Maternal health disparities: Economic & psychosocial hardships  during pregnancy
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Maternal health disparities: Economic & psychosocial hardships during pregnancy May 18-19, 2005 Jacob’s Institute For Women’s Health. Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health. Hardships during pregnancy.

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Economic and psychosocial disparities

Maternal health disparities: Economic & psychosocial hardships during pregnancyMay 18-19, 2005Jacob’s Institute For Women’s Health

Paula Braveman, MD, MPH

Professor of Family & Community Medicine

Director, Center on Social Disparities in Health


Hardships during pregnancy
Hardships during pregnancy hardships during pregnancy

  • Major economic and psychosocial hardships are not rare during pregnancy

  • Large disparities

  • But hardships are prevalent among all groups except the most affluent (22% with highest incomes)

  • Of concern in itself, re maternal well-being

  • If reflects chronic stress, also could adversely affect maternal & infant health, thus health over life course

  • Need to re-assess prenatal services

  • And policies across the life course


Acknowledgements
Acknowledgements hardships during pregnancy

  • Collaborators

    • Soowon Kim & Kristen Marchi, Center on Social Disparities in Health, UCSF

    • Tonya Stancil, CDC Div. of Repro. Health (PRAMS)

    • Marilyn Metzler, CDC Coordinating Center on Health Promotion, Adult & Community Health

    • Moreen Libet & Shabbir Ahmad, CA Dept Health Services MCAH Branch

  • Funding

    • Division of Reproductive Health, CDC Coordinating Center on Health Promotion


Ca maternal and infant health assessment 2002 03
CA. Maternal and Infant Health Assessment, 2002-03 hardships during pregnancy

  • Statewide postpartum survey on maternal and infant health and health care, yearly since 1999

  • Collaborative effort of CA. Dept. Health Services MCH Branch & UCSF CSDH

  • Modeled on CDC’s PRAMS survey

  • Mail/telephone in English and Spanish

  • N = 7,206, with > 70% response

  • Generally representative but under-representation of most disadvantaged is likely


Most women 53 had low incomes were poor or near poor
Most women (53%) had low incomes hardships during pregnancy (were poor or near-poor)

High income:

over 400% of poverty

22%

Poor:

at or under the poverty line

33%

Moderate:

3-4 x poverty

7%

Low-moderate:

2-3 x poverty

10%

Near-poor:

101-200% of poverty

20%



Very hard to get by on her income racial ethnic disparities 2002 2003
Very hard to get by on her income: income,2002 - 2003racial/ethnic disparities, 2002 - 2003


Separated or divorced disparities by income 2003 only n 3 728
Separated or divorced: disparities by income income,2002 - 2003(2003 only, n=3,728)





Homeless disparities by income 2003 only n 3 728
Homeless: disparities by income n=3,728)(2003 only, n=3,728)


Homeless racial ethnic disparities 2003 only n 3 728
Homeless: racial/ethnic disparities n=3,728)(2003 only, n=3,728)


Food insecurity disparities by income 2002 2003 n 7206
Food insecurity: disparities by income, n=3,728)2002-2003, n=7206



Total number of hardships women had during pregnancy by income miha 2003
Total Number of Hardships n=3,728)* Women Had During Pregnancy: by Income, MIHA 2003

*Hardships included here are ‘hard to make ends meet’, ‘food insecurity’, ‘no practical support’, ‘no emotional support’, ‘separated/divorced during pregnancy’, ‘homeless’, ‘job loss of spouse/partner’, ‘involuntary job loss of herself’, ‘incarceration’, and ‘domestic violence’. Note that ‘poverty’ and ‘near-poverty’ are not included as hardships in this analysis by income groups.


Total number of hardships 1 women had during pregnancy by racial ethnic group miha 2003
Total number of hardships n=3,728)1 women had during pregnancy: by racial/ethnic group, MIHA 2003

2

3

4

3

4

Race/Ethnicity

1Hardships included here are ‘poverty’, ‘hard to make ends meet’, ‘food insecurity’, ‘no practical support’, ‘no emotional support’, ‘separated/divorced during pregnancy’, ‘homeless’, ‘job loss of spouse/partner’, ‘involuntary job loss of respondent, ‘incarceration of respondent or her spouse/partner’, and ‘domestic violence’.

2N=3,692; 3Born in the United States; 4Born outside the United States.


Big disparities but hardships were prevalent overall
Big disparities, but hardships were prevalent overall n=3,728)

  • Black, Latina, and Am. Indian women had more hardships

    • but all age and racial/ethnic groups had hardships

  • Poor & near-poor women had more hardships

    • But women with incomes 201-300% of poverty also had hardships (e.g., ~10%: hard to live on income, job loss, food insecurity…)

    • And women with incomes 301-400% of poverty had some hardships (~10% partner lost job)


Most women giving birth had low incomes
Most women giving birth had low incomes n=3,728)

  • A third were poor (family income < 100% of federal poverty line)

  • Another fifth (20%) were near-poor (101-200% of poverty)

  • 53% were low-income (up to 200% of poverty)

  • Who is the maternity mainstream?


California is not unique
California is not unique n=3,728)

  • Data from 17 PRAMS states (CDC survey, 2000-01) paint a similar picture

    • Similar prevalence of poverty (32%) and low income (53%)

    • Hardships prevalent overall

    • Big disparities

    • But affected all social groups except high-income women (28% of sample)


Impact on maternal infant health
Impact on maternal & infant health? n=3,728)

  • Food insecurity & homelessness: maternal health impact is obvious

  • Poor maternal nutrition a known risk for LBW

  • Homelessness: Threat to maternal nutrition, and major stressor

  • All other hardships are major stressors. If chronic, evidence indicates could affect birth weight and prematurity


What is known about impact of stress on birth outcomes
What is known about impact of stress on birth outcomes? n=3,728)

  • Stress can adversely impact birth outcomes through direct physiologic pathways:

    • Neuro-endocrine mechanisms

    • Immune/inflammatory response

    • Vascular effects

  • And stress  adverse behaviors with impact on birth outcomes

    • Effects can be modified by social support


And what about values
And what about values? n=3,728)

  • Compassion for suffering

  • Ethical principles: justice

  • Human rights:

    • Right to attain highest biologically possible state of health

    • Right to a standard of living adequate for health


Implications
Implications? n=3,728)

  • Prenatal care in US: a medical model

    • More visits for low-risk women than in most western European countries

    • Very limited psychosocial/economic services

      • “Comprehensive” care: primarily adds health education

      • WIC

      • Few low-income women qualify for TANF or housing assistance


Are there other models
Are there other models? n=3,728)

  • Contrast with some western European countries that provide all pregnant women with:

    • Universal, cradle-to-grave health insurance

    • Income support (“prenatal allowance”)

    • Housing assistance

    • Range of services to reduce poverty and buffer psychosocial consequences of low income

    • Could deficiencies of US model help explain our worse birth outcomes?

  • What about policies & services affecting pre-pregnancy conditions, including in childhood?


Conclusions
Conclusions n=3,728)

  • Many women experience major economic & psychosocial hardships during pregnancy

  • Most pregnant women are low-income

  • Big disparities but diverse socioeconomic, age, and racial/ethnic groups are affected

  • Science & values support need to address these hardships

  • Need to re-assess content of prenatal care & consider models used elsewhere – including policies affecting psychosocial & economic stressors across the life course