# Presentation: 498971

## Reducing disparities in perinatal outcomes: looking upstream 

- May 8, 2006
- Paula Braveman, MD, MPH
- Professor of Family & Community Medicine
- Director, Center on Social Disparities in Health
- University of California, San Francisco
- www.ucsf.edu/csdh

## The case for prevention

- LBW/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 birthweight distribution—not just the extremes
- Values: equalizing opportunities to be healthy

**Notes:**
Q:  Paul  has made a compelling case for the ability to reduce the damages associated with LBW/PTB if pregnant women and their newborns receive the best in high-technology care available.  What else plays an important role in disparities in birth outcomes, besides obstetric and neonatal intensive care?

A:  As long as beneficial treatments exist and are available for some, it is unethical to deny those treatments to some groups.  So I agree completely that we must make sure that high-technology obstetric and neonatal care are available to all.  But I think it is also

## Causes of LBW & 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?

## Causes of LBW & PTB disparities

- Only partly explained by:
- Tobacco
- Excessive alcohol
- Drugs
- Nutrition
- Chronic disease

- Infections?
- Rx hasn’t improved outcomes
- Genetic component?
- Hypothetical
- Some patterns don’t fit
- Stress?
- Accumulating evidence

## Stress and its influence on PTB & LBW

- Physiological pathways have been documented in humans
- Neuro-endocrine pathways ― e.g., release of hormones that could trigger vascular effects and/or premature labor
- Immune/inflammatory pathways

## Sources of stress

- Range of psychosocial stressors associated with poverty/lower income
- Divorce/separation, moving, job loss, financial insecurity, food insecurity, domestic violence, lack of social support
- Women of color experience more poverty/low-income and more stressors
- We have found high rates of stressors among low-income pregnant women in California and 17 other states, e.g...

## Separated/divorced during pregnancy, by income group, California MIHA 2003 

## Partner’s job loss during her pregnancy, by income (similar pattern for her job loss)

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

## Understanding the causes of LBW/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 vs. lower SES women
- Difficult to explain with genetics
- By nativity (born in vs. outside US)

## Disparities by nativity

- _Latinas_
- Immigrants have good birth outcomes despite poverty, low education, less care
- US-born have unfavorable outcomes

- _Blacks_
- African/Afro-Caribbean immigrants have relatively good outcomes
- US-born (African-Americans) have unfavorable outcomes

## Nativity patterns

- Difficult to explain with genetics
- Nativity differences persist even after considering healthier “lifestyle”
- Immigration is stressful, so difficult to explain by stress in general
- What about chronic stress &/or at critical periods, e.g., awareness of discrimination in childhood for US-born?
- Resources that buffer effects of stress?

## Life course exposure to stress  

- Poverty/lower income in childhood, adolescence (& adulthood before pregnancy) could be stressful
- Black women of a given SES are more likely to have had lower SES as children (vs. Whites of similar income/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:  e.g., via neuroendocrine dysregulation

## 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?

## Role of public health

- Targeted programs to reduce the known risk factors (smoking, under-nutrition, etc) ― 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/by other sectors to reduce stress health-damaging effects of poverty/near-poverty and racial discrimination