PowerPoint Presentation

A Parallel Universe: Giving Birth on the BorderAmanda Gomez and Dr. Theresa Morris, Texas A&M University

Southwestern Social Sciences Association 2016 Annual MeetingMarch 25, 2016Las Vegas Nevada

NOTE ON THE TITLEGeneral Intro: Good morning! Id like to say thank you to Dr. Theresa Morris, my co-author, for organizing the Sociology of Reproduction sessions. I am very excited to be a part of the Reproductive Justice session! I would also like to give Dr. Morris credit for inspiring my new presentation title. She used the phrase quoted on the screen to describe what seems to be happening to women particularly Latina women who give birth along the U.S.-Mexico border. These border women are giving birth in an area where national c-section trends are completely reversedessentially, a parallel universe.1

No Ms BebsU.S. Latinas and Reproductive Justice

No Ms Bebs-PBS Documentary released in February about the events surrounding the Madrigal v. Quilligan lawsuit-Government supported sterilization of Latina women in Los Angeles, California without informed consent-Tubal ligations were performed under the guise of necessary c-sections

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Theoretical FrameworkReproductive Justice and Human RightsComprehensive Intersectional

Biopsychosocial Model of Health

Hispanic Paradox

Its our decision (referring to previous slide)-Decision to have children (rather than the decision to not have children)-Women of color have a history of conceptualizing reproductive justice outside of the pro-life/pro-choice dichotomy

Reproductive Justice and Human Rights(Smith 2005) (SisterSong)-Thinking about reproductive justice beyond abortion debates; reproductive justice must be comprehensive-And if reproductive justice is to be comprehensive, it must be intersectional. The SisterSong Women of Color Reproductive Justice Collective, a grassroots organization credited with coining the term reproductive justice, maintains that reproductive justice should be understood from a human rights framework. Reproductive justice must encompass civil rights, economic rights, social rights, and environmental rights. -In regards to my research, I argue that it would be problematic for women to have different (and potentially unfavorable) health outcomes based on identities or circumstances largely out of their control.

Biopsychosocial Model (Borrell-Carri 2004) -Related to the comprehensive and intersectional aspects of reproductive justice, the biopsychosocial model recognizes the roles of biological, psychological, and social factors in the context of both wellness and disease.-This requires understanding health circumstances through multiple levels of organization.-I apply this model to my research by examining social determinants of health and observing how they impact c-section rates.

Hispanic Paradox(McClade 2004)-Despite socioeconomic disadvantage, Latinas in the U.S. have birth outcomes comparable to those of White Women (lower incidence of low birth rate babies and lower incidence of infant mortality)-The World Health Organization recommends that no country have a c-section rate above 10-15% (WHO 1985), indicating that vaginal birth is a more favorable form of delivery than c-section.-Though this is not directly related to incidence of c-section, Latinas do have a slightly lower rate of c-section than the national average not to WHO standards, but indeed lower than average.-How does the Hispanic paradox hold in the U.S.-Mexico border region in regards to c-section rates?3

BackgroundTrendsCalifornia: Hispanic women less likely to have c-sections than white women Texas: Increased c-section rate for all Texas border residents (even greater for Hispanic women) U.S.- Mexico Border: Hispanic women in border region more likely to have c-sections than all U.S. Hispanics

ExplanationsLimited childbirth educationStructure of prenatal care Types of hospitals available

TrendsMAKE A DISCLAIMER ABOUT THE USE OF HISPANIC-CDC 2013 Vital Stats: U.S. trends -Henke 2014 Hispanic negative indicator for c-section-Getahun 2009: California study; Hispanic women less likely to have cesarean sections when compared to white women REFERENCE CDC NATIONAL STUDY ABOVE-McDonald 2014a: Analysis of US and Mexican birth certificates; Cesarean Birth is more prevalent in the US-Mexico border region than among all US Hispanics (consistent with rates in other Latin American countries)-Walker 2014: Increased likelihood of cesarean for Texas border residents (all women, but greater for Hispanic women)-The limited border state and border region studies show that Hispanic women along the border have higher rates of c-section.

Explanations-Limited access to childbirth education (DeSisto 2014)-logistic issues (cant take time off of work, cant find babysitter, cant afford to travel, etc)-Limited access to childbirth education along the border prevents women from obtaining the knowledge and thus the confidence to take a more active role in their birth decision-making-Structure of prenatal care (DeSisto 2014) (Fullerton 2004)-McDonalds interviews show that some prenatal care visits are too brief for the women to process information and respond with questions. Many healthcare providers dismiss women and point them to other (overwhelming) sources of information like pamphlets and the internet.-Fullerton finds that the majority of women in his El Paso study receive inadequate prenatal care based on the Kotelchuck Index, an index that assesses prenatal care based on time of initiation and the number of following prenatal care visits until delivery. -Types of Hospitals Available(McDonald 2014a)-Given that private and for-profit hospitals are associated with a higher risk of CB in the U.S., Mexico, and elsewhere, maybe the types of hospitals along the border vary from the rest of the country. For instance, McDonald finds that the majority of border hospitals in Texas are for-profit.

My research-How do c-section rates along the U.S.-Mexico border compare to the rest of the United States? Does being Latina affect ones likelihood of delivering via c-section?4

BackgroundSES TrendsC-section rates higher for women with higher educational attainmentC-section rates higher for women with private insurance.ExplanationsWomen with higher educational attainment are olderService fee differentials

SES Trends-Educational Attainment-Colorado: C-section rates increase as maternal education increases (Moscariello 2011)-Indiana: C-section rates increase as maternal education increases (Indiana State Department of Health)-New York: Primary cesarean delivery rates highest among most educated and lowest among the least educated (Wang 2012)-Private Insurance-U.S.: Women with private insurance have a higher rate of c-section than women with Medicaid (Henke 2014)-California: Women with private insurance have a higher rate of c-section than women with any other source of payment studied (Stafford 1990)-U.S.: Adjusted odds ratio increased 6% for women with private insurance (Kozhimannil 2013)

Explanations-Women with higher educational attainment are older. Older women have higher rates of c-section. (Roth 2012)-Service fee differentials. Through private insurance plans, c-sections may generate more money than vaginal deliveries. This results in market pressure to perform more c-sections. (National Bureau of Economic Research)

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Methods and AnalysisListening to Mothers III SurveySurvey of 2,400 mothers who gave birth in U.S. hospitals in 2011 and 2012Dichotomized VariablesLatina/non-LatinaCollege Degree/No College DegreePrivate Insurance/No Private InsuranceBorder Region/Non-Border Region (CDC)Significance Tests

Listening to Mothers III Survey-Survey of 2,400 mothers who gave birth in U.S. hospitals in 2011 and 2012

Dichotomized Variables-Hispanic/Latino/Spanish Ethnicity = Latina/non-Latina-Highest Degree Earned = College Degree/No College Degree-Primary Source of Payment for Hospital Services = Private Insurance/No Private Insurance-Hospital = Border Region/Non-Border Region-48 U.S. Counties based on 1966 La Paz agreement CDC

Significance Tests-2-sample t-test for 100

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C-Section Rates by RegionNon-Border: 28.7%

Border: 32.7%

Not a statistically significant difference

Results-My initial question was whether there was a significant difference between the c-sections rate for the non-border region and for the border region.-What I found was that, at a superficial level, there does not seem to be an evident disparity. So, we can say that in both regions, approximately one-in-three women deliver via c-section. While we do see that border region has a slightly higher rate of c-section than the non-border region, it is not a statistically significant difference. -What is different, however, are the types of women who deliver via c-section in each region.

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C-Section Rates Within Each RegionNon-BorderBorderLatinaCollege Degree+-Private Insurance+

+: higher rates of c-section-: lower rates of c-section

I tested significance in two ways: I tested the significance of ethnicity and SES variables within each region (within the border region and within the non-border region) and I tested the significance of SES variables between the regions.

We can see that the non-border region generally follows national trends: women with college degrees are significantly more likely to have c-sections than women without college degrees & women with private insurance are significantly more likely to have c-sections than women without private insurance. The border flips the national trend for college education. On the border, women without a college degree are more likely to deliver via c-section.

How to read the table according to region:Non-Border -Within non-border regions, women with college degrees have a significantly higher rate of c-section than women without college degrees.-Within non-border regions, women with private insurance have a significantly higher rate of c-section than women without private insurance.Border -Within border regions, women with college degrees have a significantly lower rate of c-section than women without college degrees*Blank cells did not show a statistically significant difference*8

C-Section Rates Within Each RegionNon-BorderBorderLatina, No College Degree-+Latina, No Private Insurance-No College Degree, No Private Insurance-+

+: higher rates of c-section-: lower rates of c-section

Tying my analysis back to the framework of intersectionality, I also decided to see how intersecting identities/circumstances affected c-section rates. Once again, we see that the non-border region is consistent with national trends. However, on the border, we see the opposite for two of these populations.

How to read table according to table:Non-Border Within non-border regions, Latinas without college degrees have a significantly lower rate of c-section than non-Latinas with college degrees.Within non-border regions, Latinas without private insurance have a significantly lower rate of c-section than non-Latinas with private insurance.Within non-border regions, women without college degrees and without private insurance have a significantly lower rate of c-section than women with college degrees and with private insurance.Border Within border regions, Latinas without college degrees have a significantly higher rate of c-section than non-Latinas with college degreesWithin border regions, women without college degrees and private insurance have a significantly higher rate of c-section than women with college degrees and private insurance.*Blank cells did not show a statistically significant difference*9

C-Section Rates Between Regions

Border vs. Non-BorderLatina+College Degree-No College Degree+Latina, No College Degree+Latina, No Private Insurance+No College Degree, No Private Insurance+

Now, we see what was found to be significant between regions. For instance, we are comparing Latinas in the Border Region to Latinas in the Non-Border Region. What I found to be interesting is that variables that would usually serve as a c-section buffer (especially when combined) actually compound the probability of having a c-section in the border region.

How to read the table according to variable:Latinas on the border have a significantly higher rate of c-section than Latinas not on the border.Women with college degrees on the border have a significantly lower rate of c-section than women with college degrees not on the border.Women without college degrees on the border have a significantly higher rate of c-section than women without college degrees not on the border.Latinas without college degrees on the border have a significantly higher rate of c-section than Latinas without college degrees not on the border.Latinas without private insurance on the border have a significantly higher rate of c-section than Latinas without private insurance not on the border.Women without college degrees and without private insurance on the border have a significantly higher rate of c-section than women without college degrees and without private insurance not on the border.

I have prepared some infographics to illustrate how this regional difference affects Latinas birth experiences.10

2.4 out of 104.3 out of 10

A Latina in a non-border region has a 2.4 out of 10 chance of getting a c-section.

Move this Latina to a border region, and she has a 4.3 out of 10 chance of getting a c-section.11

2.4 out of 105.0 out of 10

A Latina without a college degree in a non-border region has a 2.4 out of 10 chance of getting a c-section.

A Latina without a college degree in a border region has a 5.0 out of 10 chance of getting a c-section.12

2.1 out of 105.4 out of 10

A Latina without private insurance in a non-border region has a 2.1 out of 10 chance of getting a c-section.

A Latina without private insurance on the border has a 5.4 out of 10 chance of getting a c-section.

It is evident that border region has serious implications for these disadvantaged and historically underserved populations.13

Conclusions Addressing Complications

Further ResearchHospital-level VariablesLarger Sample SizesRedefining borderImportance of Qualitative Data

Addressing Complications-It was difficult to see which exact variable caused the affect on c-section rate because many Latinas sampled in this survey did not have college degrees and did not have private health insurance. -Also, the sample size for women in the border region was relatively small and not representative of the actual demography on the border. For instance, more non-Latinas than Latinas were surveyed along the border region.

Further Research-Reflecting on the literature, future research should examine hospital level variables in order to determine whether these differences are caused by individual-level variables or institutional-level variables.-Larger sample sizes are needed to pick up significance. This may be done by either surveying more people or by redefining border region to include a larger area of land.-Finally, the Listening to Mothers III survey also provided interviews with a portion of the respondents. My next step is to analyze this qualitative data to see how different women perceived their birth experience and their treatment while in the hospital. The data is already coded, and although no formal analysis has been done, I do have instances of Latina women from the border reporting that they had a tubal ligation done during their c-section. And while I am not going to say that the sterilization that occurred in Latino communities in the 1970s is continuing today, I do think that it is important for women and healthcare providers alike to be aware of this populations history in the context of their reproductive health being subjected to institutionalized powers.

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Thank you to Dr. Christine Morton, CMQCC and Dr. Miriam Naiman-Sessions, Montana DPHHS.Questions or Comments? amanda2014@tamu.edu

CMQCC: California Maternity Quality Care Collaborative

DPHHS: Department of Public Health and Human Services15