Health disparities a 32-year-old African American woman may experience related to her pregnancy, such as the risk for preterm labor and the high rate of infant mortality in low-income women.
This is a timely topic as this year the CDC pointed out that the risk of black* women dying in pregnancy is three to four times that of white women (CDC, 2019). ACOG (2015) discusses the consistent and prevalent disparities in obstetrics and gynecology. Healthcare access is one of the documented issues. ACOG reminds us that the United States is the only country that has a market driven health care system rather than the view that healthcare is a right that every citizen should have (ACOG, 2015). In 2013, 59% of black women lived in areas where Medicaid was not going to be expanded (ACOG, 2015). Also documented is the biases and stereotyping from a provider point of view (ACOG, 2015). Demographic and social biases have been shown to influence clinican’s decisions regarding contraception and pre-natal care (ACOG, 2015). Could the mistrust of many black women with the healthcare system have anything to do with forced sterilization in the past? (ACOG, 2015).
These disparities are nothing new. In 2011, Cox, Zhang, Zotti, and Graham discussed racial disparities and unfavorable birth outcomes. The study referenced that fact that black women consistency received less than adequate pre-natal care from providers. In addition black women had a greater chance of premature babies, babies with low birth weight, and babies who die in childbirth (Cox, Zhang, Zotti, & Graham, 2011). We have the power, as Nurse Practitioners to encourage and provider early and consistent pre-natal care free of bias and judgment. With consistent care, we can assist with nutritional and psychosocial counseling as well as assisting with modifiable risk factors such as alcohol, drug use, or cigarette smoking in pregnancy (Cox, Zhang, Zotti, & Graham, 2011).
*I am African Canadian so prefer to use the word black rather than African American
American College of Obstetrics and Gynecology (ACOG). (2015). Women’s Health Care Physicians. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Racial-and-Ethnic-Disparities-in-Obstetrics-and-Gynecology
Centers for Disease Control (CDC). (2019). Pregnancy-Related Deaths | CDC. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm
Cox, R. G., Zhang, L., Zotti, M. E., & Graham, J. (2011). Prenatal care utilization in mississippi: Racial disparities and implications for unfavorable birth outcomes.Maternal and Child Health Journal, 15(7), 931-42. doi:http://dx.doi.org/10.1007/s10995-009-0542-6
Given the United States’ climate of racial inequality and health disparities, our patient, which is an African American woman is more likely to be exposed to stress and complications such as preterm labor, preeclampsia, depression, fetal demise or fetal growth restriction during the pregnancy. A healthy environment, financial stability, healthcare, education, and social community context are essential during pregnancy (Mohamed et al., 2014). In this case study, the patient is a 32-years-old, African American single mother, has three children from previous relationships, is financially unstable, overweight, with preexisting conditions such as hypertension and at risk for gestational diabetes. She has two jobs that probably does not offer benefits or insurance coverage. The patient is more likely to experience hypertensive disorders of pregnancy that may be attributable to pre-pregnancy hypertension. Her BMI is already elevated, which may lead to complications, including preterm birth, fetal death, macrosomia, gestational diabetes, and cesarean delivery.
According to Mohamed et al. (2014), women of color are less likely to have access to vital reproductive health services including screening for sexually transmitted infections and cervical cancer, family planning; and abortion, when compared with non-Hispanic white women. Although socioeconomic status is considered the main leading factor in health disparities, factors at the patient, practitioner, and health care system levels contribute to existing and evolving disparities in women’s health outcomes (Mohamed et al., 2014). In this case, I would inquire on factors that contributed to her delay in OB care and lack of follow-up visits. What determined the patient to have all this gap in care? Was it the lack of financial resources or other factors such as domestic violence? Based on the screening results, the patient should be screened for domestic violence and guided in the process of care based on her needs and beliefs.
Unfortunately, African American women receive lower-quality health care related to inequities in income, housing, education and job opportunities, which results in higher risk for mortality across the life span for this population (Bryant, 2010). This contributes to racial disparities in pregnancy-related risk factors such as hypertension, anemia, gestational diabetes, and obesity and other conditions such as heart disease, HIV, AIDS, and cancer (Bryant, 2010).
Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth. Studies showed that infants of African American mothers are more likely to be born preterm than infants of white mothers (Mohamed et al., 2014). But, why is preterm birth rate higher in African-Americans?
Women of color are 49 percent more likely than whites to deliver prematurely, and black infants are twice as likely as white babies to die before their first birthday (Mohamed et al., 2014). In this case, the stress, financial instability, lack of nutritional food, and comorbidities may put in jeopardy the patient and infant’s life. Although the Affordable Care Act (ACA) created historical advances in health insurance coverage, millions still go without health insurance each year, many of the people of color (Mohamed et al., 2014).
Low-income, lack of financial resources, maternal pre-pregnancy weight, exposure to stress, and maternal health status prior to pregnancy may lead to fetal growth restriction. Research showed that African American women are more likely to experience fetal growth restriction (FGR), a significant contributor to neonatal morbidity and mortality, than are women of other races and ethnicities (Bryant, 2010). The patient has to be enrolled in public programs such as the Special Supplemental Food Program for Women, Infants, and Children, to avoid food insecurity during pregnancy that may have a beneficial effect on FGR risk among women (Bryant, 2010).
According to Bryant (2010), there are multiple disparities in obstetrical outcomes between women of different race or ethnicities. The author suggests that stress induced by racial and gender discrimination plays a significant role in maternal and infant mortality. According to Kliff (2018), infants in the United States have a 76 percent higher risk of death compared with infants in other wealthy nations and African American women experience the most elevated rates of maternal and infant death. This inequity in health status can be reduced by properly addressing the social determinants of health and advocating for a system of more culturally and linguistically appropriate care for all. (Kliff, 2018).
In this case, it will be our responsibility as health care providers to encourage that all care is patient-centered, culturally appropriate, and listens to women’s needs. This new visit at the office represents a good opportunity for screening and education of the patient in a culturally sensitive manner about steps she can take to prevent disease conditions and any negative birth outcomes.
Bryant, A. S., Worjoloh, A., Caughey, A. B., & Washington, A. E. (2010). Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. American journal of obstetrics and gynecology, 202(4), 335-43.
Center for Reproductive Rights (2018). Addressing Disparities in Reproductive and Sexual Health Care in the U.S. Retrieved from https://www.reproductiverights.org/node/861
Mohamed, S. A., Thota, C., Browne, P. C., Diamond, M. P., & Al-Hendy, A. (2014). Why is Preterm Birth Stubbornly Higher in African-Americans? Obstetrics & gynecology international journal, 1(3), 00019.
Sarah Kliff (2018), American kids are 70 percent more likely to die before adulthood than kids in other rich countries, Retrieved from https://www.vox.com/health-care/2018/1/8/16863656/childhood-mortality-united-states.