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![Page 1: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/1.jpg)
Differing First Year Mortality Rates of Term Births to US-born and Foreign-
born Mothers
James W. Collins, Jr.
11/7/15
![Page 2: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/2.jpg)
Transgenerational Factors
Factors, conditions, and environments experienced by one generation that relate to
the pregnancy outcome of the next generation
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![Page 4: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/4.jpg)
![Page 5: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/5.jpg)
![Page 6: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/6.jpg)
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Differing Birth Weight in Illinois (David and Collins, NEJM, 1997)
0
2
4
6
8
10
12
14
US-born Blacks African-born Blacks US-born Whites
% L
BW
(<
250
0g)
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012345
6789
10
US-born Blacks African-born Blacks US-born Whites
% L
BW
(<
250
0g)
Differing LBW Rates Among Low-risk Women in Illinois
(David and Collins, NEJM, 1997)
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
US-born Blacks African-born Blacks US-born Whites
% V
LB
W (
< 1
500g
)Differing VLBW Rates Among Low-risk
Women in Illinois (David and Collins, NEJM, 1997)
![Page 10: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/10.jpg)
Maternal Race and Infant Birth Weight Among Low-Risk Women in Illinois
(Pallotto et al, AJE, 2000)
012345
6789
10
US-born Blacks Caribbean-born US-born Whites
% L
BW
(<
250
0g)
![Page 11: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/11.jpg)
Low Birth Rates by Maternal Age among Foreign-born Black Mothers
(Deal et al, Ethn Dis, 2014)
![Page 12: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/12.jpg)
VLBW RATES OF MEXICAN-AMERICANS BY MATERNAL GENERATIONAL RESIDENCE IN
THE U.S.Collins and David, Ethn Dis, 2004)
00.20.40.60.8
11.21.41.61.8
2
Mexican-Born (N=39,050) First Generation US-Born(N=2,203)
Infa
nt V
LB
W R
ates
(pe
r 10
0)
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Genetic Code vs. Zip Code?Two Leading Theories: • “Genetic Code Theory”:
– AA and MA women migrants to the US are intrinsically healthier and have better birth outcomes than those who do not migrate (Wingate, SSM, 2006; Ray et al, CMAJ, 2007).
• “Zip Code Theory”: – Lifelong residence in the US, or something closely related to it,
is detrimental to the birth outcome of AA and MA women (David and
Collins, AJPH, 2007; Collins and David, Clinics Perinat, 2009; Parker-Dominguez, SSM, 2010)
![Page 14: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/14.jpg)
Testing the Genetic Theory
• Wingate et al, MCHJ 2009:– US-born Blacks who moved out of state had better birth outcomes
compared to those who did not move, even after risk factors were controlled.
– Data support the healthy migrant theory. – Limitation: No adjustment for neighborhood income.
![Page 15: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/15.jpg)
Study Objective• To determine the association between migration
from Chicago to the suburbs and preterm birth (<37 wks, PTB) rates among African Americans and Whites.
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Natural Experiment: White Flight from Chicago
ChicagoSuburban CookCollar Counties
http://upload.wikimedia.org/wikipedia/commons/1/15/Illinois-counties-map.gif
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White Mothers
N= 45, 135African-American Mothers
N=41, 221
88%
10% 2%
ChicagoSuburban CookCollar Counties
30%
41%
29% ChicagoSuburban CookCollar Counties
White mothers were more likely to migrate Collins et al, MCHJ, 2013
P<0.0001, chi square test
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PTB rates improved with migration for both races Collins et al, MCHJ, 2013
White Mothers African American Mothers0
2
4
6
8
10
12
14
5.1
13.5
4.2
9.9
3.5
10.7
Chicago
Suburban Cook
Collar Counties
PT
B r
ates
/10
0 bi
rths
p<0.05
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White mothers who migrated had less risk factors.
White Mothers: Distribution of Risk Factors
Chicago Cook Collar
Maternal Age <20 8% 2% 2%
Education <12 yrs 19% 5% 5%
Unmarried 25% 8% 7%
Smoker 24% 18% 16%
Inadequate Prenatal Care 14% 6% 6%
Neighborhood Income in Lowest Quartile
21% <1% <1%
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AA mothers who migrated had less risk factors factors.
African-American Mothers: Distribution of Risk Factors
Chicago Cook Collar
Maternal Age <20 27% 16% 19%
Education <12 yrs 36% 15% 22%
Unmarried 83% 55% 58%
Smoker 20% 15% 18%
Inadequate Prenatal Care 33% 21% 32%
Neighborhood Income in Lowest Quartile
74% 16% 4%
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Migration benefits were explained by known risk factors Collins et al, MCHJ, 2013
Adjusted OR (95% CI)
Chicago-Chicago Reference
Chicago-Cook OR= 0.9(0.8, 1.1)
Chicago-Collar OR= 0.9(0.8, 1.1)
Adjusted OR (95% CI)
Chicago-Chicago Reference
Chicago-Cook OR= 0.9(0.8, 1.2)
Chicago-Collar OR= 1.0(0.9, 1.3)
Whites African-Americans
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Implications• Our findings do not support the healthy migrant
theory as a valid explanation for the discrepancy in birth outcomes between foreign- and US-born AA and MA women.
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Change in Mean Birth Weight Across a Generation
(Collins et al, AJE, 2002)
65
45
17
-57-80
-60
-40
-20
0
20
40
60
80
US-born White European-bornWhite
US-born AA
Cha
nge
in b
irth
wei
ght (
g)
African/Carib-AA
![Page 25: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/25.jpg)
Change in Mean Birth Weight Among infants of Married Women Across a
Generation (Collins et al, AJE, 2002)
69
3551
-95-120
-100
-80
-60
-40
-20
0
20
40
60
80
US-born White European-bornWhite
US-born AA
Cha
nge
in b
irth
wei
ght
(g)
African/Carib-AA
![Page 26: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/26.jpg)
MLBW Rates Across a Generation (Collins et al, AJE, 2002)
02
46
810
1214
US-BornWhites
Foreign-Born
Whites
US-bornAA
African-Carib-
Born AA
Women's Race and Nativity
ML
BW
rat
es (
per
100)
DaughtersGrand-daughters
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MLBW Rates Among Infants of Married Women Across a Generation (Collins et al, AJE, 2002)
02468
10121416
US-BornWhites
Foreign-Born
Whites
US-bornAA
African-Carib-AA
Women's Race and Nativity
ML
BW
rat
es (
per
100)
DaughtersGrand-daughters
![Page 28: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/28.jpg)
Study Objective
To explore the birth weights of the direct female descendants of US-Born and Mexican-Born Mexican-American Women.
![Page 29: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/29.jpg)
Change in Mean Birth Weight Across a Generation
65
45
11
-28-40
-20
0
20
40
60
80
US-born White European-bornWhite
US-born MA
Cha
nge
in b
irth
wei
ght (
g)
Mexican-born MA
![Page 30: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/30.jpg)
Change in Mean Birth Weight Between Gen 2 and Gen 3 among the Female Descendants
of Gen 1 Mexican-Born Women
-120
-100
-80
-60
-40
-20
0
20
Cha
nge
in b
irth
wei
ght
(g)
marriedunmarried< 20yrsOverall
20-35yrs
-28 (-63, 7)
-108 (-166, 50)
6 (-14, 26)
-67 (-118, 16)
-16 (-39, 10)
![Page 31: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/31.jpg)
Term Infants
![Page 32: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/32.jpg)
Study Objectives• To determine whether maternal birth in the US
is a risk factor for first year mortality among term (37-42 wks) births to non-Latino White, AA, and MA mothers.
• To ascertain the degree to which known individual level risk factors modify the relationship between maternal nativity and IMR among White, AA, and MA term births.
![Page 33: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/33.jpg)
Methods• 2003-2004 National Center for Health Statistics linked
live birth-infant death cohort files of term (37-42 wks) births to non-Latino White, AA, and MA mothers.
• Infant variables: birth weight, first year mortality.• Maternal variables: nativity, age, education, parity,
marital status, adequacy of prenatal care utilization (Kotelchuck Index).
• Stratified and multivariable binomial regression analyses were performed.
![Page 34: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/34.jpg)
Term IMR by Maternal Nativity and Race/Ethnicity(Collins et al, MCHJ, 2013)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
White* African-American* Mexican-American*
US born
Foreign born
n=22
6,62
1
n=78
2,45
2
n=38
8,3
37
n=71
0,8
37
n=3,
684,
569
n=11
8,24
6# de
aths
/1,0
00 li
ve b
irth
s
![Page 35: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/35.jpg)
Leading Cause-Specific Term IMR (per 1,000) by Maternal Race/Ethnicity and Nativity (Whites)
(Collins et al, MCHJ, 2013)
Leading Cause of Death
WhiteUS-born
WhiteForeign-born RR (CI 95%)
CongenitalAnomalies 0.6 0.5 1.3 (1.1-1.5)
SIDS 0.5 0.1 4.7 (3.2-7.1)
Injuries 0.2 0.1 2.2 (1.5-3.3)
![Page 36: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/36.jpg)
Leading Cause-Specific Term IMR (per 1,000) by Maternal Race/Ethnicity and Nativity (AA)
(Collins et al, MCHJ, 2013)
Leading Cause of Death
AAUS-born
AAForeign-born RR (CI 95%)
CongenitalAnomalies 0.9 0.9 1.0 (0.9-1.3)
SIDS 1.0 0.2 4.9 (3.3-7.3)
Injuries 0.5 0.1 4.1 (2.4-7.1)
![Page 37: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/37.jpg)
Leading Cause-specific Term IMR by Maternal Race/Ethnicity and Nativity (MA)
Leading Cause of Death
MAUS-born
MAMexican-born
RR (CI 95%)
CongenitalAnomalies
0.7 0.9 0.8 (0.7—0.9)
SIDS 0.4 0.1 3.0 (2.3-3.8)
Injuries 0.2 0.1 2.2 (1.6-3.0)
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Distribution of Selected High-Risk Individual Level Risk Factors by Maternal Nativity (Whites)
US-Born WhiteN=3,684,569
Foreign-Born WhiteN=226,621
LBW (<2500g) 2.5% 2.3%
Maternal Age <20y 7.5% 2.5%
Maternal Education <12y 11.0% 7.7%
Parity 3+ 8.5% 9.0%
Unmarried 23.9% 10.6%
![Page 39: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/39.jpg)
Term IMR by Maternal Age and Nativity(Whites)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
<20* 20-29* 30-39* 40+*
US-born
Foreign-born
# de
aths
/1,0
00 li
ve b
irth
s
Maternal Age (years)
![Page 40: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/40.jpg)
Term IMR by Maternal Education and Nativity(Whites)
0
1
2
3
4
5
6
<12* 12* >12*
US born
Foreign born
# de
aths
/1,0
00 li
ve b
irth
s
Maternal Education (years)
![Page 41: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/41.jpg)
Term IMR by Marital Status and Nativity(Whites)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Unmarried* Married*
US Born
Foreign Born
Marital Status * Signfies statistical significance
# de
aths
/1,0
00 li
ve b
irth
s
![Page 42: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/42.jpg)
Distribution of Selected High-Risk Individual Level Risk Factors by Maternal Nativity (AA)
US-Born AAN=782,452
Foreign-Born AAN=118,246
LBW (<2500g) 5.7% 3.6%
Maternal Age <20y 17.5% 4.2%
Maternal Education <12y 24.3% 14.8%
Parity 3+ 14.5% 13%
Unmarried 72.5% 38.9%
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Term IMR by Birth Weight and Nativity(AA)
0
2
4
6
8
10
12
14
16
18
LBW non-LBW*
US Born
Foreign Born
Marital Status * Signfies statistical significance
# de
aths
/1,0
00 li
ve b
irth
s
![Page 44: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/44.jpg)
Term IMR by Maternal Age and Nativity(AA)
0
1
2
3
4
5
6
<20* 20-29* 30-39* 40+*
US-born
Foreign-born
# de
aths
/1,0
00 li
ve b
irth
s
Maternal Age (years)
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Term IMR by Maternal Education and Nativity(African-Americans)
0
1
2
3
4
5
6
<12* 12* >12*
US born
Foreign born
# de
aths
/1,0
00 li
ve b
irth
s
Maternal Education (years) * Signfies statistical significance
![Page 46: Differing First Year Mortality Rates of Term Births to US-born and Foreign- born Mothers James W. Collins, Jr. 11/7/15.](https://reader035.fdocuments.us/reader035/viewer/2022062809/5697bff61a28abf838cbe5a3/html5/thumbnails/46.jpg)
Term IMR by Marital Status and Nativity(AA)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Unmarried* Married*
US Born
Foreign Born
Marital Status * Signfies statistical significance
# de
aths
/1,0
00 li
ve b
irth
s
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Distribution of Selected High-Risk Individual Level Risk Factors by Maternal Nativity(MA)
US-Born MAN=388,337
Foreign-Born MAN=710,837
LBW (<2500g) 2.5% 2.3%
Maternal Age <20y 12.5% 6.5%
Maternal Education <12y 31.4% 65.5%
Parity 3+ 12.3% 15.6%
Unmarried 48.2% 41.2%
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Term IMR by Maternal Age and Nativity(MA)
0
0.5
1
1.5
2
2.5
3
<20* 20-29* 30-39* 40+*
US-born
Foreign-born
# de
aths
/1,0
00 li
ve b
irth
s
Maternal Age (years)
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Term IMR by Maternal Education and Nativity(Mexican-Americans)
0
0.5
1
1.5
2
2.5
3
3.5
<12* 12* >12*
US Born
Foreign Born
Maternal Education (years) * Signfies statistical significance
# de
aths
/1,0
00 li
ve b
irth
s
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Term IMR by Marital Status and Nativity(MA)
0
0.5
1
1.5
2
2.5
3
Unmarried* Married*
US Born
Foreign Born
Marital Status * Signfies statistical significance
# de
aths
/1,0
00 li
ve b
irth
s
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Multivariable Binomial Regression Analyses (Collins et al, MCHJ, 2013)
• The adjusted (controlling for maternal age, education, parity, adequacy of prenatal care and region of birth) RR of infant mortality for non-LBW term births of US-born (compared to Foreign-born) White, AA, and MA mothers were 1.5 (1.3-1.7), 1.7 (1.5-2.1), and 1.6 (1.4-1.8), respectively.
• The adjusted OR of SIDS among US-born (compared to Foreign-born) White, AA, and MA mothers were 3.1 (2.0-4.7), 2.8 (1.8-4.2), and 2.9 (2.2-3.9), respectively.
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Limitations
• Vital records do not include duration of US residence for foreign-born mothers.
• No information on neighborhood level factors.
• No information of adequacy of the utilization of pediatric care.
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Conclusions• Term births to US-born White mothers have a
1.7-fold greater IMR than their peers with foreign-born mothers independent of the known individual level risk factors.
• The disparity is not limited to a singular cause of death and is widest among deaths due to SIDS.
• A similar phenomenon occurs among African-Americans and Mexican-Americans.
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Conclusions
• US-born mothers have approximately a 3-fold greater SIDS rate than their peers with foreign-born mothers.
• More detailed studies are needed to determine the extent to which term infant sleep positioning modifies the association of maternal nativity and SIDS.
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Implications
• The fact that the same phenomenon occurs among the three leading racial/ethnic groups in the US pinpoints the problem to the presence of risk factors among US-born women (i.e. lifelong residence in the US) rather than to the presence of protective factors among foreign-born women (i.e. healthy immigrant hypothesis).
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Implications• Our findings do not support the healthy migrant
theory as a valid explanation for the discrepancy in birth outcomes between foreign- and US-born African-American women.
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Speculation
• Unmeasured household factors underlie the maternal nativity disparity in term infant outcome regardless of race or ethnicity.
• Possibilities include maternal nativity differences in daycare practices and/or the presence of extended family members residing in the home.
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Term IMR by Maternal Nativity and Race/Ethnicity(Collins et al, MCHJ, 2013)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
White* African-American* Mexican-American*
US born
Foreign born
n=22
6,62
1
n=78
2,45
2
n=38
8,3
37
n=71
0,8
37
n=3,
684,
569
n=11
8,24
6# de
aths
/1,0
00 li
ve b
irth
s
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Study Objective
• To determine the extent to which maternal demographic risk factors explain the racial disparity in IMR among term infants.
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Leading Cause-Specific IMR (< 365d) by Race
0
2
4
6
8
10
12
Congenital Anomalies
SIDS Birth Asphyxia
White
African-American
dea
ths/
1,00
0 liv
e-bi
rths
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Cause Specific Neonatal Mortality Rate (NMR, <28d) by Race
0
1
2
3
4
5
6
7
Congenital Anomalies SIDS Birth Asphyxia
White
African-American
dea
ths/
1,00
0 liv
e-bi
rths
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Cause Specific Post-neonatal Mortality Rates (PNMR, 28-365d) by Race
0
2
4
6
8
10
12
SIDS Congenital Anomalies
Accidents
White
African-American
dea
ths/
1,00
0 liv
e-bi
rths
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Distribution of Selected Risk Factors
0
10
20
30
40
50
60
70
80
LBW* Age <20y* Education <12y*
Unmarried* 3+ prev births*
Inadequate PNC*
Whites
African-Americans
%
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Term IMR among Low-Risk* White and African-American Mothers
0
0.5
1
1.5
2
2.5
3
White African-American Category 3
dea
ths/
1,00
0 liv
e-bi
rths
*married, college-educated mothers who received adequate prenatal care adequate prenatal care
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Multivariable Binomial Regression Models
The raw and adjusted RR for infant death (365d) for AA (compared to Whites) were 1.7 (1.7-1.8) and 1.1 (1.1-1.2), respectively
The raw and adjusted RR for neonatal death (<28d) for AA (compared to Whites) were 1.3 (1.2-1.4) and 1.0 (1.0-1.1), respectively
The raw and adjusted RR for post-neonatal deaths (28-365d) for AA (compared to Whites) were 2.0 (1.9-2.1) and 1.1 (1.1-1.2), respectively