Achieving Equity in Women's and Perinatal Health

Peter S. Bernstein, MD, MPH

Disclosures

December 12, 2003

The large disparities between different racial and ethnic groups with regard to women's and perinatal health outcomes in the United States was the topic of this year's fall symposium, Autumn in New York, sponsored by the Department of Obstetrics & Gynecology and Women's Health of Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York. Speakers at the 22nd annual conference outlined the scope, etiologies, and complexity of the problem, and their analyses point the way for potential solutions to these growing gaps in health outcomes.

The first group of speakers at the meeting focused on maternal and perinatal issues. Dr. Karla Damus (Albert Einstein College of Medicine and the March of Dimes) began the meeting by presenting statistics that became the basis for discussion at the meeting. She pointed out, for example, that although infant mortality in the United States has continued to decline over the past 2 decades (6.8 per 1000 live births in 2001), the rate has been falling faster for white infants compared with black infants, with a resulting rise in the ratio of infant mortality between the 2 groups. That ratio now stands at about 2.5. In fact, in 2001, infant mortality for black infants was 13.3 per 1000 live births, which far exceeds the Healthy People 2010 goal of 4.5 per 1000.

Nationally, the leading cause of infant mortality remains birth defects, except in the case of black infants. For this population alone , the leading cause of mortality is the complications of prematurity and low birth weight. This becomes more understandable when it is noted that the percentage of births among blacks in the United States that qualify as low or very low birth weight far exceeds that of the white population (13.1% vs 6.8%, respectively, in 2001). Notably, it is inappropriate to lump all African-Americans into a single group. When looking at data from New York City, for the same time period, African-American mothers born in the United States had higher rates of delivering low-birth-weight children than those born in Africa or the Caribbean.

Dr. Haywood Brown (Duke University School of Medicine, Chapel Hill, North Carolina) noted that the disparities in outcomes such as infant mortality persisted in demographically different geographic areas of the United States. Similar disparities exist in the District of Columbia, Iowa, Mississippi, Oregon, and Texas. Dr. Brown also reported data that demonstrated that disparities in the rates of low-birth-weight babies persisted even after controlling for socioeconomic status. Given data that suggest higher rates of preterm birth are associated with higher maternal serum levels of cortisol and croticotropin-releasing hormone, Dr. Brown alluded to a theory that the higher rates of preterm birth in the African American population may relate to higher levels of stress in that population.

Dr. Brown also cited several of the studies that have found associations between bacterial vaginosis (BV) and preterm birth. He postulated that the excess risk of preterm birth among black women may also be related to their higher prevalence of BV, a finding that persists even after controlling for demographic and lifestyle factors. He hypothesized that there may be a genetic etiology for this association and that the link may be related to allelic variants of the TNF-alpha gene. Women with differing alleles for this gene have differing rates of bacterial vaginosis.

Dr. Cynthia Chazotte (Albert Einstein College of Medicine) focused her presentation on the disparities in the rates of maternal mortality for various groups between the years 1987-1996. The maternal mortality ratios (per 100,000 live births) vary substantially by state in the United States, with a high of 12.3 in Mississippi and a low of 3.3 in Washington State. But even more dramatic were the differences between the ratios for white women compared with black women during the same period. The maternal mortality ratio was as high as 28.7 for black women, far exceeding even the highest ratio for white women of 7.8 in New York State. As a result, much of the variation in the overall ratios between states may be accounted for by the distribution of the African American population in the various states. The disparities in the maternal mortality ratios between black and white women persisted even when stratified by maternal age, marital status, parity, or trimester of initiation of prenatal care.

Dr. Chazotte also commented on the difficulties of studying the maternal mortalities as a way to gain insight into the problem given the rarity of the event. She suggested that a better way to get at the root causes that lead to maternal mortality in the United States may be to study "near-miss" mortalities. That is, cases in which the mother would have died if not for heroic interventions; this would include cases of severe hemorrhage, eclampsia, and pulmonary embolism, for example . Dr. Chazotte discussed unpublished data of her own, which found that near-miss maternal mortality was associated with black race, obesity, significant past medical history, prior cesarean delivery, and increasing parity. In a multivariate analysis, black race remained a significant risk factor for near-miss maternal mortality.

Dr. Kimberly Yonkers (Yale University, New Haven, Connecticut) approached the problem of the disparities in women's and perinatal health outcomes. Her presentation focused on the psychiatric problems of inner-city pregnant women. She referred to data on the higher rates of mood disorders in fertile women and the associations of mood disorders in pregnancy, especially depression, with poor perinatal outcomes. Such poor outcomes include a 3- to 4-fold higher risk of delivering a baby of low birth weight or one that is small for gestational age, and premature delivery. Dr. Yonkers argued that seen in this light, screening for depression during pregnancy is a critical element of prenatal care, particularly in an inner-city environment. She reported that 10% to 27% of women experience depressive symptoms during pregnancy and 2% to 11% suffer from a major depressive disorder. Women with depression are also less likely to be compliant with recommended care. Dr. Yonkers concluded with her own data, which found that providers failed to identify women suffering from depression up to 88% of the time.

The diversity of the problem of disparities in maternal and neonatal health outcomes when comparing non-Hispanic whites and blacks in the United States was further underscored by Dr. Rodney Wright (Albert Einstein College of Medicine). He reported on the declining proportion of AIDS cases among whites over the past decade compared with the rising proportion among blacks. He noted that AIDS has become the leading cause of death among African American women ages 25 to 34. Dr. Wright hypothesized that these discrepancies in rates between different populations may be related to poverty and other social factors such as that many African American women may not be aware of their partner's high-risk behaviors and are uncomfortable insisting on condom use. He also cited the high rates of sexually transmitted diseases among blacks as another contributing factor.

Dr. Brown believes that all these growing disparities in health outcomes for African Americans point to failures in our healthcare system. The solution does not only lie with improved access to services, however. The services themselves need to be tailored to the needs of the population. He suggested that social interventions may be just as important as medical ones. Given that the rising rates of early entry into prenatal care for black women in the United States have not translated into improved outcomes on a par with whites, new and different solutions are urgently needed.

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