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 • 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 • 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 • 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) 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: disparities by income,2002 - 2003
Very hard to get by on her income: racial/ethnic disparities, 2002 - 2003
Separated or divorced: racial/ethnic disparities (2003 only, n=3,728)
Total Number of Hardships* 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 hardships1 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 • 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 • 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 • 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? • 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? • 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? • 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? • 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? • 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 • 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