Women’s needs, science, and prenatal care

1. Women’s needs, science, and prenatal care CityMatCH, Sept. 12, 2004, Portland Paula Braveman, MD, MPH Director, Center on Social Disparities in Health Professor of Family & Community Medicine

2. Women’s needs, science, and prenatal care • Economic and psychosocial challenges during pregnancy • Current science on the likely impact • Implications for action

3. Women’s needs, science, and prenatal care • Major economic and psychosocial hardships are relatively common during pregnancy • They affect a broad and diverse cross-section of women • Current science indicates these are likely to adversely affect maternal and infant health (and health throughout the life course) • Need to re-assess prenatal services

4. Collaborators • Kristen Marchi, MPH, Center on Social Disparities in Health, UCSF • Marilyn Metzler, CDC Coordinating Center on Health Promotion • Moreen Libet, PhD, CA Dept Health Services MCH Branch • Shabbir Ahmad, DVM, CA Dept Health Services MCH Branch

5. Maternal and Infant Health Assessment • Modeled on CDC’s PRAMS (Pregnancy Risk Assessment and Monitoring System) • CA Statewide representative postpartum survey on maternal and infant health and health care • Collaborative effort of CA Dept. Health Services MCH Branch & our group at UCSF • Mail/telephone in English and Spanish • 3,500 women annually since 1999 • Response rate 74% in 2003

6. Major psychosocial challenges during pregnancy • Separated/divorced 7% • No practical support 14% • No emotional support 9% • Physically abused by partner 3% • She or partner went to jail 3% • Partner didn’t want pregnancy 7%

7. Economic hardship during pregnancy, California 2003 • Over a third (37%) of women giving birth were poor (family income < 100% of the federal poverty line) • Another fifth (21%) were near-poor (101-200% of poverty) • Most women (58%) giving birth were low-income (up to 200% of poverty) • Who is the maternity mainstream?

8. Most (58%) women who gave birth in California in 2003 had low incomes (poor or near-poor) Higher income: over 4 x poverty 25% Poor: at or under the poverty line 37% Moderate: 3-4 x poverty 8% Near-poor: 1-2 x poverty 21% Low-moderate: 2-3 x poverty 10%

9. Economic hardship during pregnancy • Hard to live on that income 16% • A lot of bills she couldn’t pay 19% • Partner involuntarily lost job 12% • She involuntarily lost her job 10% • Homeless at some point 7%

10. Economic hardship during pregnancy: food insecurity • Often couldn’t afford enough food 4% • Sometimes couldn’t afford enough food 19% • Often couldn’t afford balanced meals 4% • Sometimes couldn’t afford balanced meals 18% • Cut/skipped meals (or ate less than she thought she should) because couldn’t afford food 9% • Hungry because couldn’t afford food 6%

11. Is California unique? • No • Preliminary analyses of data from 7 PRAMS states paint a similar picture • Prevalence of poverty/low income • Prevalence of stressful life events • Tonya Stancil, CDC PRAMS, analyzing data from 18 PRAMS states

12. Were just a few groups affected? • Poor and near-poor women had more hardships • But several hardships also affected women of low/moderate income (201-300% of poverty) • Food insecurity (“sometimes could not…”) 10-14% • Lack of emotional or practical support 6-10% • Job loss (her and/or her partner) 8-10% • Hard to live on her income/many unpaid bills 8-18% • Uninsured during first trimester 8%

13. Were just a few groups affected? • No • Even women with incomes from 301-400% of poverty faced challenges • E.g., 5-6% sometimes could not afford enough food… • The challenges cut across all age and racial/ethnic groups

14. Other challenges recent science suggests should be considered • Neighborhood conditions • Lack of nutritious food nearby • Stress due to violence, concentrated deprivation/despair • Exposure to adverse health-related behaviors (and lack of support for healthy behaviors) • Accumulating literature suggests neighborhood context can matter, although complex • Racism • A source of chronic/acute stress. Studies of impact in early stages but plausible

15. What is known about the impact on birth outcomes? • Food insecurity and homelessness: • Homelessness reflects severe lack of resources likely to result in poor nutrition; also likely to make it difficult to eat properly • Poor maternal nutrition is a known risk factor for low birth weight and preterm delivery • inadequate pregnancy weight gain • micronutrients may also be important • Poor nutrition before pregnancy could lead to low pre-pregnancy BMI or short stature (life course effects)

16. What is known about the impact on birth outcomes? Stress • Stress can adversely impact birth outcomes through direct physiologic pathways involving: • Neuro-endocrine mechanisms • Immune/inflammatory response • Vascular effects • Stress also can lead to adverse behaviors with known impact on birth outcomes • Effects can be modified by social support

17. Implications? • Prenatal care in US: a medical model • More visits for low-risk women than in most western European countries • Medi-Cal now covers vast majority by end of pregnancy but many are uninsured in 1st trimester. In several states, more women are uninsured. • Very limited social services • “Comprehensive” prenatal care: primarily health education • WIC • Few poor women and fewer near-poor women qualify for TANF or housing assistance

18. Implications? • Contrast with several western European countries, which provide to all pregnant women: • Income support (“prenatal allowance”) • Housing assistance • Social worker services • Universal health insurance coverage (cradle-to-grave) • Coordinated services designed to reduce poverty and buffer the psychosocial consequences of low income • Could deficiencies of US model help explain our worse birth outcomes and lower life expectancy?

19. Are the other countries’ approaches “evidence-based?” • Is it plausible that actively addressing the social determinants of maternal and infant health could lead to better outcomes? • Isn’t it better to emphasize the medical side of prenatal care?

20. Scarlet fever– mean annual death rate in children under 15: England and Wales Streptococcus identified Sulphonamides Penicillin

21. Measles– mean annual death rate of children under 15: England and Wales Immunization began

22. Infant mortality rate: England and Wales

23. Respiratory tuberculosis– mean annual death rate: England and Wales

24. Limited role of medical care • “When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.” • Rene Dubos, Mirage of Health. NY: Perennial Library, 1959, p. 23

25. Conclusions • Many women experience major economic and psychosocial hardships during pregnancy • These hardships affect diverse social groups, including women of moderate income, all ages, and all racial/ethnic groups • Science indicates that these hardships threaten maternal and infant health (and health throughout the life course)

26. Conclusions • We need to re-assess the social and economic (as well as medical) content of prenatal services, and consider models used elsewhere

27. What could we do in the U.S.? • If you could shape the relevant policies, what would you recommend? • At national, state, and local levels? • What evidence would you cite to defend your recommendations? • What values?