Latina Reproductive Health in New York City

Latina Reproductive Health in New York City Presentation by Joann Casado Executive Director, Bronx Healthlink June 1, 2005 QCPC Reproductive Mini Health Forum The Work of The Bronx Health Link and the Perinatal Information Network    To identify and organize information about the service systems in the Bronx to improve perinatal health, which includes maternal and child health issues. To identify gaps in local services and to ensure that these are addressed and opportunities for collaboration and cooperation are identified to maximize services and prevent duplication. To support healthy women, children and families in the Bronx Who is the Latino (a) Community in the United States       Hispanics or Latinos are persons of Cuban, Mexican, Puerto Rican, South or Central-American, or other Spanish culture or origin, regardless of race. The federal government considers race and Hispanic origin to be two separate and distinct concepts; Hispanic Americans may be any race. According to the 2000 U.S. Census, Hispanics of all races represent 12.5 percent of the U.S. population, about 35 million individuals. The Census Bureau projects that by the year 2035 there will be 75 million Hispanic individuals, comprising 20 percent of the population. It is estimated that by the year 2050, one in every four women in the United States will be Latina. Latinas are also young – 40% of the Latina population is under the age of 21 and the median age is 27 years of age, compared to a median age of 37 for white woman and a median age of 30 years for African American/Black women. Half of all Latinas are of reproductive age (9 million) Who is the Latino (a) Community in the United States     Though we share many aspects of a common heritage such as language and emphasis on extended family, Latino/Hispanic cultures vary significantly by country of origin. Latinos/Hispanics tend to be younger than the white nonHispanic population (except for Cubans, who have a higher proportion of elderly than other Hispanic groups). Our health profiles are also unique: Puerto Ricans suffer disproportionately from asthma, HIV/AIDS, and infant mortality, while Mexican Americans suffer disproportionately from diabetes. We are not all the same – “a one model fits all” will not help Latinas – where we live, how we live, who we live with- all these factors affect our health. The Health Status of Women in New York City  The health of women in New York City has greatly improved over the past decade, but some groups of women - particularly black, Hispanic, and low-income women - still experience poor health. -- Women in New York City's poorest neighborhoods have a life expectancy 5 years shorter than those who in the highest income neighborhoods. Black women have a life expectancy almost 5 years shorter than white women. -- Black women are more than twice as likely as white women to die from pregnancy-related complications. -- Nearly one-quarter of women age 40 and older have not received a mammogram in the past two years; fewer than half of women age 50 and over have ever had a colon cancer screening; and 1 in 5 women have not had a Pap test in the past three years. Asian women are least likely to receive colon cancer screenings and Pap tests. -- The rate of new AIDS diagnoses is 11 times higher among black women than white women and the rate of AIDS deaths is 7 times higher. Who is the Latino(a) Community in New York City ?      New York has the largest expatriate community of Puerto Ricans in the country Immigration status affects accurate data on foreign born residents. Data on recent immigrants indicates that the number of Mexicans and other Latino immigrants is increasing yet the numbers belie the reality. Anecdotal comments from the community evidence increasing numbers and shifting demographic characteristics. Individuals from the Dominican Republic are the primary Latino foreign born residents in New York City. Latinos are not homogenous e.g. Garifunas from Hondurans is a community with its own unique cultural and linguistic identity. There are thousands of undocumented Latino immigrants in New York City, many of whom will never be counted in Census data. Factors affecting the reproductive health of Latinas  Poverty  Despite tremendous contributions to the economy, Latinas continue to be employed in the lowest paying jobs, and they have the second highest rate of unemployment  23% of Latinas live in poverty  In the United States, 31% of children live in poverty. Lack of access to health care Lack of insurance  Without health insurance many Latinas delay or go without medical care  Latinas have the highest rate of being uninsured  Approximately 31% of Latinas do not have a regular medical provider  In New York City, it is estimated that 28% of working age adults, ages 18 – 64, or more than one million, men and women are uninsured.  There continues to be a decrease in the number of women receiving Medicaid – according to the Kaiser Family Foundation the percentage of Latinas covered by Medicaid decreased from 29% to 21% in a 4 year period.   Factors affecting the reproductive health of Latinas Under-representation of Minorities in the Health Field While underrepresented racial/ethnic group make up 21 percent of the U.S. population, they comprise only 8.6 percent of U.S. physicians. Moreover, the number of minority physicians in training is declining. The lack of diversity in the health care profession impedes access to services for women of color. Most U.S. medical schools provide inadequate cultural sensitivity training, with over two-thirds failing to teach about African American cultural issues, nearly 75 percent failing to provide instruction on Latino cultural issues, and over 80 percent failing to teach about Asian/Pacific Islander or Native American cultural issues. Twenty-one percent of minority adults report having difficulties in receiving health care due to language barriers. Factors affecting the reproductive health of Latinas: Fatalism and Sexual Silence Fatalism Fatalism can be described as the general outlook on life that is associated with the belief that destiny is out of our hands and that events are inevitable. Fatalism results in a feeling of predetermination, pessimism, fear and the inevitability of death (Chavez et al 418). Various factors are strongly associated with a fatalistic view amongst Latinas, including immigration and educational level. In fact, the lower the level of education attained, the stronger likelihood to hold fatalistic beliefs Source: (Chavez et al 422). Sexual silence Sexual silence is considered to be a cultural characteristic that affects the behavior of the individuals in a Latino family. For example, the attitude that sexuality is personal and is not to be talked about openly is a behavior that is influenced by the Latino culture. This cultural influence is so pervasive that those who are open about their own sexuality are labeled and stigmatized. Consequently, sexual silence leads to a lack of communication amongst the Latino family and between sexual partners. Source: Chavez, LR, et al. "The Influence of Fatalism on SelfReported Use of Papanicolaou Smears." American Journal of Preventive Medicine 13(1997): 41824. What is reproductive health?    According to the World Health Organization, reproductive health implies a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Reproductive health addresses the reproductive processes, functions and system at all stages of life. Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.  Source: Global Policy Committee of the World Health Organization, 2 May 1994; and the WHO Position paper on health, Population and Development, Cairo 5-13 September 1994 What is reproductive health?  Reproductive health applies to a number of different health issues affecting women – these include:  Family planning  Contraception  Prenatal care  Treatment of cancers affecting the reproductive health system such as breast and cervical cancer  Prevention and treatment of sexually transmitted diseases  HIV/AIDS prevention, treatment, education and care  Access to safe and legal abortion  Sexuality education What are some of the reproductive health issues affecting Latinas in the United States      More than 25% of Latinas in the United States do not receive pre natal care during the first trimester Latinas account for more than 20% of all AIDS cases among women, and the HIV infection rate for Latinas is 7 times higher than for white women Among Mexican American and Puerto Rican women, the rate of cervical cancer is two to three times higher than for white women The rate of unintended pregnancies for Latinas is almost two times what it is for white women Factors that contribute to poor health outcomes among Hispanics include poverty, discrimination, political and socio-economic marginalization, lack of access to preventive care, and lack of health insurance. Although some would attribute poor health outcomes to culture and language – these should be seen as community assets that can be utilized to develop targeted health promotion and community empowerment activities.   Source: Issue Brief, The Reproductive Health of Latinas in the United States, National Latina Institute for Reproductive Health, March 2002 Family Planning Issues for Latinas   Latinas have the highest fertility rate of any group and account for 18% of all births yet 50% of all pregnancies are unintended and of these unintended pregnancies, one half result in an abortion. The 1995 National Survey of Growth indicated that only 32% of Latinas aged 15 -44 reported visiting a family planning provider within the last 12 month period. Contraception Issues affecting Latinas in the United States   Female sterilization remains the most popular method of birth control for Latinas, an estimated 37% use this method Finally, only 59% of Latinas between the ages of 22 and 44 reported using some form of contraception as  compared to 66% of white women and 62% of African American women. Various factors affect Latinas and contraception:    Historical abuses – sterilization without consent Promotion of permanent birth control (Norplant) Because of the high rates of non insurance – Latinas do not have access to regular, quality care Prenatal Care Issues for Latinas More than 25% of Latinas do not receive prenatal care during the first trimester. Early prenatal care can encourage healthy habits during pregnancy, help to identify potential medical problems, and facilitate involvement with support, and other educational resources. A CDC study revealed that African American women and Latinas were over twice as likely as white women to obtain delayed or no prenatal care. The majority of women with late or no prenatal care wanted to enter care earlier; however, they cited various barriers that prevented them from doing so, including: they didn’t know they were pregnant (44 percent of African American women); they lacked the money or insurance to pay for their visits (41 percent of Latinas); and they were unable to obtain an appointment (27 percent of Latinas). Maternal Morbidity     According to the World Population Bureau, the United States’ 2002 infant mortality rate was 6.6 deaths per 1000 births. Though the United States has the largest Gross Domestic Product in the world (2000/2001), its current infant mortality rate is higher than such significantly poorer nations as Ireland and Cuba. Latinas have the highest birth and fertility rates in the U.S. Nationally, the number of live births per 1,000 women ages 15-44 years (fertility rate) in 1990 was 107.7 for Latinas compared to 67.1 for non-Latino women, the highest fertility rates being among Mexican women. In 1998, for mothers of Mexican ethnicity, 5.6 out of every 1000 children under one year of age died. The rate for babies with non-Hispanic white mothers was 5.98 per 1000 births for 1998, a decline from the previous year’s rate of 6.02. The rate for babies with non-Hispanic black mothers was 13.88 per 1000 births. The rate of maternal morbidity for Latinas is 1.7 times higher than for white women  Source: NARAL Foundation, The Reproductive Rights and Health of Women of Color www.geohive.com/global/c_ec_gdp1.php. [2003, March 24]. www.prb.org/pdf/WorldPopulationDS02_Eng.pdf [2003, March 24]. Cancer in the Latino Community           According to SEER data for the period between 1988-1992, Latinos had a slightly lower incidence of prostate cancer than whites (89.0 versus 134.7 per 100,000). However, Latinos were almost twice as likely to die from the disease. The average time between mammography results and follow-up was 7 weeks for Hispanic women, compared with 4 weeks for non-Hispanic White women. Latino women are less likely to be aware of Pap tests. Cervical cancer mortality rates for Latino women have increased an average of .2% per year. Overall, lung cancer is the leading cause of cancer death among Latinos. Lung cancer deaths are three times higher for Latino men than for the women. · Of all ethnic/racial groups in NYC, Hispanic men and women less than 40 years old are the highest users of tobacco. The smoking prevalence among NYC Spanish-speaking females over 40 years is substantially higher than rates in Spanish-speaking women over 40 nationwide. From 1991 to 1997, the prevalence of current cigarette smoking among high school student increased 32%. Current cigarette smoking increased 34% among Hispanic students, versus 28% among white students. Source: Center for Immigrant Health : NYU School of Medicine Breast Cancer     Uninsured Latinas with breast cancer are 2.3 times more likely to be diagnosed at a later stage of the disease. Latinas also have the lowest rates of breast cancer among other minority groups including Whites. Although Latinas are less likely to get breast cancer, when they do get it they are more likely to die from it because they tend to be diagnosed at later stages, when the cancer is harder to combat. Breast cancer is the most commonly diagnosed cancer among Latinas. Breast cancer is still the leading cause of cancer death among Latinas. Only 70 per 100,000 Hispanic women per year get breast cancer. Latinas have a low prevalence of breast cancer because they tend to smoke less, drink less, and eat healthier. Other factors that protect Latinas and make them less at risk of getting cancer are early and multiple pregnancies, and low dietary fat intake. Environmental Links to Breast Cancer A report from the Center for Disease Control in February 2003 revealed shocking racial disparities in the amount of toxic chemicals found in the bodies of Americans. Evidence indicates that these chemicals are significantly linked to breast cancer. The CDC report showed: African-Americans are more likely to be exposed to dioxins and PCBs. . Whites had higher levels of polycyclic aromatic hydrocarbons (PAHs) than other groups in the study. Mexican-Americans had higher levels of pesticides, herbicides and pest repellants. In fact, the average level of DDE, a metabolite of DDT, is 210 percent greater in Mexican-Americans than in Whites.     Source: US Centers for Disease Control. (2003) Second National Report on Human Exposure to Environmental Chemicals. Cervical Cancer and Latinas    Cervical cancer is the third most common cancer amongst Latinas (Molina & Aguirre-Molina 226). Moreover, in some highly populated Latino communities, the incidence rate of having cervical cancer is higher amongst Latino women than White women (Molina & Aguirre Molina 229 ) Latina women are not being diagnosed at an early, curable stage. Instead, they are diagnosed at a much later, severe stage which is indicative to the high incidence and mortality rate amongst Latinas with cervical cancer than amongst other ethnic groups (Hubbell et al 2353) Cervical Cancer and Latinas  Immigrant women were more likely to prefer to remain uninformed of whether they are at risk for cervical cancer, believing that fate will ultimately decide the outcome (Chavez et al 422). Furthermore, a study conducted on Latinas concluded that these strongly held fatalistic beliefs are among the various factors that contribute to the low practice of cervical cancer screening tests (Chavez et al 418). Hence, cultural beliefs, such as fatalism, contribute to the lack of use of preventative screening for cervical cancer, thus affecting the incidence rate of this cancer amongst Latinas. Sexually Transmitted Infections and Latinas  According to the National Latina Institute for Reproductive Health Every year, there are an estimated 15 million new cases of sexually transmitted infections in the United States. 25% of all Americans are believed to have been infected by an STI by the age of 24. Young people under the age of 25 account for 67% of all new cases of sexually transmitted infections.  Latinas have the highest rate of cervical cancer caused by human papillomavirus (HPV).  The rate of recently reported cases of young Latinas – between the ages of 10-19 – with Chlamydia is more than double that of young white females.  Latinas have higher rates of syphilis than non-Hispanic white women.   Among ethnic minorities, Latinas report the second highest number of cases of gonorrhea. HIV/AIDS is the leading cause of death among Latinos aged 2544. HIV/AIDS      As of December 2001, the CDC estimates there have been 149,752 cumulative Latino AIDS cases in the United States - 28,554 female and 121,198 male The rates per 100,000 of Latino AIDS cases reported in 2001 differs sharply from that for Whites. For Latino males, the rate was 43 per 100,000 contrasted to 13.7 for Whites per 100,000 for Whites. For Latinas, the rate was 12.9 per 100,000 contrasted to 2.4 for White women. The distribution of countries of origin tells us much about the diversity of AIDS cases among Latinos. In 2001, new cases of Latino AIDS were 43% of reporting being born in continental United States, 23% from Puerto Rico, 14% Mexico, 7% Central/South America, 2% Cuba, and 13% unknown country of birth. Although there has been a decline in the number of AIDS death, women continue to die sooner than men from time of diagnosis and the AIDS rate of death fell 35% for women while the rate for men fell almost 64% In a 2001 survey by Kaiser Family Foundation, Latinos (40%) view HIV/AIDS as the most urgent health problem facing the nation today when compared to cancer and heart disease. Significantly larger numbers of Latinos for whom Spanish is their primary language (55%) viewed AIDS as more urgent than English dominant Latinos (30%). HIV/AIDS and Latinas in New York City    The rate of Latinas with AIDS as a proportion of all Latino AIDS cases has climbed from 15% in 1990 to 23% in 2000.1 The AIDS case rate is five times more for Latinas than white women. Latina women along with Latino men are more likely to test later in their illness than any other racial/ethnic group at 48%. HIV/AIDS is the number one killer of women ages 25 -44 in New York City. According to the Latino Commission on AIDS, heterosexual contact accounts for 47% of reported AIDS cases for Latina women as of December 2001. Using adjustments to data and estimates, the CDC estimates this number may be as high as 55%. HIV/AIDS and Latinas in New York City  Intravenous and other drug use has been a critical mode for HIV transmission among Latinas.    About 38% of Latina women are infected through injection drug use. Using adjustments to data and estimates, the CDC estimates this number may be as high as 42%. There are marked regional differences in this transmission profile with many more women in the Northeast and Puerto Rico reporting intravenous drug use as the source of their infection compared to Latinas in other parts of the nation. Reports of recent drug use were highest among Puerto Rican (6.6%) and Mexican (4.8%) women. Deaths- For Latinas, AIDS is the 3rd ranked cause of death for 35-44 (9th White women) and 4th for 25 - 34 (8th White women). HIV/AIDS and Latinas in New York City  Prevention - Latinas confront several obstacles in both preventing HIV infection and seeking treatment once they are infected.  First, most of the approaches used to prevent HIV infection were based on an approach used with men who have sex with men. Recommendations were recently made to employ targeted social marketing techniques which may change the approaches employed to reach women at risk  Second, depending on levels of acculturation, Latina gender roles encourage the view that Latinas are not a "risk group" and that being married or in an apparently monogamous relationship protect them from infection.  Third, for many Latinas there are several other priorities beside their own health causing some women to focus primarily on HIV only when it can be demonstrated to have an impact of their familial role.  Fourth, the ability of Latinas to negotiate safer sex practices is very difficult at best.  Fifth, for Latinas that are intravenous drug users there are few treatment options that enable them to maintain their familial responsibilities and seek in patient treatment.  Source: Latino Commission on AIDS HIV/AIDS in New York City  New York City Women Living with HIV/AIDS Women as a percent of the Total 35 30 25 20 15 10 5 0 Bronx Bronx Man Bklyn Queens SI Access to Safe and Legal Abortion   Women of color have been instrumental in the fight for reproductive freedom and, in significant numbers, support a woman’s right to legal abortion. According to a survey by the National Latina Institute for Reproductive Health, 68 percent of Latinas believe that women should have unrestricted access to abortion or that women should have access to abortion under almost all circumstances. Health Literacy  The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.  DHHS, Healthy People 2010 What are the consequences of limited Health Literacy     Limited participation in medical decision making. People with low health literacy are more likely to be disempowered during a clinical encounter More medication and treatment errors are possible because individuals cannot read the labels A higher rate of non adherence to medication Ineffective communication between the consumer and the provider can lead to misdiagnosis because consumers may not be able to explain and effectively communicate what they are feeling Recommendations        Increase the rate of federal matching funds for language services through Medicaid Access to health care – support universal health care Latinos are not part of the national debate on health disparities – the debate is framed in terms of race – black and white and the health disparity issue must consider the health concerns and issues affecting the million of latino residents of this country. Support laws that protect the rights of Latinas to access safe and legal abortion services . Increase funding for research that addresses the needs of Latinas in the field of reproductive health Increase funding for promodoras de salud – to create community based education vehicles that utilize language and culture Promote application of CLAS standards in all health care facilities thereby increasing the availability of culturally competent and linguistically appropriate health care services for Latinas  Recommended Standards for Culturally Appropriate Health Care Recommendations  Oppose actions and policies that remove the control of reproductive health from the individual Latina – let us not forget that 40 years have passed since Puerto Rican women were routinely sterilized and deprived of their reproductive choice without their consent. If we are silent – it could happen again.