CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 2 • Spring/Summer 2002

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Disparities in Maternal and Child Health

Maternal and child health professionals see some of the worst cases of health disparities and are painfully aware that black infants are far more likely than white infants to die or be born prematurely. To eliminate these disparities, researchers are studying how factors such as stress, poverty, and lack of social services affect pregnancy. 

“Ten years ago, the variables we were looking at were not explaining racial/ethnic disparities in health,” said CDC Epidemiologist Cynthia Ferré, MA. “Poverty was the most common explanation for disparities at that time. Yet Ken Schoendorf’s 1992 study¹ indicated that even college-educated black women were more likely than college-educated white women to have infants born with low birth weight or who died within the first year of life. This meant that poverty could not, by itself, account for the disparities we see in health. We needed to develop new explanatory variables, and this fit with the work of the CDC Preterm Delivery Research Group since 1991. The group considers pregnancy as both a biologic and a sociocultural process.” 

In 1992, the group launched studies in Los Angeles (the Healthy African American Families project) and New York City (the Harlem Birth Right Project) to learn what happens to African American women during pregnancy. Community members participated in the research, which studied women at all levels of socioeconomic (SES) status. This was a way to begin identifying possible new explanations for the persistently observed disparities.

Healthy African American Families, in Los Angeles, examined the roles of health care, stress, family relationships, spirituality, nutrition, work, and community and family assets during pregnancy. In New York City, the Harlem Birth Right project explored how pregnancy was affected by social contexts and support, health care, communitywide stresses (such as housing problems), personal and community economics, work, social services, and resiliency (resistance to stress). 

Both studies used qualitative research methods, such as focus groups, ethnography, and open-ended interviews, to describe in detail African American women’s experiences during pregnancy. Qualitative research is important when little is known about a phenomenon. It seeks to provide an insider’s viewpoint, answer questions of how and why, and reveal new explanations and hypotheses. “We also found that qualitative research was critical in allowing community voices and perspectives to be heard,” added Ms. Ferré. “This was important because we were working with disenfranchised and stigmatized communities.” 

 
Similar projects were later conducted in Atlanta (the Atlanta Chronic Stress and Strain project) and Chicago (Social Networks project). In Atlanta, focus groups and interviews were conducted to identify “stressors” (i.e., factors that create stress) and “supports” (i.e., factors that alleviate stress) among college-educated African American women. In Chicago, researchers looked at how family, friends, and community influence a woman’s use of prenatal care and other health behaviors during pregnancy. 

Researchers found that racial disparities in SES may be so great that studies cannot adequately adjust for them. Traditional risk factors for very low birth weight (VLBW) infants—the mother’s use of alcohol at time of conception, the father having a blue-collar job and low educational level— were not associated with VLBW delivery in black women. Among black women, the only SES factor that affected VLBW was being unmarried.² 

On the basis of such studies, stress is emerging as a leading risk factor in preterm delivery. “Stress affects many domains, including relationships with partners, housing needs, income, and work,” Ms. Ferré said. “Pregnancy is a catalyst that increases the stressors in each domain.” 

Pregnancy can add more stress for a woman when she does not feel well but still must work and care for her family. She may also worry about how illness will affect her baby. In a 2001 Philadelphia study, researchers learned that women with high chronic stress were more likely to have bacterial vaginosis, an infection associated with poor birth outcomes.³ 

A later analysis showed that housing problems were the factor most highly associated with bacterial vaginosis in pregnancy. The highest levels of interpersonal conflict, material hardship, and neighborhood danger were also significantly associated with the infection.⁴ The physical demands of pregnancy also increase work stress, and the overall effects of stress can suppress a woman’s immune system, potentially worsening the effects of infection. 

Researchers have also found that social support from other women can be both a stressor and a support for pregnant women. Although older women often serve as mentors and role models for younger mothers, they may also make demands that conflict with good health. In the Harlem study, for example, one young woman reported missing prenatal visits because her mother needed her to babysit with younger siblings. In the national “Back to Sleep” educational campaign, which promoted putting babies to sleep on their backs to prevent sudden infant death syndrome, researchers found that many women instead followed the advice of their mothers and placed infants on their stomachs. 

Many stressors and other risk factors exist before a pregnancy. These include racism, job stress, stressful relationships, housing problems, lack of social support, low education, low income, and living in run-down communities without important services such as nearby grocery stores.⁵ Other factors, such as nutrition and environmental toxins, may also play a role in preterm delivery, said Ms. Ferré. To counter these factors, preventive care should be in place before pregnancy occurs. Another way to improve birth outcomes is to increase the social support available to women during pregnancy. Through the community’s dedication and initiative, Healthy African American Families in Los Angeles has compiled a list entitled “100 Intentional Acts of Kindness to a Pregnant Woman,” which includes cooking meals and offering a seat on buses or trains. They also developed a door-knob brochure to spread information about preterm labor to pregnant women’s support networks. The goal of both activities is to focus on social support and other community strengths. 

“Improving health holistically during reproductive years may have a lasting influence on a woman’s health and the health of her children,” Ms. Ferré said. 

 
References 

1. Schoendorf KC, Hogue CJ, Kleinman JC, Rowley D. Mortality among infants of black as compared with white collegeeducated parents. New England Journal of Medicine 1992;326: 1522–1526.
2. Berg CJ, Wilcox LS, d’Almada PJ. The prevalence of socioeconomic and behavioral characteristics and their impact on very low birthweight in black and white infants in Georgia. Maternal and Child Health Journal 2001;5(2):75–84. 
3. Culhane JF, Rauh V, McCollum KF, Hogan VK, Agnew K, Wadwa PD. Maternal stress is associated with bacterial vaginosis in human pregnancy. Maternal and Child Health Journal 2001;5(2):127–134. 
4. Rauh VA, et al. Chronic stressors and health behaviors contribute to the excess burden of bacterial vaginosis in pregnancy among inner-city minority women. (In press). 
5. Kaplan G, Lynch J. Some new observations on social class and health. Available at: http://www.sph.umich.edu/miih/ papers/1.pdf*. Accessed August 9, 2002.

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