prevent pregnancy (19.9%). See Figure 10. • In 2011, the top three reasons for not using birth control among all women in the U.S. who delivered live births were the same as Oklahoma’s top three reasons: they didn’t mind if they got pregnant (43.8%), they thought they could not get pregnant at that time (26.5%), and their husband or partner didn’t want to use anything (18.5%).5

Chapter 2 | Reproductive health

Figure 9: Feelings About Being Pregnant Among Women Delivering Live Births (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS, Oklahoma State Department of Health, Maternal and Child Health Services

16.6%

21.2%

Wanted to be pregnant (sooner or then)

8.3%

50.1%

Mistimed (wanted pregnancy later) Didn’t want to be pregnant

36.1%

10.6%

25.0% 32.1%

Non-AI/AN

AI/AN

Figure 10: Reasons for Not Using Birth Control Among Women Delivering Live Births (%), Oklahoma, 2012-20131 Data Source: Oklahoma PRAMS, Oklahoma State Department of Health, Maternal and Child Health Services

The number of AI/ANs are unavailable due to the small sample size of AI/AN mothers answering “yes” to the question.

Chapter 3 | infant mortality and adverse birth outcomes

INFANT MORTALITY Infant mortality is defined as the death of a baby less than one-year old.1 Because factors that affect the population’s health also impact infants, the rate of infant mortality is used as an indicator to measure the nation’s health and well-being.1 Infant mortality causes were ranked according to the National Center for Health Statistics, NCHS 71 Rankable Causes of Infant Death, for consistent grouping and ranking standards.2 The infant mortality rate that is displayed in this data book reflects a three-year trend, while the leading cause of infant mortality rate reflects a two-year trend. • Nationally, the infant mortality rate dropped from 6.9 per 1,000 live births in 2001-2003 to 5.9 per 1,000 live births in 2013-2015.4 • Like the national trend, the non-American Indian/Alaska Native (non-AI/AN) population in Oklahoma also experienced a decreased infant mortality rate from 7.6 per 1,000 live births in 2001- 2003 to 7.0 live births in 2013-2015. See Figure 1. • In contrast to the national, and Oklahoma non-AI/AN trends, American Indian/Alaska Native (AI/AN) experienced an increase in the infant mortality rate from 8.4 per 1,000 live births in 2001-2003 to 10.5 per 1,000 live births in 2013-2015. The infant mortality rate for AI/ANs in 2013-2015 was almost twice the infant mortality rate at the national level. See Figure 1. • Nationally, the five most common leading causes of infant death in 2014-2015 were birth defects (1.2 per 1,000), preterm birth and low birth weight (1.0 per 1,000), maternal complications of pregnancy (0.4 per 1,000), sudden infant death syndrome (SIDS) (0.4 per 1,000), and accidents or unintentional injuries (0.3 per 1,000).3 • According to Figure 2, in Oklahoma, the highest three leading causes of infant death in 2014-2015 were birth defects, preterm births and low birth weight, and sudden infant death syndrome (SIDS) for both AI/ AN and non-AI/AN mothers. However, the rate of each leading cause of infant death is even higher in AI/ AN infants, when compared to non-AI/AN infants. For instance, the rate of birth defects for AI/AN infants was 2.8 per 1,000 live births, twice the rate of non-AI/AN infants, 1.4 per 1,000 live births.

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 1 Centers for Disease Control and Prevention. Infant Mortality. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ infantmortality.htm Accessed February 2, 2017. 2 New Jersey State Health Assessment Data. NCHS 71 Rankable Causes of Infant Death. https://www26.state.nj.us/doh-shad/query/ ICDInf71Rankable.htm. Accessed February 2, 2017 3 Kochanek KD, Murphy SL, Xu JQ, Tejada-Vera B. Deaths: Final data for 2014. National Vital Statistics Reports, vol 65 no 4. Hyattsville, MD: National Center for Health Statistics. 2016. 4 Centers for Disease Control and Prevention. Infant Mortality Rates by State. https://www.cdc.gov/nchs/pressroom/sosmap/infant_ mortality_rates/infant_mortality.htm Accessed February 3, 2017.

Chapter 3 | infant mortality and adverse birth outcomes

Figure 1: Infant Mortality Rate (per 1,000 live births) Trend by American Indian/Alaska Native Status, Oklahoma and U.S., 2001-2015 Data Source: Oklahoma Vital Statistics (OK2SHARE), National Vital Statistics (CDC Wonder)

7.6

10.5

8.4

7.0 5.9

6.9

2010-12

2013-15

Figure 2: Leading Cause of Infant Mortality Rate (per 1,000 live births) by American Indian/ Alaska Native Status, Oklahoma and U.S., 2014-2015 Data Source: Oklahoma Vital Statistics (OK2SHARE), National Vital Statistics Report

Chapter 3 | infant mortality and adverse birth outcomes

AGE OF INFANT DEATH Age of infant death can be divided by two main categories: neonatal and post neonatal. Neonatal mortality refers to the death of an infant before the age of 28 days.5 Neonatal mortality is often associated with a condition during the perinatal period, such as maternal complications related to pregnancy or by the birth of newborn with congenital malformations, preterm birth, and low birth weight.5 Post neonatal mortality, which is defined as the death of an infant between 28 days to one year old, includes sudden infant death syndrome (SIDS), unintentional injuries, and congenital malformations.5 The age of infant death rate by year that is displayed in this data book reflects a threeyear trend, while it reflects a two-year trend by race. • According to Figure 3, in the past 10 years, the neonatal mortality rate for AI/AN infants in Oklahoma increased from 4.6 per 1,000 live births in 2001-2003 to 6.0 per 1,000 live births in 2013-2015. The post neonatal mortality rate for AI/AN infants in Oklahoma also increased from 3.7 per 1,000 live births in 20012003 to 4.5 per 1,000 live births in 2013-2015. • Based on Figure 3, among AI/ANs, it is interesting that in 2001-2003, the rate of neonatal mortality was higher than the rate of post neonatal mortality; then, the pattern reversed in 2004-2006, and in 2013-2015, the pattern reversed back again but with a wider gap between the two rates. • According to Figure 4, age of infant death rate also varied by race. In Oklahoma, the rate of neonatal mortality was the highest among black infants (8.3 per 1,000 births), followed by AI/AN infants (7.4 per 1,000 births), Asian infants (4.4 per 1,000 births), and the lowest was among white infants (4.0 per 1,000 births) in 2014-2015. • However, the pattern of the rate of post neonatal mortality was different than the pattern of the rate of neonatal mortality. In Oklahoma, the rate of post neonatal mortality was the highest among AI/AN infants (5.2 per 1,000 births), followed by black infants (4.8 per 1,000), white infants (2.3 per 1,000 births), and the lowest was among Asian infants (1.4 per 1,000 births). See Figure 4. • Based on Figure 4, similarly, the rates of post neonatal mortality among AI/ANs, blacks, and whites in Oklahoma were higher than the national (all races combined), which had the rate of 1.9 per 1,000 births in 2014.6

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 5 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2011. Rockville, Maryland: U.S. Department of Health and Human Services, 2011. 6 United States Department of Health and Human Services (USDHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics (DVS). Linked Birth/Infant Death Records 2007-2014, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program, on CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/lbd- curent.html on Aug 25, 2017

Chapter 3 | infant mortality and adverse birth outcomes

Figure 3: Age of Infant Death Rate (per 1,000 live births) Trend Among American Indian/Alaska Native, Oklahoma 2001-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

10.5

8.4 4.6

6.0 4.5

3.7

2001-03

2004-06

Neonatal

2007-09

Postneonatal

2010-12

2013-15

Infant Mortality

Figure 4: Age of Infant Death Rate (per 1,000 live births) by Race, Oklahoma, U.S. (2014 Only) 2014-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Chapter 3 | infant mortality and adverse birth outcomes

BIRTH DEFECTS Birth defects can be defined as structural changes, which may or may not affect body systems at birth.16 Birth defects are quite common, with 1 in every 33 babies born in the United States being affected each year.16 Birth defects can occur in any pregnancy stage. However, the stage most prone to birth-defect development is during the first 3 months of pregnancy.16 There are many factors that increase the risk of birth defects, such as prenatal substance use, genetics, and maternal age over 34 years.16 Birth defects can be categorized by body systems. Cardiovascular birth defects involve malformation of the heart present at birth.17 Orofacial birth defects are comprised of cleft lip and cleft palate.18 Gastrointestinal birth defects involve abnormalities of the digestive system present at birth. Genitourinary defects include abnormalities in the sex organs and/ or kidneys and bladder.19 Musculoskeletal birth defects include malformation in muscles and/or bones. Chromosomal birth defects are due to missing or having extra genes.20 Other birth defects include abnormalities in the central nervous system (brain), eyes, and ears. • From 2000-2011, the rate of birth defects among non-AI/AN infants was quite stable, 41.0 per 1,000 live births in 2000-2001 to 40.2 per 1,000 live births in 2010-2011. See Figure 5. • According to Figure 5, the rate of birth defects among AI/AN infants had a different trend than the rate of non-AI/AN infants. The rate of birth defects for AI/ANs decreased from 40.5 per 1,000 live births in 20002001 to 28.8 per 1,000 live births in 2010-2011. • From 2000-2011, the highest birth defects among AI/AN infants was cardiovascular defects (49%), followed by musculoskeletal defects (15.5%), and orofacial defects (11.0%). See Figure 6. • AI/AN infants had a higher percentage of cardiovascular and orofacial defects. On the other hand, non-AI/ AN infants had higher percentages of genitourinary and chromosomal defects. See Figure 6.

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 16 Centers for Disease Control and Prevention. Facts about Birth Defects. https://www.cdc.gov/ncbddd/birthdefects/facts.html. Accessed November 15, 2017 17 American Heart Association. Common Types of Heart Defects. Accessed at http://www.heart.org/HEARTORG/Conditions/ CongenitalHeartDefects/AboutCongenitalHe artDefects/Common-Types-of-Heart-Defects_UCM_307017_Article.jsp#.WsTLg38h270 on April 4, 2018 18 Centers for Disease Control and Prevention. Facts about Cleft Lip and Cleft Palate. Accessed at https://www.cdc.gov/ncbddd/ birthdefects/cleftlip.html on April 4, 2018 19 March of Dimes. Genital and Urinary Tract Defects. Accessed at https://www.marchofdimes.org/complications/genital-and-urinarytract-defects.aspx on April 4, 2018 20 March of Dimes. Genetic and Chromosomal Conditions. Accessed at https://www.marchofdimes.org/pregnancy/genetic-andchromosomal-conditions.aspx on April 4, 2018

Chapter 3 | infant mortality and adverse birth outcomes

Figure 5: Birth Defect Rate (per 1,000 live births) Trend by American Indian/Alaska Native Status, Oklahoma 2000-2011 Data Source: Oklahoma Birth Defects Registry Figure 5: Birth Defect Rate (per 1,000 live births) Trend by American Indian/Alaska Native Status, Oklahoma 2000-2011 Data Source: Oklahoma Birth Defects Registry

Figure 6: Birth Defects (%) by American Indian/Alaska Native Status and Body System, Oklahoma, 2000-2011 Data Source: Oklahoma Birth Defects Registry 100.0

Percent of Birth Defect

80.0

60.0 49.0

46.1

40.0

15.5 15.6

20.0

11.0

9.0

5.1

8.1

5.4

11.0 6.0

7.5

5.4

5.5

0.0 Cardiovascular

Orofacial

Gastrointestinal tract

Genitourinary

Musculoskeletal

Chromosomal

Other

Body Systems AI/AN

Non-AI/AN

Chapter 3 | infant mortality and adverse birth outcomes

PRETERM BIRTH Normal pregnancy lasts approximately 40 weeks. Those births before 37 weeks of pregnancy, which are considered too early, are termed preterm birth.7 Premature birth gives the baby less time to develop inside the mother’s womb; therefore, it can lead to many complicated medical problems.8 • In Oklahoma, the percentages of preterm birth among AI/AN infants were relatively constant, 9.9% in 2004-2005 to 10.1% in 2014-2015. The pattern of preterm birth for non-AI/ANs during those years was also similar, 10.6% in 2004-2005 to 10.3% in 2014-2015. See Figure 7. • In 2014-2015, AI/AN infants experienced preterm birth (10.1%) at approximately the same rate as non-AI/ ANs (10.3%) in Oklahoma. See Figure 7. • According to Figure 8, when the percentage of preterm birth was compared by race, black infants experienced the highest percentage of preterm birth (13.5%), while Asians had the lowest percentage of preterm birth (8.9%). • AI/AN, white, and Asian infants in Oklahoma experienced preterm birth at a lower rate than the national rate (11.3%). However, black infants in Oklahoma experienced preterm birth at a higher rate (13.5%) than the national rate.15 See Figure 8.

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 7 Centers for Disease Control and Prevention. Preterm Birth. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth. htm. Accessed August 26, 2017. 8 Mayo Clinic. Disease and Condition: Premature Birth. http://www.mayoclinic.org/diseases-conditions/premature-birth/basics/ definition/con-20020050. Accessed August 26, 2017.

Chapter 3 | infant mortality and adverse birth outcomes

Figure 7: Preterm Birth (%) Trend by American Indian/Alaska Native Status, Oklahoma 2004-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

20.0

Percent of Preterm Birth

15.0

10.6

10.3

10.0

10.1

9.9

5.0

0.0 2004-05

2006-07

2008-09

2010-11

2012-13

2014-15

Year AI/AN

Non-AI/AN

Figure 8: Preterm Birth (%) Trend by Races in Oklahoma and Compared U.S., 2014-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Chapter 3 | infant mortality and adverse birth outcomes

LOW BIRTH WEIGHT Birth weight is one of many indicators that can predict the health of an infant. Approximately, 8 pounds is the average weight for a newborn.9 Low birth weight is defined as an infant born weighing less than 2,500 grams or 5 pounds 8 ounces, which increases many medical risks to the infant.10 There are many factors that can cause a baby to be born at low birth weight, such as premature birth and fetal growth restriction (birth defects and infection).10 • The percentage of low birth weight among AI/AN infants was relatively constant from 2004-2005 (6.8%) to 2014-2015 (6.9%). Similarly, the percentage of low birth weight among non-AI/AN infants was also relatively constant from 2004-2005 (8.2%) to 2014-2015 (8.1%). See figure 9. • According to Figure 10, in Oklahoma, AI/AN infants had the lowest percentage (6.9%) of low birth weight, when compared to the other races. Black infants had the highest percentage (13.0%) of low birth weight among all races. • Based on Figure 10, the percentages of low birth weight among AI/AN (6.9%), white (7.4%), and Asian (7.7%) infants in Oklahoma are lower than the percentage of low birth weight among all infants in the U.S. (8.0%),14 except among black infants (13%).

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 9 Stanford Children’s Health. Low Birth weight. http://www.stanfordchildrens.org/en/topic/default?id=low-birthweight-90-P02382. Accessed August 26, 2017. 10 March of Dimes. Low Birth weight. https://www.marchofdimes.org/complications/low-birthweight.aspx. Accessed August 26, 2017.

Chapter 3 | infant mortality and adverse birth outcomes

Figure 9: Low Birth weight (%) Trend by American Indian/Alaska Native Status, Oklahoma 2004-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

10.0 8.2

8.1

Percent of Low Birthweight

8.0

6.0

6.9

6.8

4.0

2.0

0.0

2004-05

2006-07

2008-09

2010-11

2012-13

2014-15

Year AI/AN

Non-AI/AN

Figure 10: Low Birth weight (%) by Race, Oklahoma and U.S., 2014-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Chapter 3 | infant mortality and adverse birth outcomes

SUDDEN UNEXPECTED INFANT DEATH A death of an infant that occurs unpredictably and suddenly, without any obvious cause of death before investigation, is called Sudden Unexpected Infant Death (SUID).11 Sudden infant death syndrome (SIDS), unintentional suffocation and strangulation in bed, and other deaths from unknown causes are considered SUID.11 The cause of infant death because of SIDS is still unknown,11 but many studies have indicated a few risk factors that increase the likelihood of SIDS, including physical factors (birth defects, low birth weight, respiratory infection), sleeping environmental factors (sleeping on stomach, side, or a soft surface, as well as sharing a bed), and maternal risk factors (inadequate prenatal care and prenatal substance use).12 • According to Figure 11, the rate of SUIDs among AI/AN infants had decreased from 3.0 per 1,000 births in 2004-2006 to 2.7 per 1,000 births in 2013-2015. • The rate of SUIDs among non-AI/AN infants had increased slightly, from 1.3 per 1,000 births in 2004-2006 to 1.4 per 1,000 births in 2013-2015 compared to AI/AN infants which had a decreased from 3.0 per 1,000 births in 2004-2006 to 2.7 per 1,000 births in 2013-2015. See Figure 11. • Among AI/ANs in Oklahoma, the rate of SIDS was 46.9% compared to accidental suffocation and strangulation in bed (22.5%) in 2013-2015. See Figure 12.

Endnotes- Chapter 3: Infant Mortality and Adverse Birth Outcomes 11 Centers for Disease Control and Prevention. Sudden Unexpected Infant Death and Sudden Infant Death Syndrome. https://www.cdc. gov/sids/aboutsuidandsids.htm. Accessed August 28, 2017. 12 Mayo Clinic. Sudden Infant Death Syndrome (SIDS). http://www.mayoclinic.org/diseases- conditions/sudden-infant-death-syndrome/ symptoms-causes/dxc-20322702. Accessed August 28, 2017.

Chapter 3 | infant mortality and adverse birth outcomes

Figure 11: Sudden Unexpected Infant Death (SUID) Rate (per 1,000 live births) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Figure 12: Sudden Unexpected Infant Death (SUID) (%) Among American Indians/ Alaska Natives by Type of SUID, Oklahoma, 2013-2015 Data Source: Oklahoma Vital Statistics, OK2SHARE

Sudden Infant Death Syndrome (SIDS)

30.6%

46.9%

Unknown (Ill -Defined Infant Deaths) Accidental suffocation and strangulation in bed

22.5%

Chapter 4 | prenatal care

PRENATAL CARE VISITS Poor infant and maternal outcomes are associated with infrequent or inadequate prenatal visits, and not having access to care, including late initiation of care.1 Mothers have preterm or low birth weight infants, and are at increased risk for complications of childbirth and pregnancy-related mortality as a result of having late or no prenatal care.1 Prenatal care visits give providers the opportunity to offer education and counseling about behaviors that may affect maternal and infant health. • According to Figure 1, in the U.S., the percent of women delivering live-born infants receiving

prenatal care during the first trimester of pregnancy increased from 53.1% in 2010 to 71.7% in 3 2015. The percent of women delivering a live-born infant in Oklahoma (all races combined) who began prenatal care during the first trimester of pregnancy also increased from 65.4% in 2010 to 70.2% in 2015 (data not shown on the graph).

• During 2012-2013 in Oklahoma, American Indian/Alaska Native (AI/AN) women reported that their prenatal care provider most commonly discussed topics pertaining to medicines safe to take during pregnancy (86.8%), followed by breastfeeding (85.5%), and smoking during pregnancy (83.3%). Among non-AI/AN women, the most common topics reported were breastfeeding (91.9%), followed by medicines safe to take during pregnancy (89.9%), and doing screening tests for birth defects (83.8%). See Figure 2. • According to Figure 2, AI/AN women were more likely than non-AI/AN women to report having a discussion with a prenatal care provider on physical abuse by partners, smoking during pregnancy, HIV testing, substance abuse during pregnancy, such as illegal drugs, and drinking alcohol. • Non-AI/AN women were more likely than AI/AN women to report having a discussion with a

prenatal care provider on doing tests to screen for birth defects, breastfeeding, medicine safe to take during pregnancy, and signs and symptoms of preterm labor. See Figure 2.

Chapter 4 | prenatal care

Figure 1: First Trimester Initiation of Prenatal Care (%) Trend by American Indian/Alaska Native Status, Oklahoma and U.S., 2010-2015 Data Source: Oklahoma Vital Statistics; CDC Wonder

Figure 2: Prenatal Care Counseling Received (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 4 | prenatal care

MOTHER’S HEALTH INSURANCE AND WIC PARTICIPATION Lack of health insurance is one of many factors associated with the level of prenatal care needed during pregnancy, such as fewer prenatal care services and poorer outcomes during pregnancy and delivery.2 However, there are services to support pregnant and breastfeeding women, mothers of newborns (6 months old or younger), and young children (less than 5 years old) to eat healthy, stay fit, and learn about good nutrition which is called the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).1 They provide vouchers to purchase healthy foods such as milk, cereal, eggs, cheese, and juice.1 Assistance with finding health care, breastfeeding support, nutrition counseling, and other community services are also provided through this program.1 • According to 2012-2013 PRAMS data, American Indian/Alaska Native (AI/AN) mothers in

Oklahoma received their health insurance more from Medicaid/SoonerCare (71.2%), followed by Indian Health Service or tribal services (46.9%), and health insurance through their employment (24.9%). When comparing the type of health insurance between AI/AN and non-American Indian/Alaska Native (non-AI/AN) mothers, AI/AN mothers received their health insurance from Medicaid/SoonerCare at a higher percentage (71.2% vs. 59.8%, respectively), and from their jobs at a lower percentage (24.9% vs. 40.2%, respectively). See Figure 3.

• AI/AN and non-AI/AN mothers started with relatively the same percentage of prenatal WIC

participation in 2004 (54.1% vs. 52.3%). However, after 9 years in 2013, the percentage of AI/AN mothers who participated in WIC during pregnancy is higher than non-AI/AN mothers (62.2% vs. 56.3%). See Figure 4.

Chapter 4 | prenatal care

Figure 3: Motherâ&#x20AC;&#x2122;s Health Insurance (%) by American Indian/Alaska Native Status, Oklahoma, 2012- 2013 Data Source: Oklahoma PRAMS

Figure 4: Prenatal WIC Participation (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2013 Data Source: Oklahoma PRAMS

Chapter 4 | prenatal care

HIV TESTING AND FLU/TDAP VACCINATION Comprehensive prenatal care should include screening for certain risk factors and conditions such as Human Immunodeficiency Virus (HIV) infection and immunization for flu and Tdap.1 It is recommended by the Centers for Disease Control and Prevention (CDC) that pregnant women should be screened for HIV infection because it can be transmitted to their infants.6 It is important to note that not all mothers are familiar or aware of HIV tests done during the prenatal period. Flu can be more severe in pregnant mothers and women who recently gave birth due to changes in their immune system, heart, and lungs during pregnancy.4 To protect pregnant women and their newborn babies, the CDC recommends that pregnant women get a flu shot during any trimester of their pregnancy.4 Another serious disease that can be deadly for babies is whooping cough. The CDC recommends that pregnant women get the whooping cough vaccination, called Tdap, between 27 and 36 weeks of their pregnancies.5 • In 2013, American Indian/Alaska Native (AI/AN) mothers who reported being tested for HIV

during their pregnancy or delivery was 24.5% higher than non-American Indian/Alaska Native (non-AI/AN) mothers in Oklahoma. See Figure 5.

• The percentage of AI/AN mothers in Oklahoma who reported having been tested for HIV during

their pregnancy or delivery has increased from 70.2% in 2004 to 82.3% in 2013. On the other hand, the percentage of non-AI/AN mothers in Oklahoma who reported having been tested had a slight decrease from 69.3% in 2004 to 66.1% in 2013. See Figure 5.

• Among AI/AN mothers, 31.5% reported receiving a Tdap vaccination after pregnancy, 29.4%

during pregnancy, and 13.3% before pregnancy, compared to non-AI/AN mothers, 34.6% reported receiving a Tdap vaccination after pregnancy, 21.8% during pregnancy, and 16.8% before pregnancy. See Figure 6.

Endnotes- Chapter 4: Prenatal Care 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 4 Centers for Disease Control and Prevention. Flu Vaccine Safety and Pregnancy. Accessed at https://www.cdc.gov/flu/protect/vaccine/ qa_vacpregnant.htm on February 11, 2018. Centers for Disease Control and Prevention. Flu Vaccine Safety and Pregnancy. Accessed at https://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm on February 11, 2018. 5 Centers for Disease Control and Prevention. Pregnant? Get Tdap in Your Third Trimester. Accessed at https://www.cdc.gov/features/ tdap-in-pregnancy/index.html on February 11, 2018. 6 Centers for Disease Control and Prevention. Pregnant Women, Infants and Children. Accessed at https://www.cdc.gov/hiv/group/ gender/pregnantwomen/opt-out.html on February 11, 2018.

Chapter 4 | prenatal care

Figure 5: HIV Testing During Pregnancy or Delivery (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2013 Data Source: Oklahoma PRAMS

Figure 6: Flu and Tdap Immunizations Before/During/After Pregnancy (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 4 | prenatal care

MULTIVITAMIN OR PRENATAL VITAMIN Neural tube defects (NTDs) is a serious birth defect of the brain or spinal cord that can be prevented by taking a daily multivitamin including folic acid during the prenatal period.1 Deficiency of folic acid in women during early pregnancy causes about half of NTDs.1 In the earliest days of pregnancy and when the baby is conceived is the time for pregnant women to have adequate supplies of folic acid stored in their bodies.1 Eating a balanced diet that includes whole grains, fruits, and vegetables, and taking a multivitamin with 400 micrograms of folic acid every day are necessary for women who might become pregnant.1 â&#x20AC;˘ In 2012-2013, the majority of AI/AN mothers in Oklahoma reported that they did not take any

multivitamin or prenatal vitamin in the month prior to their pregnancy (70.0%). Only 14.8% of AI/ AN mothers reported that they took a multivitamin or prenatal vitamin 1-6 times a week, and 15.2% took a multivitamin or prenatal vitamin every day of the week. See Figure 7.

â&#x20AC;˘ According to Figure 7, a lower percentage of AI/AN mothers reported taking a multivitamin or a

prenatal vitamin every day of the week in the month before their pregnancy when compared to non-AI/AN mothers in Oklahoma (15.2% vs. 30.3%, respectively).

Chapter 4 | prenatal care

Figure 7: Multivitamin or Prenatal Vitamin Use One Month Before Pregnancy (%) by American Indian/ Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

15.2% Every day of week 14.8%

1-6 times a week Didnâ&#x20AC;&#x2122;t take a multivitamin

70.0%

AI/AN

30.3%

56.0%

32.4%

52.9% 13.8%

Non-AI/AN

14.7%

U.S.

Chapter 5 | prenatal substance use

PRENATAL HARMFUL SUBSTANCES USE Among infants with birth defects, 10% are born to American Indian/Alaska Native (AI/AN) women.4 Interventions should emphasize prevention rather than treatment, since prenatal substance use by mothers can have serious effects on the child and family.1 According to the Oklahoma Birth Defects Registry, 22% of infant deaths in Oklahoma are as a result of birth defects.4 • In 2012-2013, approximately 20% of AI/AN mothers delivering live births reported cigarette use

during the last three months of pregnancy compared to 11.8% non-American Indian/Alaska Native (non-AI/AN).2 See Figure 1.

• According to Figure 1, prenatal alcohol use (during the last three months) showed a reverse

pattern when compared to prenatal cigarette use. In Oklahoma, women (all races combined) delivering live births reported alcohol use during the last three months of pregnancy at approximately 5% (data not shown due to small cell size), which is lower than all women at the national level (8.0%).

• According to the Oklahoma Birth Defects Registry, in the years of 2002-2012, AI/AN mothers of

infants with a birth defect reported using alcohol at a rate 26.0% higher than non-AI/AN mothers. Tobacco use among AI/AN mothers of infants with a birth defect was 20.0% higher than non-AI/ AN mothers in Oklahoma. See Figure 2.

Endnotes- Chapter 5: Prenatal Substance Use 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 4 Oklahoma State Department of Health, Screening and Special Services. Oklahoma Birth Defects Registry Factsheet.

Chapter 5 | prenatal substance use

Figure 1: Prenatal Substance Use (%) by Type and American Indian/Alaska Native Status, Oklahoma and U.S., 2012-2013 Data Source: Oklahoma PRAMS, National PRAMS

Figure 2: Alcohol & Tobacco Use During Pregnancy Among Mothers of Infants with Birth Defects (%) by Type of Substance Use and American Indian/Alaska Native Status, Oklahoma, 2002-2012 Data Source: Oklahoma Birth Defects Registry

Chapter 5 | prenatal substance use

PRENATAL CIGARETTE USE The sole most avoidable cause of infant low birth weight and prematurity is smoking during pregnancy.1 Women who smoke can reduce the amount of oxygen the baby receives by exposing the fetus to dangerous chemicals such as nicotine, carbon monoxide, and tar.1 Still birth, placental abruption ,and ectopic pregnancy can most likely occur to women who smoke.1 • AI/AN women delivering live births smoked during pregnancy at higher percentages than non-

AI/AN women across all years. Even though the percentage of prenatal cigarette use for AI/AN women has decreased, the disparity for AI/AN women and non-AI/AN women in 2012-2013 was larger than 2004-2008. See Figure 3.

• According to Figure 4, time of cigarette use is divided into three categories: cigarette use before

pregnancy, during pregnancy, and after pregnancy. In 2012-2013, AI/AN women delivering a live birth used cigarettes at a higher percentage than non-AI/AN women in Oklahoma across all categories of time of cigarette use.

• In 2012-2013, among AI/AN women delivering live births, 49.3% used cigarettes before pregnancy,

and during pregnancy, approximately 20% of AI/AN women used cigarettes. However, after the pregnancy, the percentage who used cigarettes increased again to 42.1%. See Figure 4.

• According to Figure 4, about 26.5% of non-native women delivering live births used cigarettes

before pregnancy, then the percentage of cigarette use dropped to 11.8% during pregnancy, and after pregnancy, the percentage of cigarette use slightly increased to 17.5% in 2012-2013.

Chapter 5 | prenatal substance use

Figure 3: Cigarette Use During Pregnancy (%) Trend by PRAM Phase and American Indian/Alaska Native Status, Oklahoma, 2004-2013 Data Source: Oklahoma PRAMS

Figure 4: Cigarette Use Before, During, and After Pregnancy (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 5 | prenatal substance use

PRENATAL ALCOHOL USE Some birth defects and developmental disabilities are the result of alcohol use during pregnancy.1 In 2011-2013, it was found that 1 in 10 pregnant women ages 18-44 years old reported alcohol consumption.3 Approximately 1 in 3 of those pregnant women ages 18-44 years old who consumed alcohol engaged in binge drinking.3 Healthcare providers should inform women of childbearing age to avoid alcohol consumption at any time during pregnancy or when trying to get pregnant, because alcohol can cause problems for a developing baby throughout pregnancy, especially during the first trimester.1,3 • According to Figure 5, across all PRAM phases from 2004-2013, Oklahoma women delivering live

births reported alcohol use during pregnancy at lower percentages than national rates.

• In 2012-2013, 55.2% of AI/AN and 52.8% of non-AI/AN women in Oklahoma delivering live births

reported using alcohol before pregnancy, which was slightly less than AI/AN mothers at the national level of 56.0%. See Figure 6.

Endnotes- Chapter 5: Prenatal Substance Use 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 3 Centers for Disease Control and Prevention. Key Findings: Alcohol Use and Binge Drinking Among Women of Childbearing Age—United States, 2011-2013. Accessed at https://www.cdc.gov/ncbddd/fasd/features/drinking-childbearing-age.html on May 31, 2018.

Chapter 5 | prenatal substance use

Figure 5: Alcohol Use During Pregnancy (%) Trend by PRAM Phase, Oklahoma and National, 2004-2013 Data Source: Oklahoma PRAMS, National PRAMS

Figure 6: Alcohol Use Before and During Pregnancy (%) by PRAM Phase, Oklahoma and National, 2012-2013 Data Source: Oklahoma PRAMS, National PRAMS

Chapter 6 | Maternal health

PRE-PREGNANCY BODY MASS INDEX (BMI) Pre-pregnancy Body Mass Index (BMI) can be divided into four categories: underweight (less than 18.5), normal (18.5-24.9), overweight (25-29.9), and obese (30 or greater).5 A variety of poor physical and emotional health outcomes are associated with obesity and overweight which can threaten health at all stages of life.1 From 1999-2014, the number of obese adults had increased by 24%, and the number of obese youth had also increased by 24% in the United States.3 In 2011-2014, 36.5% of U.S. adults and 17.0% of U.S. youth were obese.3 According to the Oklahoma Behavioral Risk Factor Surveillance System, 35.0% of American Indian/Alaska Native (AI/AN) adults 18 years or older were overweight and 41.7% of AI/AN adults were obese in 2013-2017.2 Non-American Indian/Alaska Native (non-AI/ AN) adults in Oklahoma had the same percentage of overweight as AI/ANs, but a lesser percentage of obesity (32.3%) than AI/AN adults.2 Risk of diabetes and congenital abnormalities can increase among obese women prior to pregnancy.1 According to all women at the national level, 24.6% of mothers had a pre-pregnancy BMI of overweight and 22.0% were obese.4 • According to Figure 1, between 2004 and 2013, the percentage of women with a pre-pregnancy

BMI of overweight or obesity increased by 62.5% for AI/AN women delivering live births. There was a large disparity between AI/AN and non-AI/AN mothers regarding a pre-pregnancy BMI of overweight or obesity (69.4% vs. 44.7%, respectively in 2013). See Figure 1.

• According to Figure 1, the percentage of pre-pregnancy overweight or obesity had also increased

slightly for non-AI/AN mothers in Oklahoma from 38.4% to 44.7% between 2004-2013

• Non-AI/AN mothers in Oklahoma between 2009-2013 had a higher percentage of normal pre-

pregnancy BMI 49.5% compared to AI/ANs of 31.4 %, and a lower percentage of overweight pre-pregnancy BMI of (24.2% vs. 34.4%) among AI/ANs, and lower percentage of obese prepregnancy BMI of (21.3% vs. 30.5%) among AI/AN mothers. See Figure 2.

Endnotes- Chapter 6: Maternal Health 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 2 Oklahoma State Department of Health (OSDH), Center for Health Statistics, Health Care Information, Behavioral Risk Factor Surveillance System 2013 to 2015, on Oklahoma Statistics on Health Available for Everyone (OK2SHARE). Accessed at http://www.health.ok.gov/ ok2share on June 2, 2018. 3 Ogden CL, Carroll MD, Fryer CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS data brief, No 219. Hyattsville, MD: National Center for Health Statistics. 2015. 4 Centers for Disease Control and Prevention. Prevalence of Selected Maternal and Child Health Indicators—United States, All Sites, Pregnancy Risk Assessment Monitoring System (PRAMS), 2012 and 2013. Accessed at https://www.cdc.gov/prams/pramstat/pdfs/mchindicators/PRAMS-All-Sites_508tagged.pdf on June 2, 2018. 5 National Heart, Lung, and Blood Institute (NIH). Calculate Your Body Mass Index. Accessed at https://www.nhlbi.nih.gov/health/ educational/lose_wt/BMI/bmicalc.htm?source=quickfit nesssolutions on June 2, 2018.

Chapter 6 | Maternal health

Figure 1: Pre-pregnancy Overweight or Obesity (%) Trend by American Indian/Alaska Native Status, Oklahoma, 2004-2013 Data Source: Oklahoma PRAMS

Figure 2: Pre-pregnancy Body Mass Index (BMI) (%) by American Indian/Alaska Native Status, Oklahoma, 2009-2013 Data Source: Oklahoma PRAMS

3.7%

5.0% 21.3% Underweight 49.5%

Normal

31.4% 30.5%

Overweight Obese

24.2% 34.4% Non-AI/AN

AI/AN

Chapter 6 | Maternal health

PRIOR TO PREGNANCY It is important for women, especially those who are planning to become pregnant, to have preconception-care checkups, and live a healthy lifestyle. The purpose of the preconception-care checkup is to identify conditions or risk factors that could affect pregnancies, such as diet and lifestyle, medical and family history, current medications, and any previous pregnancies.9 • According to Figure 3, the three highest health-related activities done during the 12 months before

pregnancy for both AI/AN and non-AI/AN women delivering live births in 2011-2013 were “had my teeth cleaned by a dentist or dental hygienist” (43.5% and 52.0%), “exercise three or more days of the week” (42.2% and 47.2%), and “on diet to lose weight” (37.1% and 30.8%).

• AI/ANs had the highest percentage of visiting a healthcare worker to be checked or treated for

depression or anxiety compared to non-AI/ANs (30.1% vs. 19.1%), regularly taking prescription medicines other than birth control (25.4% vs. 20.0%), on diet to lose weight (37.1% vs. 30.8%), and talked to a healthcare worker about family medical history (30.6% vs. 29.2%). See Figure 3.

• In 2011-2013, non-AI/AN mothers visited a healthcare worker to be checked or treated for high

blood pressure during the 12 months before pregnancy which was 59% higher than AI/AN mothers. See Figure 3.

Endnotes- Chapter 6: Maternal Health 9 The American College of Obstetricians and Gynecologists. Good Health Before Pregnancy: Preconception Care. Assessed at https:// www.acog.org/patient-resources/faqs/pregnancy/good-health-before-pregnancy-prepregnancy-care on June 4, 2018.

Chapter 6 | Maternal health

Figure 3: Health Activity Done During the 12 Months Before Pregnancy (%) by American Indian/Alaska Native Status, Oklahoma, 2011-2013 Data Source: Oklahoma PRAMS

Chapter 6 | Maternal health

LIFE STRESSORS Mental health of mothers during and after pregnancy is very important. Depression during pregnancy (perinatal depression) and after pregnancy (postpartum depression) is relatively common but treatable.6 In the United States, approximately one in eight mothers experiences postpartum depression.7 The physical and emotional health of the mother, the infant, and the whole family can be affected by experiencing stressful events during pregnancy.1 • The top three most common life stressors among AI/AN mothers were “moved to a new address”

(42.3%), “argued with husband/partner more than usual” (36.4%), and “close family member sick” (35.2%). See Figure 4.

• According to Figure 4, AI/AN mothers experienced a higher percentage of all life stressors than

non-AI/AN mothers in Oklahoma between 2011-2013.

Chapter 6 | Maternal health

Figure 4: Life Stressors Among Women Recently Delivering a Live Birth (%) by American Indian/Alaska Native Status, Oklahoma, 2011-2013 Data Source: Oklahoma PRAMS

Chapter 6 | Maternal health

EMOTIONAL & PHYSICAL ABUSE Physical abuse increases the likelihood that women will have adverse birth outcomes pregnancy complications and adverse birth outcomes like antenatal hospitalizations, perinatal hemorrhage, uterine rupture, increased risk of cesarean delivery, preterm birth, and low birth weight.1 Furthermore, lifelong health effects can happen for children by growing up in a home with violence.1 â&#x20AC;˘ According to Figure 5, the percentage of new mothers in Oklahoma reporting physical abuse by

a husband or partner during the 12 months before they became pregnant decreased from 6.0% in 2009 to 4.1% in 2013. The percentage of mothers in the U.S. reporting physical abuse by their husbands or partners before pregnancy for the same time frame is lower than in Oklahoma, but has a similar trend, decreasing from 3.9% in 2009 to 2.6% in 2013.

â&#x20AC;˘ According to Figure 6, the percentage of Oklahoma mothers prenatal physical abuse by husband

or partner declined from 4.8% to 3.4% in comparison to the U.S. level of 3.2% to 2.2% at a lower level.

Chapter 6 | Maternal health

Figure 5: Physical Abuse by Husband or Partner During the 12 Months Before Pregnancy (%) Trend by Oklahoma and U.S., 2009-2013 Data Source: Oklahoma PRAMS, National PRAMS

Figure 6: Prenatal Physical Abuse by Husband or Partner (%) Trend by Oklahoma and U.S., 2009-2013 Data Source: Oklahoma PRAMS, National PRAMS

Chapter 6 | Maternal health

PRENATAL ORAL HEALTH An important part of a healthy lifestyle is a good oral health.1 Mixed results were found by studies examining the association between oral infections or disease and pregnancy outcome.1 The adverse effect of dental plaque can increase by hormonal changes that arise during pregnancy.1 • According to Figure 7, in 2012-2013, the highest prenatal oral health issues among AI/AN women

in Oklahoma were “knew it was important to care for teeth and gums during pregnancy” (86.8%), “had insurance to cover dental care during pregnancy” (81.3%), and “dental worker talked about care of teeth” (58.2%).

• AI/AN and non-AI/AN mothers in Oklahoma had a relatively similar percentage of each prenatal

oral health issue. However, the oral health issues “dental worker talked about care of teeth” (58.2% vs. 49.8%), and “had insurance to cover dental care during pregnancy” (81.3% vs. 74.6%) were slightly higher among AI/AN mothers than for non-AI/AN mothers. See Figure 7.

Chapter 6 | Maternal health

Figure 7: Prenatal Oral Health Issues (%) by American Indian/Alaska Native Status, Oklahoma, 2012- 2013 Data Source: Oklahoma PRAMS

Chapter 6 | Maternal health

HEALTH-RELATED DISCUSSIONS WITH HEALTHCARE PROVIDERS The Pregnancy Risk Assessment Monitoring System (PRAMS) asks women who recently delivered a live birth about health-related discussions that they had with their healthcare providers prior to their pregnancies. This information can be used to assess the level of prevention and screening that the mothers received from their healthcare providers. It is very important for healthcare professionals to incorporate prevention during doctor visits. Prevention and screening can help improve the health of women who are planning to be pregnant to get them ready for their pregnancies and reduce any risk of complications during pregnancy and delivery. • According to Figure 8, in Oklahoma in 2012-2013, the five most common topics discussed by

health professionals monitoring AI/AN mothers prior to pregnancy were “birth control or family planning” (59.9%), “smoking” (55.6%), “healthy eating or nutrition” (52.0%), “current medications” (49.4%), and “drinking alcohol” (45.6%).

• However, among non-AI/AN mothers in Oklahoma in 2012-2013, the five most common topics

discussed during doctor’s visits were “birth control or family planning” (57.3%), “taking folic acid or a multivitamin” (55.6%), “current medications” (55.5%), “healthy eating or nutrition” (54.6%), and “smoking” (47.5%). See Figure 8.

Chapter 6 | Maternal health

Figure 8: Discussion Between Health Professionals and Mother Prior to Pregnancy (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 6 | Maternal health

MATERNITY LEAVE Maternity leave can provide a quality time for new mothers and babies to make changes to new life together.8 Maternal mental health and child development can be improved by having a longer maternity leave which is related to longer breastfeeding duration, according to many studies.8 In the United States, the Family and Medical Leave Act (FMLA) allows parents, both women and men, to have unpaid leave up to 12 weeks, if they meet certain criteria.8 Paid maternity leave is not mandated in the United States which is one of only five countries in the world that unfortunately does not qualify new mothers for maternity leave.8 â&#x20AC;˘ According to Figure 9, in 2012-2013, 56.3% of AI/AN mothers in Oklahoma who did not take

maternity leave after delivering a baby stated that they could not financially afford to take leave compared to 31.0% of non-AI/AN mothers.

â&#x20AC;˘ In 2011-2013, 45.2% of AI/AN mothers in Oklahoma who did not take maternity leave after

delivering their baby stated that it was due to not having paid leave, compared to 35.8% of nonAI/AN mothers in Oklahoma. See Figure 9.

Figure 9: Barriers to Not Taking Maternity Leave from Work (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 7 | Infant health

BARRIERS TO BREASTFEEDING Infants should be breastfed for at least 12 months, and after that, for as long as the mother desires, according to the American Academy of Pediatrics recommendation.1 Until six months of age, infants can receive necessary nutrition through breast milk. Throughout the first year, the main source of nutrition should be breast milk and infants in this time frame can be introduced to solids foods to complement breast milk.1 â&#x20AC;˘ In 2012-2013, the majority of AI/AN mothers in Oklahoma reported stopping breastfeeding,

because they did not produce enough milk (61.9%), followed by their baby having difficulty nursing or latching (39.7%). Those barriers were more prevalent among AI/AN mothers than nonAI/AN mothers in Oklahoma. See Figure 1.

Figure 1: Reasons for Stopping Breastfeeding (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 7 | infant health

BREASTFEEDING Mother and infant both can benefit from breastfeeding.1 Mothers’ milk contains antibodies that helps fight disease and it is easier to digest than formula.1 Risk of sudden infant death syndrome, childhood leukemia, diabetes, respiratory infections, asthma, and obesity can decrease in children who were breastfed.1 Mother-infant connection can be increased and money can be saved if the mother chooses breastfeeding.1 Women who breastfeed can return to their pre-pregnancy weight more easily than women who don’t breastfeed. Risk of ovarian and breast cancer can be decreased in women who breastfeed as well.1 • From 2004 to 2013, the percent of American Indian/Alaska Native (AI/AN) women in Oklahoma

who initiated breastfeeding increased by 10.8% from 73.0% to 80.9%. Similarly, the percent of mothers who initiated breastfeeding increased by 11.3% for non-American Indian/Alaska Native (non-AI/AN) mothers in Oklahoma (from 74.4% to 82.8%) and 13.2% for all women at the national level (from 75.2% to 85.1%).2

• The percent of AI/AN women who initiated breastfeeding in 2013 was 2% and 3% lower

compared to non-AI/AN women and all women at the national level, respectively.2

• According to Figure 2, AI/AN breastfeeding initiation trend rose from 73.0% to 80.9%. However,

that was still lower than the U.S. trend at 85.1%.

• According to Figure 3, in 2012-2013, approximately 73.5% of AI/AN mothers in Oklahoma initiated

breastfeeding, 55.9% still breastfed at four weeks postpartum, and 41.3% still breastfed at eight weeks postpartum.

• In 2012-2013, breastfeeding was more common among non-AI/AN women compared to AI/

AN women at all durations measured: 85.2% initiated breastfeeding, 67.2% still breastfed at four weeks, and 53.5% still breastfed at eight weeks. See Figure 3.

Endnotes- Chapter 7: Infant Health 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 2 Centers for Disease Control and Prevention. Prevalence of Selected Maternal and Child Health Indicators—United States, All Sites, Pregnancy Risk Assessment Monitoring System (PRAMS), 2012 and 2013. Accessed at https://www.cdc.gov/prams/prams-data/mchindicators.html on June 2, 2018.

Chapter 7 | infant health

Figure 2: Breastfeeding Initiation (%) Trend by American Indian/Alaska Native Status, Oklahoma and U.S., 2004-2013 Data Source: Oklahoma PRAMS, National PRAMS

Figure 3: Breastfeeding Initiation, 4 Weeks and 8 Weeks Postpartum (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Chapter 7 | infant health

SAFE INFANT SLEEP The position that mothers lay their babies to sleep is very important. The Centers for Disease Control and Prevention (CDC) recommends that mothers place their babies on their back for every sleep as it can reduce the risk of sleep-related infant deaths, called sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), accidental suffocation, and deaths from unknown cause.3 Accidental suffocation associated with an unsafe sleep environment may have caused many infants’ deaths according to researchers. However, the cause of SIDS is not fully understood yet.1 • According to Figure 4, the percentage of AI/AN mothers in Oklahoma who placed infants to sleep

on their backs increased from 61.3% in 2004 to 67.9% in 2013. Non-AI/AN mothers had a higher percentage increase from 56% in 2004 to 68.0% in 2013 for placing infants to sleep on their backs.

• In 2004, the percentage of mothers who placed infants to sleep on their backs among AI/ANs

in Oklahoma and all women at the national level was relatively similar. However, in 2013, the percentage of mothers who placed infants to sleep on their backs was higher nationally than among AI/AN mothers in Oklahoma (78.5% vs 67.9%, respectively). See Figure 4.

• According to Figure 5, in Oklahoma in 2012-2013, approximately 70% of both AI/AN and non-AI/

AN mothers laid their babies on their backs.

Endnotes- Chapter 7: Infant Health 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 3 Centers for Disease Control and Prevention. Safe Sleep for Babies. Accessed at https://www.cdc.gov/vitalsigns/safesleep/index.html on June 6, 2018.

Chapter 7 | infant health

Figure 4: Placing Infants to Sleep on Their Backs (%) Trend by American Indian/Alaska Native Status, Oklahoma and U.S., 2004-2013 Data Source: Oklahoma PRAMS, National PRAMS

Figure 5: Position which Mothers Lay Their Babies to Sleep (%) by American Indian/Alaska Native Status Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

13.3%

8.7%

15.5%

20.2%

On his or her side On his or her back On his or her stomach

70.4%

Non-AI/AN

69.2%

AI/AN

Chapter 7 | infant health

INFANT SLEEP ENVIRONMENT The American Academy of Pediatrics recommends a close sleeping space, keeping loose bedding and soft stuff out of the crib, and using a secure sleep surface for a safe infant sleeping environment.1 Environmental tobacco smoke (ETS) or “second-hand smoke” is another risk factor for sudden unexpected infant death (SUID), as well as other health problems for infants, including asthma attacks, respiratory infections, and ear infections.5 ETS contains more than 7,000 chemicals. Hundreds of them are considered toxic and about 70 causes cancer.5 Non-smoking pregnant women who are exposed to ETS have an increased risk of adverse pregnancy outcomes such as lower birth weight, smaller head circumference, and stillbirth.1 • According to Figure 6, in 2012-2013, over 70% of AI/AN mothers in Oklahoma placed their babies

to sleep in a crib or portable crib or on a firm or hard mattress. Over 80% of non-AI/AN mothers in Oklahoma placed their babies to sleep in a crib or portable crib or on a firm or hard mattress, which was higher than AI/AN mothers.

• There was a higher percentage of AI/AN mothers in Oklahoma compared to non-AI/AN who

placed their babies to sleep with a blanket (77.3% vs. 66.6%) and/or share a bed with them or another person (33.3% vs. 29.0%). See Figure 6.

• According to Figure 7, approximately 12% of AI/AN mothers in Oklahoma in 2012-2013 reported

that smoking is allowed inside their home, whereas only 4% of non-AI/AN mothers in Oklahoma reported so.

Endnotes- Chapter 7: Infant Health 1 Young MB, Perham-Hester KA, Kemberling MM. Alaska Maternal and Child Health Data Book 2011: Alaska Native Edition. Anchorage, AK: A collaboration of the Alaska Department of Health and Social Services, Division of Public Health, and the Alaska Native Tribal Health Consortium, Alaska Native Epidemiology Center. October 2011. 5 Centers for Disease Control and Prevention. Health Effects of Secondhand Smoke. Accessed at https://www.cdc.gov/tobacco/data_ statistics/fact_sheets/secondhand_smoke/health_effects/ on June 12, 2018.

Chapter 7 | infant health

Figure 6: Infant Sleep Environment (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

Figure 7: Rules about Smoking Inside Their Home (%) by American Indian/Alaska Native Status, Oklahoma, 2012-2013 Data Source: Oklahoma PRAMS

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