[Slide 1]{.underline}

**Reducing disparities in perinatal outcomes: looking upstream**

May 8, 2006

Paula Braveman, MD, MPH

Professor of Family and Community Medicine

Director, Center on Social Disparities in Health

University of California, San Francisco

[www.ucsf.edu/csdh](http://www.ucsf.edu/csdh)

[Slide 2]{.underline}

The case for prevention

LBW slash PTB: Serious cognitive, emotional-behavioral and physical
disabilities

Placing affected individuals at disadvantage across life course

Burden on families

Societal costs: human, economic

A gradient of adverse outcomes across the birth weight distribution, not
just the extremes

Values: equalizing opportunities to be healthy

[Slide 3]{.underline}

**Causes of LBW and PTB**

Known

Tobacco

Excessive alcohol

Drugs

Nutrition

Short maternal stature

Chronic disease

Suspected

Infections?

Genes?

Stress?

> Lack of social support as a stressor and/or modifier of effects of
> stress?

[Slide 4]{.underline}

**Causes of LBW and PTB disparities**

Only partly explained by:

Tobacco

Excessive alcohol

Drugs

Nutrition

Chronic disease

Infections?

Prescription hasn't improved outcomes

Genetic component?

Hypothetical

Some patterns don't fit

Stress?

Accumulating evidence

[Slide 5]{.underline}

**Stress and its influence on PTB and LBW**

Physiological pathways have been documented in humans

Neuro-endocrine pathways; EG, release of hormones that could trigger
vascular effects and-or premature labor

Immune slash inflammatory pathways

[Slide 6]{.underline}

**Sources of stress**

Range of psychosocial stressors associated with poverty slash lower
income

> Divorce slash separation, moving, job loss, financial insecurity, food
> insecurity, domestic violence, lack of social support
>
> Women of color experience more poverty slash low income and more
> stressors

We have found high rates of stressors among low-income pregnant women in
California and 17 other States, EG, dot dot dot

[Slide 7]{.underline}

**Separated slash divorced during pregnancy, by income group, California
MIHA 2003**

On a bar graph, the x-axis lists ranges of percentages of the Federal
poverty level and the y-axis shows percentages of women. The 0 to 100
Percent bar is at 11.6 percent. The 101 to 200 Percent bar is at 7.3.
The 201 to 300 Percent bar is at 4.4. The 301 to 400 Percent bar is at
2.5. The More than 400 Percent bar is at 1.2.

[Slide 8]{.underline}

**Partner's job loss during her pregnancy, by income; similar pattern
for her job loss**

On a bar graph, the x-axis lists ranges of percentages of the Federal
poverty level and the y-axis shows percentages of women. The 0 to 100
Percent bar is at 17.3 percent. The 101 to 200 Percent bar is at 12.1.
The 201 to 300 Percent bar is at 9.8. The 301 to 400 Percent bar is at
8.1. The More than 400 Percent bar is at 5.4.

[Slide 9]{.underline}

**Often could not afford to buy enough food during pregnancy, by income
group**

On a bar graph, the x-axis lists ranges of percentages of the Federal
poverty level and the y-axis shows percentages of women. The 0 to 100
Percent bar is at 8.7 percent. The 101 to 200 Percent bar is at 4.1. The
201 to 300 Percent bar is at 1.7. The 301 to 400 Percent bar is at 0.6.
The More than 400 Percent bar is at 0.

[Slide 10]{.underline}

**Understanding the causes of LBW slash PTB disparities**

More questions than answers, but what can we learn from the patterns?

By SES and by race or ethnic group

> Racial disparities are greater among higher SES women versus lower SES
> women
>
> Difficult to explain with genetics

By nativity, born in versus outside US

[Slide 11]{.underline}

**Disparities by nativity**

Latinas

> Immigrants have good birth outcomes despite poverty, low education,
> less care

US-born have unfavorable outcomes

Blacks

African slash Afro-Caribbean immigrants have relatively good outcomes

US-born, African-Americans, have unfavorable outcomes

[Slide 12]{.underline}

**Nativity patterns**

Difficult to explain with genetics

Nativity differences persist even after considering healthier, quote,
lifestyle, unquote

Immigration is stressful, so difficult to explain by stress in general

> What about chronic stress and-or at critical periods, EG, awareness of
> discrimination in childhood for US-born?

Resources that buffer effects of stress?

[Slide 13]{.underline}

**Life course exposure to stress**

Poverty slash lower income in childhood, adolescence, and [adulthood
before pregnancy]{.mark} could be stressful

Black women of a given SES are more likely to have had lower SES as
children, versus Whites of similar income slash education now

Weathering hypothesis: cumulative stress

But could past exposures lead to LBW/PTB in current pregnancy, if a
woman is no longer poor?

Yes: EG, via neuro-endocrine dysregulation

[Slide 14]{.underline}

**Racism as a source of chronic stress: cumulative across life course**

Stress associated with unfair treatment

> Concern about being treated unfairly, based on being in a group that
> has historically suffered discrimination
>
> Even without major incidents of clear-cut discrimination

Some studies have linked racism with adverse birth outcomes; some have
not

Inadequate measures; we, Nuru-Jeter et al, are trying to systematically
develop measures for birth outcomes research

Could racism help explain racial disparities and nativity paradoxes?

[Slide 15]{.underline}

**Role of public health**

Targeted programs to reduce the known risk factors: smoking,
under-nutrition, et cetera, even though these don't account for all the
disparities

Encourage life course research on psychosocial factors

Bold experiments with plausible interventions

Support efforts with slash by other sectors to reduce stress
health-damaging effects of poverty slash near-poverty and racial
discrimination