GRSJ224/ Racial Disparities in Birth Outcomes

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Adverse Birth Outcomes

There are two main adverse birth outcomes that are important. The first is preterm birth, which is defined as a pregnancy that has had a gestation period less than 37 weeks. The second important outcome is low birth weight. Low birth weight infants are defined as weighing less than 2500 grams or 5 pounds, 8 ounces[1].

The Importance of Adverse Birth Outcomes

Infants who are preterm or low birth weight are at a greater risk of mortality. They are also at a higher risk for developing a variety of health and developmental problems. This can lead to negative emotional and economical impacts on the infant's family[1].

Preterm infants may experience immediate complications related to the respiratory system and the gastrointestinal tract. They may also develop problems related to their immunological function and central nervous system function. Some of the long-term effects for preterm infants include motor, cognitive, visual, auditory, behavioural, social-emotional, health and growth problems which can persist throughout their lifetime. Low birth weight infants are more likely to have underdeveloped lungs leading to breathing problems. In addition, they may be more susceptible to heart problems, liver malfunction, insufficient levels of red blood cells, inadequate levels of body fat and increased risk of infection[1].

Racial Disparities

The infants of African American women experience more adverse birth outcomes than do infants of White women. Black infants have a 50% higher risk of being born preterm and are twice as likely to be born with a low birth weight[2]. Although there is no singular explanation for the disparities observed, there are many important factors that likely all contribute to the observed disparities. Some factors include: education, residency, stress and experiences within the healthcare system.

Genetics

Researchers once believed that genetics may explain the racial disparities in birth outcomes. It was believed that all black women would experience the same reproductive challenges and disadvantages, regardless of their society and culture. However, it has been found that pregnant African American are at a greater risk of experiencing infant mortality, low birth weight and preterm birth than black women who live outside of the United States. This suggests that environmental factors may play a larger role in shaping disease risks of a given population[3].

Education Inequality

The United States has a long history of segregation and inequality within their school system. In a 2015 American report from the National Assessment of Educational Progress, it was found that there was an achievement gap between Black and White students. Furthermore, these gaps were observed regardless of the school. It was also found that completion rates of a 4-year high school program were lower for Black students than White students. These findings are significant as fewer years of education is associated with increased risk of preterm birth, suboptimal fetal growth, stillbirth and infant mortality[2].

Simply addressing barriers to education may not reduce the racial disparities in birth outcomes. This is evidenced by the observation that as class standings and education levels of pregnant black women increase, they tend to have more contact with white, middle to upper class people and become more conscious of how others perceive them. As a result of this, pregnant black women become more vulnerable to stress. Black women who live in a wealthy neighbourhood experience higher rates of preterm birth and low birth weight compared to black women residing in predominantly black neighbourhoods[4].

Residency

During the post-Civil War period, African American citizens were limited in their choice of residency and as a result were placed in poorer neighbourhoods[3]. In these neighbourhoods, residents were subjected to harmful stimuli such as crime[3], pollution[3], toxic waste[3], overcrowding[3], noise levels[2], exposure to allergens[2] and poverty[3]. This residential segregation leads to health disparities, which negatively impacts black families[2].

Psychological Stressors

Maternal psychological stress (defined as stressful life events or perceived stress and anxiety) is associated with increased risk of low birth weight and preterm birth[5]. Racial disparities in birth outcomes may be partially explained by exposure to stressors, such as violence and discrimination experienced during pregnancy. The depression and anxiety related to these experiences can also predict the occurrence of birth outcomes, such as preterm birth[2]. Black women report feeling more stressed and are more likely to experience discrimination during their pregnancy. Stressors may also result from environmental factors. Environmental stressors include natural disasters, noise and air pollution[2].

In addition to stress experienced during pregnancy, allostatic load must also be considered. Allostatic load is the accumulation of stress over life. It can result in poor physiological adaptation, which can then manifest as health problems. The cumulative effects of discrimination experienced before and during pregnancy can lead to poorer health outcomes in African American women[4].

Another important consideration is the intersection of discrimination and sexism. Along with the stress associated to discrimination, black women also experience sexism. The combination of both discrimination and sexism form a high psychological stress situation that can negatively impact the health of a pregnant African American women[4].

Experiences in the Health Care System

African Americans have a long history of receiving substandard and biased care within the health care system. For example, women of colour were the targets of non-consensual hysterectomies and the efforts of birth control clinics have historically targeted women of colour, in the attempt to control their reproductive freedom[4].

It has also been found that black women experience a larger power asymmetry between themselves and their obstetricians, compared to white women. However, this is only true if the obstetrician is of a different racial or ethnic background. As a result of this substandard care, African Americans carry a lot of anxiety and mistrust towards physicians. This leads to an unwillingness to seek care when necessary[4].

Clinical Implications

A woman's pregnancy is heavily influenced by all of their experiences. Given that African American women experience racism, sexism and inequalities within the health care system, their reproductive health may be compromised even prior to a pregnancy. As a result, even the best prenatal care may not be able to completely eliminate birth outcomes disparities. Physicians must then consider pregnancy beyond the gestation period. This will aid in promoting women's overall health[3].

References

  1. 1.0 1.1 1.2 Health: Adverse Birth Outcomes – Report Contents. (2019, August 7). Retrieved from https://www.epa.gov/americaschildrenenvironment/health-adverse-birth-outcomes-report-contents
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Burris, H. H., & Hacker, M. R. (2017). Birth outcome racial disparities: A result of intersecting social and environmental factors. Seminars in Perinatology, 41(6), 360–366. doi: 10.1053/j.semperi.2017.07.002
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Dominguez, T. P. (2008). Race, Racism, and Racial Disparities in Adverse Birth Outcomes. Clinical Obstetrics and Gynecology, 51(2), 360–370. doi: 10.1097/grf.0b013e31816f28de
  4. 4.0 4.1 4.2 4.3 4.4 Rosenthal, L., & Lobel, M. (2011). Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women. Social Science & Medicine, 72(6), 977–983. doi: 10.1016/j.socscimed.2011.01.013
  5. Lu, M. C., & Halfon, N. (2003). Racial and Ethnic Disparities in Birth Outcomes: A Life-Course Perspective. Maternal and Child Health Journal, 7, 13–30.