Racial Disparities in Perinatal Outcomes and Pregnancy Spacing Among Women Delaying Initiation of Childbearing

Introduction Reducing racial/ethnic disparities is a key objective of the Healthy People 2010 initiative. Unfortunately, racial disparities among women delaying initiation of childbearing have received limited attention. As more women in the US are delaying initiation of childbearing, it is important to examine racial disparities in reproductive health outcomes for this subgroup of women. Objective To examine racial disparities in perinatal outcomes, interpregnancy interval, and to assess the risk for adverse outcomes in subsequent pregnancy for women delaying initiation of childbearing until age 30 or older compared to those initiating childbearing at age 20–29. Methods We conducted a retrospective cohort study using the Missouri maternally linked cohort files 1978–1997. Final study sample included 239,930 singleton sibling pairs (Whites and African Americans). Outcome variables included first and second pregnancy outcomes (fetal death, low birth weight, preterm delivery and small-for-gestational age) and interpregnancy interval between first and second pregnancy. Independent variables included maternal age at first pregnancy and race. Analysis strategies used involved stratified analyses and multivariable unconditional logistic regression; interactions between maternal race, age and interpregnancy interval were examined in the regression models. Results Compared to Whites, African American mothers initiating childbearing at age 30 or older had significantly higher rates of adverse outcomes in the first and second pregnancy (P < 0.0001). Generally, African Americans had significantly higher rates of second pregnancy following intervals <6 months compared to Whites; however, no significant racial differences were noted in interpregnancy interval distribution pattern after controlling for maternal age at first pregnancy. African Americans delaying initiation of childbearing had significantly higher risk for adverse perinatal outcomes in the second pregnancy compared to Whites after controlling for potential confounders, however there were no significant interactions between maternal age at first pregnancy, race and short interpregnancy interval. Conclusion Although African Americans were less likely to delay initiation of childbearing than were White women, their risk for adverse perinatal outcomes was much greater. As health care providers strive to address racial disparities in birth outcomes, there is need to pay attention to this unique group of women as their population continues to increase. Greg R. Alexander—Deceased.     

Explaining racial disparities in adverse birth outcomes: unique sources of stress for Black American women

The infant mortality rate for Black Americans in the US is more than twice the rate for White Americans, with similar racial disparities existing in rates of low birthweight and preterm delivery. Survivors of these adverse birth outcomes have poorer development and health in infancy, childhood, and adulthood. Increasingly, evidence suggests that maternal stress is an important risk factor for adverse birth outcomes. We offer a novel perspective on racial disparities in birth outcomes suggesting that Black American women are subject to unique sources of stress throughout their lives and particularly during pregnancy based on their multiple identities as women, Black, and pregnant. We draw on interdisciplinary work to examine three unique sources of stress for Black American women that elevate their risk for adverse birth outcomes: 1) abuses of Black American women by the medical system and issues of power in obstetrics that disadvantage Black American women; 2) contradictory societal pressures exerted on Black American women about whether they should have children; and 3) historical and contemporary stereotypes about Black American women related to sexuality and motherhood. We discuss implications of this analysis, including applications to research and intervention. Developing a better understanding of the experience of Black American women during pregnancy and throughout their lives offers insight into ways to reduce racial disparities in adverse birth outcomes and their lifelong consequences.     

Prenatal care and infant birth outcomes among Medicaid recipients

Infant morbidity due to low birth weight and preterm births results in emotional suffering and significant direct and indirect costs. African American infants continue to have worse birth outcomes than white infants. This study examines relationships between newborn hospital costs, maternal risk factors, and prenatal care in Medicaid recipients in an impoverished rural county in South Carolina. Medicaid African American mothers gave birth to fewer preterm infants than did non-Medicaid African American mothers. No differences in the rates of preterm infants were noted between white and African American mothers in the Medicaid group. Access to Medicaid services may have contributed to this reduction in disparities due to race. Early initiation of prenatal care compared with later initiation did not improve birth outcomes. Infants born to mothers who initiated prenatal care early had increased morbidity with increased utilization of hospital services, suggesting that high-risk mothers are entering prenatal care earlier.     

Preconception subsidized insurance: Prenatal care and birth outcomes by race/ethnicity

Low‐income pregnant women have been Medicaid eligible since the 1980s, but the Affordable Care Act (ACA)'s expansion of Medicaid to women preconception has the potential to improve pregnancy and birth outcomes by removing delays in Medicaid enrollment. More substantially, the ACA expanded subsidized nongroup maternity coverage. Pre‐ACA, nongroup health insurance had generally excluded maternity coverage and was prohibitively expensive for low‐income individuals, but the ACA's creation of the Marketplace made maternity coverage mandatory and provides income‐based subsidies. I use a simulated eligibility approach to measure how these two aspects of the ACA impacted pregnancy and birth outcomes for first‐time mothers, paying special attention to racial‐ethnic differences. I find expanding Medicaid to women prior to pregnancy significantly improves the share of women with a prenatal care visit in the first trimester for non‐Hispanic Whites and Blacks. Expansions in non‐Medicaid subsidized insurance, such as Marketplace insurance, significantly reduce the share of births paid by Medicaid and increased breastfeeding across all racial and ethnic groups. Neither type of subsidized insurance had significant, robust impacts on birth outcomes.     

Racial Disparity in Infant and Maternal Mortality: Confluence of Infection,and Microvascular Dysfunction

OBJECTIVES: Racial disparities in infant and maternal mortality have been attributed to the unique stresses faced by Black women in the United States, but the underlying pathophysiological pathways are poorly understood. This paper reviews the literature related to potential causes of racial disparities in infant and maternal mortality. METHODS: A review of the literature from 1966 to 2003 was conducted using a series of searches of Medline, obstetrical journals, and bibliographies. The review focused on potential contributing pathophysiological factors to infant and maternal mortality. RESULTS: Racial disparities in neonatal mortality largely result from excess rates of preterm birth, fetal growth restriction, and neonatal sepsis while racial disparities in maternal mortality reflect greater prevalence and/or severity of cardiovascular/preeclamptic complications, hemorrhage, and infection among African American women. A large body of epidemiological, placental, and pathophysiological evidence suggests that racial disparities in these disparate outcomes result from two distinct, but potentially converging, pathways: infection and vascular. Racial disparities in intrauterine infection and microvascular dysfunction during pregnancy may result from a constellation of environmental and intergenerational risk factors including psychosocial stress, douching, bottle-feeding, lead exposure, diet, intrauterine growth, and genes. CONCLUSIONS: Disparities in infant and maternal mortality appear to reflect a confluence of infections and microvascular dysfunction during pregnancy among African American women. Interventions that target these conditions offer promise for reducing racial disparities in these critical outcomes.     

Adverse birth outcomes in African American women: the social context of persistent reproductive disadvantage

African Americans have the highest rates of infant mortality and adverse birth outcomes of all major racial/ethnic groups in the United States. The long-standing nature of this disparity suggests the need to shift epidemiologic focus from individual-level risk factors to the larger social forces that shape disease risk in populations. In this article, the African American reproductive disadvantage is discussed within the context of American race relations. The review of the literature focuses on racism as a social determinant of race-based disparities in adverse birth outcomes with specific attention to the viability of genetic explanations, the role of socioeconomic factors, the multidimensional nature of racism, and the stress-induced physiologic pathways by which racism may negatively affect pregnancy. Implications for social work research and practice also are discussed.     

Save 100 Babies©: Engaging Communities for Just and Equitable Birth Outcomes Through Photovoice and Appreciative Inquiry

This paper presents a community engagement model designed to advance social justice and equity for African American birth outcomes through the combined techniques of Photovoice and Appreciative Inquiry. In response to the persistent racial disparities in birth outcomes, Save 100 Babies© was constructed as a 2-day summit where the emphasis was placed on individual and community assets rather than deficits. The engagement was designed to create a level of readiness among individuals working within and outside the field of Maternal and Child Health to envision strategies to attain equitable birth outcomes. The goal of the conference was to facilitate higher level consciousness by guiding the participants though a process aimed at articulating assets, possibilities and the potential for co-creating the desired future where racial disparities in birth outcome are eliminated. As the result of the guided discourse that began with photographs of the lives of African American women, participants articulated the strengths they detected from the pictures, their recommendations for multifaceted changes in policies and practices, and their individual and organizational commitments for a changed future. Since the summit, participants have indicated ways they have fulfilled their vows that include informing families and communities about pregnancy risks, working with youth programs, supporting fatherhood involvement in pregnancy and birth, and advancing case management that is more attuned to women’s strengths. Save 100 Babies© is evolving into a network and clearinghouse for sharing and disseminating information and resources for collaboration.     

Health service use and outcomes among disabled Medicaid pregnant women

PURPOSE: We investigated differences in health service use and pregnancy outcomes among women enrolled in Medicaid under eligibility categories for the blind and disabled and those enrolled under other eligibility categories. METHODS: We used Medicaid enrollment and claims data to create episodes of pregnancy- and delivery-related care for women with and without disabilities who had Medicaid-covered deliveries in Florida, Georgia, and New Jersey during 1995 and Texas during 1997. We linked birth certificate information on prenatal care and birth outcomes to the files for Georgia and Texas. We then computed the unadjusted and adjusted odds ratios for the receipt of selected routine prenatal and illness-related services and the occurrence of selected pregnancy outcomes among women with disabilities relative to women without disabilities. FINDINGS: In all states, women with disabilities were more likely than women without disabilities to have had continuous Medicaid coverage from preconception through the postnatal period. Women with disabilities were equally or less likely to have received adequate prenatal care compared to women without disabilities in the two study states with these data. They were also more likely to have had emergency room visits, hospital admissions during pregnancy, cesarean deliveries, and readmissions within 3 months of delivery in all study states. We also found women with disabilities to have been more likely to deliver preterm and low birthweight infants. CONCLUSION: Our results suggest that opportunities exist to improve access to prenatal care among women with disabilities enrolled in Medicaid under blind and disabled eligibility categories who become pregnant.     

Women’s Perspectives of Needs Surrounding Adverse Birth Outcomes: A Qualitative Assessment of the Neighborhood Impact of Adverse Birth Outcomes

Objectives African Americans are two times more likely to suffer adverse birth outcomes (i.e., low birth weight, preterm birth, and infant mortality) when compared to all other ethnic groups and this pattern is no different for Douglas County, Nebraska, where the majority of African Americans in Nebraska reside. Our goal was to identify factors, as described by local women, that contribute to adverse birth outcomes in the predominantly African American community of Northeast Douglas County in Omaha, NE, to ensure that these women’s voices were included in the development of interventions to improve their neighborhood’s birth outcomes. The paper describes the results of a qualitative needs assessment of these women which will aid in the design and implementation of neighborhood-based solutions. Methods We brought together a group of women with varying levels of birthing experience, time spent living in the neighborhood, and overall community involvement. Individual in-depth, in person, and telephone interviews were used to collect participants’ perceptions of birth outcomes, neighborhood resources for pregnant women, and neighborhood strengths and weaknesses. Results The needs assessment identified that, although women in this neighborhood have experience with adverse birth outcomes, these experiences are not discussed resulting in a lack of awareness of the wide spread racial disparities in birth outcomes and the efforts and resources to address this public health problem. Conclusions for Practice This study reveals the power of direct conversations with women impacted by adverse birth outcomes, as they must be primary partners in any efforts to improve birth outcomes.     

Differences in Use of Health Services Between White and African American Children Enrolled in Medicaid in North Carolina

Objectives: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. Methods: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for NorthCarolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect ofrace, controlling for other variables such as low birth weight, WICparticipation, and mother's age, education, and marital status. Since allchildren enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled.Results: African American children had consistently lower Medicaidexpenditures and lower use of health servicesthan did White children,after statistically controlling for other maternal and infantcharacteristics that affect health service use, including child WICparticipation. For example, total annual Medicaid expenditures were $207–303 less for African American children than for White children,controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. Conclusions: African American children enrolled in Medicaid use healthservices much less than White children, even when controlling forsocioeconomic status and other factors that affect service use. Linkingstate administrative databases can be a cost-effective way of addressingimportant issues such as racial disparities in health service use.     

Prenatal and Postpartum Care Disparities in a Large Medicaid Program

Objectives Pennsylvania’s maternal mortality, infant mortality, and preterm birth rates rank 24th, 35th, and 25th in the country, and are higher among racial and ethnic minorities. Provision of prenatal and postpartum care represents one way to improve these outcomes. We assessed the extent of disparities in the provision and timeliness of prenatal and postpartum care for women enrolled in Pennsylvania Medicaid. Methods We performed a cross-sectional evaluation of representative samples of women who delivered live births from November 2011 to 2015. Our outcomes were three binary effectiveness-of-care measures: prenatal care timeliness, frequency of prenatal care, and postpartum care timeliness. Pennsylvania’s Managed Care Organizations (MCOs) were required to submit these outcomes to the state after reviewing administrative and medical records through a standardized, validated sampling process. We assessed for differences in outcomes by race, ethnicity, region, year, and MCO using logistic regression. Results We analyzed data for 12,228 women who were 49% White, 31% Black/African American, 4% Asian, and 15% Hispanic/Latina. Compared to Black/African American women, white and Asian women had higher odds of prenatal and postpartum care. Hispanic/Latina women had higher frequency of prenatal care than non-Hispanic women. Pennsylvania’s Southeast had lower prenatal care and Northwest had lower postpartum care than other regions. Prenatal care significantly decreased in 2014 and increased in 2015. We observed differences between MCOs, and as MCO performance diminished, racial disparities within each plan widened. We explored hypotheses for observed disparities in secondary analyses. Conclusions for Practice Our data demonstrate that interventions should address disparities by race, region, and MCO in equity-promoting measures.     

The pre-pregnancy insurance status of public aid recipients in the aftermath of welfare reform: women in the Medicaid Gap

The passage of welfare reform in 1996 led to sweeping changes in both welfare and Medicaid policy. This study examines the pre-pregnancy Medicaid coverage of women on public aid who had Medicaid payment for delivery in the time periods before and after welfare reform. Pregnancy Risk Assessment Monitoring System (PRAMS) data were used to examine changes in the prevalence of being in the Medicaid Gap (i.e., having no pre-pregnancy Medicaid coverage despite having Medicaid payment for delivery) in eight states between 1996 (n=302) and 1998-2000 (n=364). Of this population, 16.1% of women were in the Medicaid Gap in 1996, compared with 36.5% in 1998-2000. The overall adjusted relationship between time period and being in the Medicaid Gap was 4.5 (95% CI 2.1-9.6). This analysis suggests that in the period after welfare reform, there was an increase in the prevalence of very low-income women who, despite having their delivery paid for by Medicaid, did not have pre-pregnancy Medicaid coverage. Lack of Medicaid coverage regardless of pregnancy, particularly among women who historically have had such coverage and who are at higher risk of adverse pregnancy outcomes, has important implications for progress toward Healthy People 2010 objectives in prenatal care initiation and utilization, low birth weight, and other pregnancy outcomes.     

Commentary: Eliminating Disparities in Perinatal Outcomes—Lessons Learned

The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.     

Extending Delivery Coverage to Include Prenatal Care for Low-Income,Immigrant Women Is a Cost-Effective Strategy

ObjectiveTo compare the outcomes and cost effectiveness of two alternate policy strategies for prenatal care among low-income, immigrant women: coverage for delivery only (the federal standard) and prenatal care with delivery coverage (state option under the Children's Health Insurance Program).MethodsA decision-analytic model was developed to determine the cost effectiveness of two alternate policies for pregnancy coverage. All states currently provide coverage for delivery, and 19 states also provide coverage for prenatal care. An estimated 84,000 unauthorized immigrant women have pregnancies where no prenatal care is covered. Our outcomes were costs, quality-adjusted life-years, and cases of cerebral palsy and infant death before age 1. Model inputs were obtained from a database of Oregon Medicaid claims and the literature. Univariate and bivariate sensitivity analyses, as well as a Monte Carlo simulation, were performed.ResultsExtending prenatal coverage is a cost-effective strategy. Providing prenatal care for the 84,000 women annually who are currently uninsured could prevent 117 infant deaths and 34 cases of cerebral palsy. Prenatal care coverage costs $380 more per woman than covering the delivery only. For every 865 additional women receiving prenatal care, one infant death would be averted, at an average cost of $328,700. Cost-effectiveness acceptability curve analyses suggest a 99% probability that providing prenatal care is more cost effective at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.ConclusionsExtending prenatal care to low-income, immigrant women, regardless of citizenship status, is a cost-effective strategy.     

An Ecological Approach to Understanding Black–White Disparities in Perinatal Mortality

Despite appreciable improvement in the overall reduction of infant mortality in the United States, black infants are twice as likely to die within the first year of life as white infants, even after controlling for socioeconomic factors. There is consensus in the literature that a complex web of factors contributes to racial health disparities. This paper presents these factors utilizing the socioecological framework to underscore the importance of their interaction and its impact on birth outcomes of Black women. Based on a review of evidence-based research on Black–White disparities in infant mortality, we describe in this paper a missing potent ingredient in the application of the ecological model to understanding Black–White disparities in infant mortality: the historical context of the Black woman in the United States. The ecological model suggests that birth outcomes are impacted by maternal and family characteristics, which are in turn strongly influenced by the larger community and society. In addition to infant, maternal, family, community and societal characteristics, we present research linking racism to negative birth outcomes and describe how it permeates and is embedded in every aspect of the lives of African American women. Understanding the contribution of history to the various factors of life of Black women in the United States will aid in developing more effective policies and programs to reduce Black infant mortality.     

Use of Care, Outcomes and Costs of a Culturally-based Perinatal Program for Asian American and Pacific Islander Women in Hawaii

PURPOSE. This study examines whether psychosocial perinatal care services developed through community partnerships and cultural deference with attention to individual women's health issues, had an assocaited impact on use of prenatal care, birth outcomes and perinatal care costs for the three participating Asian Pacific Islander American ethinc groups. METHODS. The use of prenatal care visits and birth outcomes for women in the Malama program were compared to those for women of the same etnic groups in the community prior to the introduction of the program. Data on program participants from 1992 to 1994 were compared to birth certificate data on Hawaiian, Filipino and Japanese women from 1988 to 1991. Costs of providing Malama prenatal services were determined from data provided by cost accounting and encounter data systems for the program. SUMMARY OF IMPORTANT FINDINGS. The use of prenatal care visits and birth outcomes were significantly lower for Malama program participants than for women of the same ethnic groups prior to the introduction of the program. The costs of the prenatal program services were $846 to $920 per woman. The expected savings in medical costs per infant with the improved preterm birth rates were $680 per infant. Thus 75% to 80% of the costs of the services were likely to be saved in lower medical costs of the infants. MAJOR CONCLUSIONS. Programs that use community approaches and caring servies delivered in a cultural context, like the Malama model, have a potential for improving the use of prenatal care and birth outcomes at reasonable costs. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. The Malama approach to ascertaining cultural preferences for the content and delivery of care should prove useful in addressing public health goals of improved pregnancy outcomes for diverse groups of Asian Americans and Pacific Islanders. KEY WORDS. Asian Americans/Pacific Islanders, pregnancy, prenatal care, low birthweight, preterm birth, cultural competency, community partnerships, costs, cost effectiveness.     

Socioeconomic and Racial/Ethnic Disparities in Unintended Pregnancy Among Postpartum Women in California

Objective: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. Methods: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. Results: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. Conclusions: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.     

Peer Reviewed: Age and Racial/Ethnic Disparities in Prepregnancy Smoking Among Women Who Delivered Live Births

Introduction

Prenatal smoking prevalence remains high in the United States. To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessation interventions to women who are most likely to smoke before pregnancy. Our objective was to identify groups with the highest prepregnancy smoking prevalence by age within 6 racial/ethnic groups.

Methods

We analyzed data from 186,064 women with a recent live birth from 32 states and New York City from the 2004-2008 Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women. We calculated self-reported smoking prevalence during the 3 months before pregnancy for 6 maternal racial/ethnic groups by maternal age (18-24 y or ≥25 y). For each racial/ethnic group, we modeled the probability of smoking by age, adjusting for education, Medicaid enrollment, parity, pregnancy intention, state of residence, and year of birth.

Results

Younger women had higher prepregnancy smoking prevalence (33.2%) than older women (17.6%), overall and in all racial/ethnic groups. Smoking prevalences were higher among younger non-Hispanic whites (46.4%), younger Alaska Natives (55.6%), and younger American Indians (46.9%). After adjusting for confounders, younger non-Hispanic whites, Hispanics, Alaska Natives, and Asian/Pacific Islanders were 1.12 to 1.50 times as likely to smoke as their older counterparts.

Conclusion

Age-appropriate and culturally specific tobacco control interventions should be integrated into reproductive health settings to reach younger non-Hispanic white, Alaska Native, and American Indian women before they become pregnant.