Tagged Disparities

California Hospitals Urge Moms To Favor Breast Milk Over Formula

MONTEBELLO, Calif. — Wendy Wan, 31, said American infant formula is advertised in her native China as the most nutritious food for a newborn.

“It sounds like it’s premium,” said Wan, who gave birth in early May at Beverly Hospital here. Wan said she was skeptical of the ads and had planned to feed her baby son only breast milk. But when her milk failed to come in quickly, she didn’t hesitate to supplement it with formula.

“I prefer breastfeeding, but I think it’s almost the same,” she said from her hospital bed the day after her son was born.

It’s not the same. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of a baby’s life because of the well-known health benefits for both infants and mothers. Women, like Wan, who start with the intention of feeding their babies exclusively breast milk but then supplement it with formula while still in the hospital are nearly three times more likely to stop breastfeeding within two months, according to one study.

California has made significant progress in recent years promoting exclusive breastfeeding in hospitals, but many women aren’t sticking with it. All but a small fraction of women start breastfeeding while in the hospital, but nearly one-third introduce their babies to formula before leaving, according to data from the California Department of Public Health.

And significant disparities — both ethnic and socioeconomic — persist. While women of color are exclusively breastfeeding their babies more frequently than in the past, they still lag far behind whites: In 2016, nearly 82 percent of white moms gave their infants only breast milk in the hospital, compared with 60 percent of black moms and 65 percent of Asian and Latina moms, according to the department’s data. (Data for individual race groups exclude persons of Hispanic ethnicity, who can be of any race.)

Wide gaps also separate California’s counties and hospitals. Some facilities reported exclusive breastfeeding rates of more than 90 percent and others less than 25 percent. Some of the hospitals with the lowest rates are in lower-income communities. The statewide average is 69 percent.

“Where you deliver … and what race you are have a huge impact on breastfeeding,” said Arissa Palmer, executive director of the nonprofit advocacy group Breastfeed LA. “Those are barriers that we haven’t touched the surface on.”

In an effort to diminish the disparities and improve the health of babies, state law requires hospitals to implement concrete measures to promote breastfeeding no later than 2025.

Research shows that breastfeeding babies can reduce their risk of obesity, diabetes and asthma. It can also lessen the chance of heart disease and cancer in mothers.

Nationally, non-Hispanic black babies are significantly less likely to breastfeed than non-Hispanic whites or Hispanics, according to the Centers for Disease Control and Prevention. Mississippi, West Virginia, Louisiana and Arkansas have the lowest breastfeeding rates in the U.S. Colorado, Oregon, Idaho and Washington have the highest.

About 60 percent of women in the U.S. stop breastfeeding before they had initially intended to, the CDC said. Among the reasons: worries about their infants’ weight, problems with latching, unsupportive policies at work and lack of education about the benefits of breastfeeding.

Another factor may be the unintended consequences of patient satisfaction scores, said Carmen Rezak, maternal-child health quality coordinator for AHMC Healthcare, a Southern California hospital chain. Because patient ratings are tied to hospital reimbursement, nurses are sometimes afraid to deny patients’ wishes. They may not want to tell relatives they cannot visit, for example, even if more privacy and quiet time do encourage breastfeeding, Rezak said.

The publication of statewide data on exclusive breastfeeding rates places “pressure on hospitals” to really look at their policies and practices compared with their competitors, said Jen Goldbronn of the state’s public health department.

One of the best-known ways to increase rates of exclusive breastfeeding is by following the “Ten Steps to Successful Breastfeeding.” These include helping mothers start nursing within one hour of birth, not giving formula to babies unless medically necessary and informing all pregnant women about the benefits of breastfeeding.

The organization Baby-Friendly USA requires hospitals seeking its “baby-friendly” seal to follow the 10 steps. In California, nearly 100 hospitals have that designation, up from 12 in 2006. The state law requiring hospitals to have breastfeeding support measures in place by 2025 specifically names the 10 steps, but also allows hospitals to adopt alternative practices proven to encourage breastfeeding.

Trish MacEnroe, executive director of Baby-Friendly USA, said hospitals across the country used to discourage breastfeeding inadvertently by whisking babies away to nurseries. Now, newborns typically stay in the room with the mother and start nursing immediately after birth. Urging moms to hold their babies “skin to skin” right after birth helps encourage breastfeeding because of the physical proximity, according to research.

Some of the hospitals with the lowest rates of exclusive breastfeeding in the state are Whittier Hospital, at 20 percent, and Monterey Park Hospital, at 22 percent. The two hospitals, both run by AHMC Healthcare, serve a high number of Asian moms and others who come to the country for the sole purpose of giving birth, Rezak said.

Foreign parents are among the most difficult to convince about the importance of exclusive breastfeeding, in part because of cultural barriers or myths about the value of formula, she said. Education is also important, Rezak said. Hospital staff try to teach all new moms to recognize when their infants are hungry or tired.

Newborn Ella Lang is cradled by registered nurse Kam Ho at Beverly Hospital in Montebello, Calif., on May 8. Nurses at the hospital taught Ella’s mother, Peng Peng, to breastfeed and encouraged her to continue. (Ana Venegas for KHN)

At PIH Health Hospital Whittier, moms who want formula have to sign a form acknowledging they understand their decision, said Valerie Martin, clinical director of maternity care. The hospital’s rate of exclusive breastfeeding is 80 percent, compared with 33 percent at its sister hospital in Downey.

At Beverly Hospital, where Wan gave birth, nurses show patients different positions for breastfeeding and reinforce the importance of exclusive breastfeeding. But they also try not to push new mothers, said Melissa Morita, director of maternal and child health.

Peng Peng, who lives in China, came to the U.S. about a month before giving birth to her daughter, Ella Lang, at the hospital earlier this month. Peng, 34, said that soon after Ella was born, a nurse gave her formula because her blood sugar was low.

Peng said she didn’t mind too much but still wanted to breastfeed as much as possible.

“It’s natural and it’s more nutritious,” she said. “But I’m not super against formula.”


KHN’s coverage of these topics is supported by
Blue Shield of California Foundation
and
The David and Lucile Packard Foundation

Opioid Overdoses Are Rising Faster Among Latinos Than Whites Or Blacks. Why?

The tall, gangly man twists a cone of paper in his hands as stories from nearly 30 years of addiction pour out: the robbery that landed him in prison at age 17; never getting his high school equivalency diploma; going through the horrors of detox, maybe 40 times, including this latest bout, which he finished two weeks ago. He’s now in a residential treatment unit for at least 30 days.

“I’m a serious addict,” said Julio Cesar Santiago, 44. “I still have dreams where I’m about to use drugs, and I have to wake up and get on my knees and pray, ‘Let God take this away from me,’ because I don’t want to go back. I know that if I go back out there, I’m done.”

Santiago has reason to worry. Data on opioid addiction in his home state of Massachusetts show the overdose death rate for Latinos there has doubled in three years, growing at twice the rates of non-Hispanic whites and blacks.

Opioid overdose deaths among Latinos are surging nationwide as well. While the overall death toll is still higher for whites, it’s increasing faster for Latinos and blacks, according to data from the Centers for Disease Control and Prevention. Latino fatalities increased 52.5 percent from 2014 to 2016, compared with 45.8 percent for whites. (Statisticians say Hispanic overdose counts are typically underestimated.) The most substantial hike was among blacks: 83.9 percent.

The data portray a changing face of the opioid epidemic.

Rates of fatal opioid overdoses per 100,000 across the U.S. from 2014-2016. Deaths rose 45.8% for whites, 52.5% for Hispanics and 83.9% for blacks, according to the Centers for Disease Control and Prevention. (Source: CDC; Credit: NPR)

“What we thought initially, that this was a problem among non-Hispanic whites, is not quite accurate,” said Robert Anderson, mortality statistics branch chief at the CDC’s National Center for Health Statistics. “If you go back into the data, you can see the increases over time in all of these groups, but we tended to focus on the non-Hispanic whites because the rates were so much higher.”

There’s little understanding about why overdose deaths are rising faster among blacks and Latinos than whites. Some physicians and outreach workers suspect the infiltration of fentanyl into cocaine is driving up fatalities among blacks.

The picture of what’s happening among Latinos has been murky, but interviews with nearly two dozen current and former drug users and their family members, addiction treatment providers and physicians reveal that language and cultural barriers, even fear of deportation, could limit the access of Latinos to lifesaving treatment.

Bilingual Treatment Options Are Scarce

Irma Bermudez, 43, describes herself as a “grateful recovering addict.” She’s living in the women’s residential unit at Casa Esperanza, a collection of day treatment, residential programs and transitional housing in Boston’s Roxbury neighborhood.

Bermudez said the language barrier keeps anyone who can’t read English out of treatment from the start, as they try to decipher websites or brochures that advertise options. If they call a number on the screen or walk into an office, “there’s no translation — we’re not going to get nothing out of it,” Bermudez said.

Rates of fatal opioid overdoses per 100,000 from 2014-2016 in Massachusetts. (Source: Massachusetts Department of Health; Credit: NPR)

Some of the Latinos interviewed for this story described sitting through group counseling sessions, part of virtually every treatment program, and not being able to follow much, if any, of the conversation. They recalled waiting for a translator to arrive for their individual appointment with a doctor or counselor and missing the session when the translator is late or doesn’t show up at all.

SAMHSA, the federal Substance Abuse and Mental Health Services Administration, maintains a Find Treatment website that includes listings of treatment offered in Spanish. But several Massachusetts providers listed there could not say how many translators they have or when they are available. The SAMHSA site is available only in English, with Spanish-language translators available only by phone.

At Casa Esperanza, 100 men are waiting for a spot in the male residential program, so recovery coach Richard Lopez spends a lot of time on the phone trying to get clients into a program he thinks has at least one translator.

After battling with voicemail, said Lopez, he’ll eventually get a call back; the agent typically offers to put Lopez’s client on another waiting list. That frustrates him.

“You’re telling me that this person has to wait two to three months? I’m trying to save this person today,” he said. “What am I going to do, bring these individuals to my house and handcuff them so they don’t do nothing?”

Casa Esperanza Executive Director Emily Stewart said Massachusetts needs a public information campaign via Spanish-language media that explains treatment options. She’d like that to include medication-assisted treatment, which she said is not well understood.

Some research shows Latino drug users are less likely than others to have access to or use the addiction treatment medicines, methadone and buprenorphine. One study shows that may be shifting. But, Latinos with experience in the field said, access to buprenorphine (which is also known by the brand name Suboxone) is limited because there are few Spanish-speaking doctors who prescribe it.

A Matter Of Machismo: ‘It’s Not Cool To Call 911’

Lopez has close ties these days with health care providers, the police and EMT rescue squads. But that has changed dramatically from when he was using heroin. On the streets, he said, “it’s not cool to be calling 911” when a person sees someone overdose. “I could get shot, and I won’t call 911.”

It’s a machismo thing, said Lopez.

“To the men in the house, the word ‘help’ sounds, like, degrading, you know?” he said. Calling 911 “is like you’re getting exiled from your community.”

Santiago said not everyone feels that way. A few men called EMTs to help revive him. “I wouldn’t be here today if it wasn’t for them,” he said.

But Santiago and others say there’s growing fear among Latinos they know of asking anyone perceived as a government agent for help — especially if the person who needs the help is not a U.S. citizen.

“They fear if they get involved they’re going to get deported,” said Felito Diaz, 41.

Bermudez said Latina women have their own reasons to worry about calling 911 if a boyfriend or husband has stopped breathing.

“If they are in a relationship and trying to protect someone, they might hesitate as well,” said Bermudez, if the man would face arrest and possible jail time.

A Tight Social Network

Another reason some Latino drug users said they’ve been hit especially hard by this epidemic: A 2017 DEA report on drug trafficking noted that Mexican cartels control much of the illegal drug distribution in the United States, selling the drugs through a network of local gangs and small-scale dealers.

In the Northeast, Dominican drug dealers tend to predominate.

“The Latinos are the ones bringing in the drugs here,” said Rafael, a man who uses heroin and lives on the street in Boston, close to Casa Esperanza. “The Latinos are getting their hands in it, and they’re liking it.”

Kaiser Health News and NPR agreed not to use Rafael’s last name because he uses illegal drugs.

A resident walks into the Casa Esperanza’s men’s program in Roxbury. (Jesse Costa/WBUR)

Some Spanish-speaking drug users in the Boston area said they get discounts on the first, most potent cut. Social connection matters, they said.

“Of course, I would feel more comfortable selling to a Latino if I was a drug dealer than a Caucasian or any other, because I know how to relate and get that money off them,” said Lopez.

The social networks of drug use create another layer of challenges for some Latinos, said Dr. Chinazo Cunningham, who treats many patients from Puerto Rico. She primarily works at a clinic affiliated with the Montefiore Medical Center in the Bronx, in New York City.

“The family is such an important unit — it’s difficult, if there is substance use within the family, for people to stop using opioids,” Cunningham said.

The Burden Of Poverty

Though Latinos are hardly a uniform community, many face an additional risk factor for addiction: poverty. About 20 percent of the community live in poverty, compared with 9 percent of whites, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

In Massachusetts, four times as many Latinos live below the poverty line as do whites. The majority of Casa Esperanza clients were recently homeless. The wait time for one of the agency’s 37 individual or family housing units ranges from a year to a decade.

“If you’ve done all the work of getting somebody stabilized and then they leave and don’t have a stable place to go, you’re right back where you started,” said Casa Esperanza’s Stewart.

Cunningham said the Latino community has been dealing with opioid addiction for decades and it is one reason for the group’s relatively high incarceration rate. In Massachusetts, Latinos are sentenced to prison at nearly five times the rate of whites.

“It’s great that we’re now talking about it because the opioid epidemic is affecting other populations,” Cunningham said. “It’s a little bit bittersweet that this hasn’t been addressed years before. But it’s good that we’re talking about treatment rather than incarceration, and that this is a medical illness rather than a moral shortcoming.”

Nationally, says the CDC’s Anderson, there’s no sign that the surge of overdose deaths is abating in any population.

“We’ve already had two years of declining life expectancy in the U.S., and I think that when we see the 2017 data we’ll see a third year,” said Anderson. “That hasn’t happened since the great influenza pandemic in the early 1900s.”

The fatality counts for 2017 are expected out by the end of this year.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Lack Of Insurance Exposes Blind Spots In Vision Care

Every day, a school bus drops off as many as 45 children at a community eye clinic on Chicago’s South Side. Many of them are referred to the clinic after failing vision screenings at their public schools.

Clinicians and students from the Illinois College of Optometry give the children comprehensive eye exams, which feature refraction tests to determine a correct prescription for eyeglasses and dilation of their pupils to examine their eyes, including the optic nerve and retina.

No family pays out-of-pocket for the exam. The program bills insurance if the children have coverage, but about a third are uninsured. Operated in partnership with Chicago public schools, the program annually serves up to 7,000 children from birth through high school.

“Many of the kids we’re serving fall through the cracks,” said Dr. Sandra Block, a professor of optometry at the Illinois College of Optometry and medical director of the school-based vision clinics program. Many are low-income Hispanic and African-American children whose parents may not speak English or are immigrants who are not in the country legally.

Falling through the cracks is not an uncommon problem when it comes to vision care. According to a 2016 report from the National Academies of Sciences, Engineering and Medicine, as many as 16 million people in the United States have undiagnosed or uncorrected “refractive” errors that could be fixed with eyeglasses, contact lenses or surgery. And while insurance coverage for eye exams and corrective lenses clearly has improved, significant gaps remain.

The national academies’ report noted that impaired vision affects how people experience their world, including normal communication and social activities, independence and mobility. Not seeing clearly can hamper children’s academic achievement, social development and long-term health.

But when people must choose, vision care may lose out to more pressing medical concerns, said Block, who was on the committee that developed the report.

“Vision issues are not life-threatening,” she said. “People get through their day knowing they can’t see as well as they’d like.”

Insurance can make regular eye exams, glasses and treatment for medical problems such as cataracts more accessible and affordable. But comprehensive vision coverage is often achieved only through a patchwork of plans.

The Medicare program that provides coverage for millions of Americans age 65 and older doesn’t include routine eye exams, refraction testing or eyeglasses. Some tests are covered if you’re at high risk for a condition such as glaucoma, for example. And if you develop a vision-related medical condition such as cataracts, the program will cover your medical care.

But if you’re just a normal 70-year-old and you want to get your eyes examined, the program won’t cover it, said Dr. David Glasser, an ophthalmologist in Columbia, Md., who is a clinical spokesman for the American Academy of Ophthalmology. If you make an appointment because you’re experiencing troubling symptoms and get measured for eyeglasses while there, you’ll likely be charged anywhere from about $30 to $75, Glasser said.

There are a few exceptions. Medicare will pay for one pair of glasses or contact lenses following cataract surgery, for example. Some Medicare Advantage plans offer vision care.

Many commercial health insurance plans also exclude routine vision care from their coverage. Employers may offer workers a separate vision plan to fill in the gaps.

VSP Vision Care provides vision care plans to 60,000 employers and other clients, said Kate Renwick-Espinosa, the organization’s president. A typical plan provides coverage for a comprehensive eye exam once a year and an allowance toward standard eyeglasses or contact lenses, sometimes with a copayment. Also, individuals seeking plans make up a growing part of their business, she said.

Vision coverage for kids improved under the Affordable Care Act. The law requires most plans sold on the individual and small-group market to offer vision benefits for children younger than 19. That generally means that those plans cover a comprehensive eye exam, including refraction, every year, as well as a pair of glasses or contact lenses.

But since pediatric eye exams aren’t considered preventive care that must be covered without charging people anything out-of-pocket under the ACA, they’re subject to copays and the deductible.

Medicaid programs for low-income people also typically cover vision benefits for children and sometimes for adults as well, said Dr. Christopher Quinn, president of the American Optometric Association, a professional group.

But coverage alone isn’t enough. To bring down the number of people with undiagnosed or uncorrected vision, education is key to helping people understand the importance of eye health in maintaining good vision. Just as important, it can also reduce the impact of chronic conditions such as diabetes, the national academies’ report found.

“All health care providers need to at least ask vision questions when providing primary care,” said Block.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.