NEIGHBORHOOD HEALTH TRENDS
The previous section reviewed the characteristics of the regions surrounding our five study sites, as well as key demographic, social, and economic conditions and trends of the sites themselves. In this section, we independently examine trends in the health related variables that are available for this analysis: the birth and mortality indicators derived from vital records files maintained by the NNIP partners in the sites. Specifically, we examine trends for five indicators: teen birth rates, rates of early prenatal care, rates of low-birth weight births, infant mortality rates, and age-adjusted mortality rates. As in the previous section, we also contrast conditions and trends in high-poverty tracts (poverty rates of 30 percent or more in 1990) with those in nonpoor tracts in each site.
As noted in section 7, prior studies have shown that health-related problems measured by these rates are generally more severe in high-poverty neighborhoods than in nonpoor areas, but these studies have typically covered only one city and dealt with different time periods. Our data allow us to go farther and examine variations in the extent of these gaps and how they have shifted over the same time period in several different cities. Also, data have already been published to show that conditions as measured by these indicators improved in many American cities in the 1990s. This analysis is the first, however, to quantify and compare the extent of the improvements between poor and nonpoor neighborhoods within cities and between cities.
TRENDS FOR KEY INDICATORS
For this analysis, to address the rare events issue noted earlier, we averaged three years of data from 1990 to 2000 to smooth out the annual variations that could occur due to small numbers of events. For simplicity's sake, the text will refer to rates by the start and end points of the data. For example, the 1990/1992 rate discussed below refers to the rate obtained by averaging 1990, 1991, and 1992 data. For three of the cities, the data were available for the full time period from 1990 to 2000. As stated in section 7, there were two exceptions. First, Providence had no mortality data and birth data only from 1995 to 2000. Second, at the time of this analysis, Oakland only had mortality up until 1999.
Births and birth rates
For each of the cities, the high-poverty areas account for very different shares of all births in 1998/2000--from a low of 9 percent in Indianapolis to 37 percent in Providence. With the exception of Providence, birth rates in the non-poor areas of our cities declined in the 1990s. The birth rates in high poverty neighborhoods also fell, but at 2 to 4 times faster than the non-poor rates.
To provide context for our analysis of trends for the five indicators, particularly those related to maternal and infant outcomes, it should be helpful to review the characteristics of the births in each city overall. As discussed in the previous section, these study areas vary greatly in population size, and this pattern carries over in the number of births (table 9.1). However, the changes in births from 1990 to 2000 did not always track with the trends in population. In the high-poverty tracts in Cleveland and Indianapolis, the number of births dropped three times faster than the general population. The percentage rise in births in high-poverty areas in Denver and Providence generally tracks the increasing total population. Oakland has the most unusual pattern--moderate growth in population with large decreases in the number of births.
|Number of births
|Pct. change in the number of births1990-2000||High-poverty tracts||-30||16||-28||-33||11|
|Pct births in high poverty areas|
|Pct. births to Hispanic mothers|
|Pct. births to black mothers**|
|* Birth Data for Providence begins in 1995, so rates labeled 1990/92 are for 1995/1997.
**In Cleveland and Indianapolis, "black" includes black mothers of Hispanic and non-Hispanic origin.
The analysis to follow discusses the aggregate indicators for high-poverty tracts and the nonpoor tracts. In 1998/2000, for each of the cities, the high-poverty areas account for very different shares of all births--from a low of 9 percent in Indianapolis to 37 percent in Providence. As expected from the racial change described in section 8, the racial/ethnic composition of births altered markedly over the decade in most of the cities. The share of Hispanic births increased in all of the cities, though it still remained low in Cleveland and Indianapolis. In Denver and Oakland, there was a corresponding loss of share for births to black mothers.
For the four cities with data for the full decade, birth rates in high-poverty areas in all the cities were higher than in the nonpoor areas throughout the decade (figures 9.1a and 9.1b). Of the high-poverty areas, Denver ended the decade with the highest rate (23 births per 1,000 population), and Providence ended with the lowest (16 births per 1,000 population).
With the exception of Providence, birth rates (births per 1,000 population) in the nonpoor areas of our cities declined in the 1990s (see figure 9.1a). The birth rates in high-poverty neighborhoods also fell, and at rates two to four times faster than in the nonpoor areas. Even Providence, with birth rate increases in the nonpoor areas, experienced a slight drop in its high-poverty areas from 1995/1997 to 1998/2000. While the rates in high-poverty areas were consistently higher than in the nonpoor areas, the patterns of change generally resulted in much smaller differentials between the two types of areas by 1998/2000.
Teen birth rates
Teen birth rates fell in both the poor and nonpoor areas in four cities in the 1990s, with the most substantial decreases in both types of areas in Oakland. Even with the decreases, considerable disparities between poor and nonpoor neighborhoods remain in Cleveland, Denver, and Indianapolis.
As shown in figure 9.2a, only the nonpoor areas of Denver and Oakland had 1990/1992 teen birth rates far above the national average of six births per 100 girls aged 15 to 19. Starting from this high level, the rates in Oakland's nonpoor areas showed a strong decline, falling twice as fast as the national average (see annex table C.15 for details). The nonpoor areas in the other cities also saw declines, but at a much slower rate. By the end of the decade, only the teen birth rate for the nonpoor areas in Denver (7.5) remained well above the national average.
In 1990/1992, the teen birth rates in the high-poverty areas for four of our cities were two to three times the national average (figure 9.2b). In Oakland, the teen birth rate in the poor areas 1990/1992 was 14 percent, lowest of the rates in that year. It fell 6 percentage points over the decade, with the majority of the gains in the first half of the decade. Figure 9.3 shows the low rates at the end of the decade, with rates in poor areas very similar to rates in nonpoor areas.
The high-poverty areas in Indianapolis had the highest rate in 1990/1992 (19 percent), but they also showed the most improvement--dropping 7 points to end at the second highest rate. This progress cut the difference between poor and nonpoor areas in half--from 12 points at the beginning of the decade to 6 points at its end. In Cleveland's high-poverty tracts, the teen birth rate fell midway between the sites and had a sharp decline like that of Oakland and Indianapolis. However, Cleveland still had the widest disparity in rates, with the 1998/2000 rate in high-poverty neighborhoods (10 percent) triple the rate of the low-poverty ones. The reduction in teen birth rates was primarily due to reductions in births to black teens. The African-American teen birth rates dropped from 2 to 9 points in high-poverty areas, while Hispanic teen birth rates stayed the same in Cleveland, increased in Indianapolis, and fell only 1 to 3 points in the remaining three cities (see annex tables C.17 to C.18 for details).
High-poverty areas in Denver (with very high rates) and Providence (with very low rates) did not experience reductions as large as the cities discussed above. Denver had the highest overall teen birth rate for most of the 10 years, surpassing Indianapolis early in the decade. Figure 9.4 clearly shows the overlap of the extreme teen birth rates with high-poverty areas in the western half of the city. This is also the predominantly Hispanic area--in 1998/2000 almost one in five Hispanic teen girls in Denver became mothers. Providence also had a very small drop over the 1995/1997 to 1998/2000 time period. This trend is not as troubling as in Denver, since the rates in Providence are remarkably low for all races and the time period covered is shorter. The Providence teen birth rates in the high-poverty areas were at the U.S. average, and the difference between the poor and nonpoor areas was less than 1 percent.
Alameda County, CA. Teen Birth Rates 1998-2000
Denver County, CO. Teen Birth Rates 1998-2000
Early prenatal care
Except for Providence, poor and nonpoor areas in all cities showed improvements in prenatal care rates. Indianapolis and Oakland stand out, with impressive expansion of early prenatal care to high-poverty areas.
Nationally, great gains were made in providing prenatal care to mothers. In 2001, 83 percent of pregnant women received prenatal care in the first trimester of pregnancy, up 7 percentage points from 1990/1992. At the beginning of the decade in nonpoor areas, only the Cleveland figure was significantly above the U.S. rate of 76 percent (figure 9.5a). For high-poverty areas, the rates in Cleveland and Oakland approached the national rate in 1990/1992, with the other three cities much farther behind (figure 9.5b). From these starting points, the improvements seen in the U.S. average are not evident in all of our sites.
In three of our cities, the change in levels of prenatal care may well be linked to specific program initiatives occurring during the 1990s. Beginning in 1991, Oakland was a demonstration site for the Healthy Start initiative, a federal program aimed at reducing infant mortality rates and generally improving maternal and infant health in at-risk communities.(31) In the city's high-poverty tracts, the prenatal care rate improved remarkably over the 1990s, moving up more than 13 percentage points in high-poverty areas to end at 85 percent--the highest rate of all the cities. Figure 9.6 shows that the declines spread across the city. The gap in rates between poor and nonpoor neighborhoods was reduced to 3 percentage points by 2000. In addition to being spatially dispersed, the increases occurred for all races. The 9-point increase in the Hispanic early prenatal care rate is particularly impressive since those rates for Hispanics fell in the other four cities (annex table C.18).
Early Prenatal Care Rates in Non-poor Tracts
Early Prenatal Care Rates in High Poverty Tracts
Alameda County, CA. Change in Early Prenatal Care Rates 1990-2000
In Indianapolis, the Campaign for Healthy Babies was formed in 1989 as a public-private partnership to develop resources and strategies to reduce infant mortality. It stressed the need to increase the percentage of women receiving adequate prenatal care. The campaign organizers placed particular geographic focus on areas with the worst infant mortality rates. The official campaign ended in 1992, although the Marion Health and Hospital Association continued with a smaller scale effort. During the period of the campaign, early prenatal care rates improved for poor neighborhoods by 6 percentage points. The high-poverty area rates then leveled off for the remainder of the decade to end at 66 percent. This was still 13 points below the rates in nonpoor areas, though progress was made in closing the gap. Figure 9.7 displays the moderate and large declines in most of the high-poverty tracts, with more mixed results outside the core city.
Cleveland/Cuyahoga County began with the highest rate for nonpoor areas and continued to improve over decade, ending at 90 percent. From 1990/1992, the rate for high-poverty tracts went up 4 percentage points to reach 77 percent (the second highest level).(32) African-American rates showed the most progress, up 8 points in both high- and low-poverty areas. Black mothers still fare better in non-poor tracts, with an early prenatal care rate 6 points higher than in high-poverty tracts (annex table C.17). In conversations with local experts, we learned of two program initiatives that could be linked to the improvements. In one, Ohio made a strong effort in the late 1990s to increase access to Medicaid coverage, particularly for pregnant women and children. Second, Cleveland has been a Healthy Start site, and is cited as one of its "success stories." (33) Cleveland's comprehensive program targets neighborhoods with high rates of infant deaths, and has built-in mechanisms for community involvement in the programs.
In the remaining two cities, local sources cited the increasing Hispanic and immigrant populations as the most likely drivers of the change in prenatal care rates. In Denver's nonpoor areas, early prenatal care declines in the beginning of the decade were reversed to reach a high of 80 percent in 1996/1998. However, falling rates in 1997/1999 and 1998/2000 eroded the progress. The high-poverty areas followed a similar trend at a lower level, beginning at 60 percent in 1990/1992 and ending at 63 percent in 1998/2000. In addition to the racial and ethnic changes, our local sources mentioned two other trends as possible contributing factors to the decrease in early initiation of prenatal care. First, cutbacks in Medicaid reimbursement caused
Indianapolis, IN. Changes in Early Orenatal Care 1990-2000
most private providers to either drop out of the Medicaid program or refuse to accept any additional Medicaid patients. The result was fewer health facilities for Medicaid patients and longer waiting lists at public clinics. Second, immigrant women may use more nontraditional health providers either from preference or because they fear that the use of public services or systems may result in exposure or deportation.
While we do not have data on early 1990s trends for Providence, toward the end of the decade it had the lowest rate of early prenatal care in nonpoor areas of all the cities, with only three-quarters of women receiving early care. The reasons for the relatively low level are not completely clear, but local sources speculated on two potential explanations. Like Denver, Providence had a growing immigrant population during the 1990s, who may be less likely to use the formal health care system for reasons described above. Local sources also spoke of the dismantling of the state-level public health system, resulting in an increased reliance on often-overburdened nonprofit providers.
Low-birth weight births
In three of the cities (Cleveland, Denver, and Oakland), rates in high-poverty neighborhoods fell over the decade, while the national trend of low birth weight rates was generally flat. The rates in both poor and nonpoor areas in Indianapolis and Providence, in contrast, are on the upswing.
Figure 9.8a shows that the earlier rates for low-birth weight births in nonpoor areas fell into two clusters: one at or below the national average of 7 percent of all births at a weight of less than 2,500 grams (Cleveland, Indianapolis, Providence) and another above 9 percent (Denver, Oakland). The nonpoor rates in Cleveland and Denver mirrored the national trend with slight increases, but Indianapolis and Providence rates (though only from 1995) rose significantly. Of the nonpoor areas, only Oakland saw decreases over the decade, moving into the cluster around the national average.
The earlier rates of low-birth weight births in high-poverty areas ranged from a low of 10.8 percent in Oakland to a high of 14.7 percent in Cleveland (see figure 9.8b). In three of the cities (Cleveland, Denver, and Oakland), the rates declined, contrary to the national trend. The rates went up in Indianapolis and Providence by 0.7 and 1.4 percentage points, respectively.(34)
Low Birth Weight Rates in Non-poor Tracts
Low Birth Weight Rates in High Poverty Tracts
While the low birth weight rates are generally higher in high-poverty areas, the size of the disparity varied significantly by city. Cleveland had the largest disparity in 1990/1992 (7 points), but has cut the difference in half over the past 10 years. Figure 9.9 illustrates the additional understanding of conditions that maps can provide. The highest levels of low birth weight are not prevalent across all poverty areas, but are concentrated in the eastern side of the central city (the predominantly African-American section). Denver began the decade with less inequity than Cleveland, but it too has reduced the gaps by more than 50 percent.
Despite differing rates and trends, Oakland and Providence are similar in that they have very small gaps between high- and low-poverty areas by this measure--about 1 percentage point. Figure 9.10 demonstrates that the greater equity does not necessarily imply greater well-being for mothers in Providence. The low-birth weight rates of several, mostly nonpoor tracts are in the higher ranges in the late 1990's.
Over time and across sites, the African-American low-birth weight rates were generally twice the Hispanic rates. Like the prenatal care rates, the black low-birth weight rates were better in nonpoor than poor areas, but the neighborhood seems to make less of a difference in this indicator. For Hispanics, hardly any difference in rates exists between poor and nonpoor tracts (see annex tables C.17 and C.18).
Infant mortality rates
Infant mortality rates (deaths of infants age 0-12 months per 1,000 live births in that year(35)) dropped in both the poor and nonpoor tracts in four of the cities, generally at a faster pace than the nation (data were not available for Providence). However, the 1998/2000 rates in the high-poverty neighborhoods in Cleveland and Indianapolis were still double the national rate.
Because of the smaller number of events when examining infant deaths, the trends in infant mortality rates are more erratic than the birth and total mortality indicators. Nonetheless, the trends in all the low-poverty areas and in the high-poverty areas of three of the cities appear stable enough to warrant some conclusions.(36)
Cuyahoga County, OH. Low Birthweight Rates 1998-2000
Providence, RI. Low Birthweight Rates 1998-2000
The infant mortality rate is defined here as the number of deaths of infants 0-12 months as a percentage of total live births in the same year. For the nonpoor areas in 1998/2000, raw rates ranged from a rate of 6.3 infant deaths per 1000 live births (Denver) to a rate of 9.1 (Indianapolis). The rates dropped 2 to 4 points over the decade, in line with the decrease in the national rate. By 1998/2000, only the rate for the Indianapolis nonpoor areas was substantially above the national rate of 7 infant deaths per 1,000 births.
In 1990/1992, the infant mortality rates in high-poverty areas were two to three times the national rate, but all cities made progress in the 1990s. Denver's high-poverty areas experienced the greatest improvements in infant mortality rates, down almost 4 infant deaths per 1000 births from 1990/1992 to 1998/2000. The 1998/2000 rate even approaches the national average. The high-poverty areas in Cleveland showed the highest rates through most of the decade, ending at 16 infant deaths per 1,000 births. The infant mortality rate in high-poverty tracts in Indianapolis was generally lower than in Cleveland, but still well above the national average of 7.5. Like Denver, both Indianapolis and Cleveland made advances in the 1990s, with respective rate declines of 3.8 and 5.4.
Age-adjusted mortality rates
The trends in age-adjusted mortality rates for nonpoor areas were inconsistent for the four sites, with two cities showing small declines and two showing virtually no change. With the exception of Indianapolis, the high-poverty areas saw some decrease in age-adjusted death rates.
By using age-adjusted death rates(37) instead of crude death rates, this analysis can compare rates across time and place while controlling for the age distribution of each area. In this way, a city's rate will not be higher just because more elderly people reside there.
In the nonpoor areas of our four analysis cities, the 1990/1992 age-adjusted death rates ranged from 810 deaths per 100,000 population in Indianapolis to a high of 960 in Oakland, with only Oakland above the national rate of 930 (figure 9.12a). While the national rates declined slightly from 1990/1992 to 1998/2000, the trends in the cities were less consistent. In general, they increased in the first half of the decade, decreased for the next couple of years, and then turned back upward. Oakland's nonpoor areas are the exception, with a steady decline for most of the decade. For all the nonpoor areas, the trends resulted in very little change in rates from start to finish.
Infant Mortality in Non-poor Tracts
Infant Mortality in High Poverty Tracts
The rates in the high-poverty areas are all higher than the rates for nonpoor areas. The high-poverty rates were clustered together in 1990/1992--from 1,160 deaths per 100,000 in Oakland to 1,280 in Cleveland--but paths diverged over the 10 years. By the end of the decade, the high-poverty rates in Oakland and Denver slipped 137 and 151 deaths per 100,000, respectively. Oakland's rate ended the lowest at 1,000 deaths per 100,000 population. The high-poverty death rate in Indianapolis increased somewhat--up 71 from 1990/1992 to the highest rate of 1,280 per 100,000 population in 1998/2000. The Cleveland pattern is the least consistent--flat until 1993/1995, decreasing to 1996/1998, and then moving up again. The rate ends the decade near the starting point.
Cleveland and Indianapolis end the decade with gaps of 360 and 450, respectively, between the poor and nonpoor rates. These rates represent improvement for Cleveland and a setback for Indianapolis. Figure 9.13 shows the high-mortality-rate areas in Indianapolis clustered in and around the city's poorest areas. In addition to having lower rates for high-poverty areas than nonpoor ones, Oakland and Denver also have smaller differentials at the end of the decade in mortality rates between those two types of areas--100 and 270 deaths per 100,000, respectively.
Indianapolis, IN. Age Ajusted Death Rates 1998-2000
SUMMARY AND IMPLICATIONS
The trends we have reviewed in this section are complex. However, the most important findings can be summarized under three points as follows:
- Gaps between high-poverty neighborhoods and others by the indicators we reviewed were indeed substantial in the early 1990s, with health-related problems in high-poverty neighborhoods more severe for almost all indicators in all cities. However, the extent of the gaps varied. The differences in low-birth weight and mortality rates were much more pronounced in Cleveland and Indianapolis (where African-Americans are the dominant minority) than in the more racially diverse cities. However, for early prenatal care rates and teen birth rates, the disparities in Denver rose to the levels of Cleveland and Indianapolis.
- In almost all cities, the 1990s saw notable improvements in the maternal and infant health indicators we have examined, in both the high-poverty and the nonpoor neighborhoods, parallel to the findings about contextual conditions in section 8. In fact, the rates of improvement in the health-related indicators were generally faster in the high-poverty neighborhoods than in the other parts of these cities. Nonetheless, these differences were not enough to eliminate the gaps between these two types of areas by the end of the decade.
- Still, there were important variations in the rates of improvement. In some cases, it appears on the surface that the change was influenced largely by the city's racial composition. For example, the teen birth rate for African Americans dropped faster than for Hispanics, so high-poverty areas that were predominantly African America, such as those in Cleveland, experienced more rapid declines. In other cases, it is hard to explain the differences without taking programmatic efforts into account. For example, Oakland, which had a highly regarded Healthy Start initiative in the 1990s, experienced a rate of improvement in prenatal care in its high-poverty areas much above those in the other sites.
Our findings so far are suggestive. Section 8 showed that a broad range of neighborhood conditions, grouped in the explanatory categories of Ellen et al (2001), generally improved in the high poverty areas and the other parts of our study sites in the 1990s. This section showed similar trends and relationships for health related indicators. We have also identified some interesting variations from the general trends and have offered a few speculations about possible causes. None of this pins down relationships between the variables in a reliable way, however. To do that, we need to conduct rigorous bivariate and multivariate correlation analysis of these indicators in a more spatially disaggregated form. This is the task of the next section.
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