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Promoting Health: Intervention Strategies from Social and Behavioral Research PAPER CONTRIBUTION C Preconception, Prenatal, Perinatal, and Postnatal Influences on Health Carol C.Korenbrot and Nancy E.Moss After more than a decade of impressive public health efforts to improve the health of infants at birth in the United States, health status indicators indicate that little progress has been made. The United States still ranks 25th in infant mortality among nations reporting to the World Health Organization (Petrini et al., 1997). While there have been reductions in infant mortality, the ranking remains as low as in 1985 when major policy and program reforms of prenatal care were initiated in the United States to reduce infant mortality and the ethnic disparities in the health outcome by focusing on reductions in low-birthweight (Institute of Medicine, 1985; U.S. Department of Health and Human Services, 1985). There have not been increases in low-birthweight rates, nor has there been any significant reduction in the ethnic disparities in infant mortality or low-birthweight rates (Figure 1) (Centers for Disease Control and Prevention, 1999). This remains true in spite of improvements in the early and continuous use of prenatal care (Figure 2) and a reduction in contributing health behaviors including smoking in pregnancy and teenage childbearing (Petrini et al., 1997; Ventura et al., 1999). The lack of measurable gains is not explained by increases in mul- Carol C.Korenbrot, Ph.D., is adjunct professor, Institute for Health Policy Studies and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, and Nancy E.Moss, Ph.D., is a consultant. This paper was prepared for the symposium, “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health,” the Institute of Medicine, and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, February 2–3, 2000.
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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 1. Percentage of low birthweight: United States, 1984–1996. SOURCE: National Center for Health Statistics, prepared by March of Dimes, Perinatal Data Center. 1997. tiple births, births to older women, or changes in medical practice such as induction of labor or cesarean sections before full gestation (Kramer, 1998; Ventura et al., 1999). Birth outcomes in the United States have behaved less like indicators of poor health care and health behaviors, and more like indicators of deeper disparities among women of different social classes and ethnicities (Collins et al., 1997; O'Campo et al., 1997; Roberts, 1997; Johnson et al., 1999). The lack of improvement in indicators of the health of babies at birth is discouraging to public health professionals, but comes as no surprise to social and behavioral scientists. Public health practice has not fully embraced the contributions that social science and behavioral research have to offer in the design of programs and policies for maternal and infant health (Mechanic, 1995; Grason et al., 1999; Hogue, 1999). The public health model for a healthy start in life is broader than the medical model and addresses disparities in health education, nutrition, and psychosocial conditions of families (Bennett and Kotelchuck, 1997). Public health professionals have long recognized the need to ameliorate effects of social policies that discriminate against economically and ethnically vulnerable populations (Aday, 1993). Public health programs for pregnant women have not had measurable effects on the country's poor pregnancy outcomes in recent years and have had limited effects on infant mortality (Willinger et al., 1998; U.S. Department of Health and Human Services, 1999). To have larger effects on maternal and infant health, innovative programs and policies need to address social, economic, cultural, political, and psychological antecedents of disparities.
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Promoting Health: Intervention Strategies from Social and Behavioral Research Social structure, the positions people hold within it, and the nature of the social relations that result from these positions are important antecedent factors in determining resources that affect health (Link and Phelan, 1995; Kennedy et al., 1996; Kiwachi and Kennedy, 1997). Gender, socioeconomic position, and racial segregation contribute to the ideological and cultural context in which social relationships occur (Williams, 1990; Benderly, 1997). These, in turn, affect people 's everyday lives. Thus, it is not difficult to see health as “the product of social relationships between…groups, with these relationships expressed through people's everyday living and working conditions, including daily interactions with others” (Krieger, 1994). Social and economic relations are causal, explicitly shaping the production and distribution of individual and population health and disease at different points across the life span (Evans, 1995; Moss, 2000a). The resources that are differentially associated with social and economic status include knowledge, income, wealth and assets, power, prestige, social networks, and psychological well-being. Availability and deprivation of these resources over time structure and differentiate the life course of individual men and women (Table 1) (Link and Phelan, 1995; Moss, 2000a). The cumulative effect of deprivation of social and material support over the life course is associated with stressful living and working conditions. Trajectories of stress and deprivation across a number of dimensions, including social class and ethnicity, may explain a higher prevalence of poor birth outcomes in groups such as African Americans (Geronimus, 1992). By contrast, resources are hypothesized to influence the ability of people to avoid health risks such as stress and to minimize their consequences if they occur (Rowley, 1998). In this framework, stress and health behaviors are mediating factors that occur in the context of an individual's social and economic position, the socioeconomic characteristics of a FIGURE 2. Onset of prenatal care use: United States, 1984–1996. SOURCE: National Center for Health Statistics, prepared by March of Dimes, Perinatal Data Center, 1997.
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Promoting Health: Intervention Strategies from Social and Behavioral Research community, and the psychosocial environment that they create (Krieger, 1994). Addressing behaviors alone, without attention to the structural and psychosocial context in which they occur, will not reduce socioeconomic and racial or ethnic disparities in outcomes. While alternative frameworks such as social selection have been proposed as explanations for health disparities (Rutter and Quine, 1990; Syme, 1998), longitudinal research continues to provide stronger support for social position as a determinant rather than consequence of health. The latter approach offers rich new opportunities to develop and test social and health policies and programs that may ultimately promote health and reduce disparities among mothers and infants. This chapter explores the opportunities offered by social and behavioral research to develop public health policies and programs that reduce or eliminate social class and ethnic disparities shaping health at birth. We use low-birthweight as the primary indicator of morbidity and mortality risk in infancy because of its links with maternal morbidity and infant morbidity, development, and mortality, as well as health conditions that can endure through childhood or appear later in life (Institute of Medicine, 1985; Hack et al., 1995; Paneth, 1995). The chapter begins with an overview of how social class, race or ethnicity, and gender roles and relations are hypothesized to affect maternal health before and during pregnancy and infant health at birth. We then examine how psychosocial factors could be a critical route for mediating the effects of social class and race or ethnicity on behaviors known to affect maternal and infant health. Following the overview of sociodemographic and psychosocial factors, we examine recent public health policy and program interventions designed to address social class and ethnic disparities in health at birth. The paper concludes with opportunities for social and behavioral research that can contribute to the design and evaluation of innovative policies and programs directed at reducing socioeconomic and racial or ethnic disparities to improve maternal and infant health. Our purpose is not to provide an exhaustive summary of the vast literature relating to these issues, but rather to provide a framework in which to take a fresh look at a persistent public health challenge. SOCIODEMOGRAPHIC ANTECEDENTS AND OUTCOMES The sociodemographic factors that best predict health at birth are social class and race or ethnicity. In the United States, poverty and wealth are closely related to ethnicity and “race” which have independent and interdependent effects on birth outcomes (Krieger, 1991; Lillie-Blanton and LaVeist, 1996). These social and demographic antecedents together shape gender, social, and economic roles and hierarchies that women experience throughout their lives (Table 1). In this section of the paper we first explore contextual effects of social class or “socioeconomic status” (SES in the public health literature) (Krieger et al., 1997), with an emphasis on gender-based, role-related, and life span issuesfor reproductive-age women that could help to explain disparities in health out-
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Promoting Health: Intervention Strategies from Social and Behavioral Research TABLE 1. Examples of Social, Economic, Psychological, and Behavioral Concepts That Could Help Explain Socioeconomic Status and Ethnic DisDarities in Health at Birth Sociodemographic Factors Psychosocial Factors Antecedents Potential Mediators Environmental Resources and Stressors Psychological and Behavioral Resources and Stressors Biological System Health Outcomes Socioeconomic Status (SES) Education Income Occupation Gender-based roles or hierarchies Social and economic roles or hierarchies (and marital status) (and age) Stressors or life events: Mediator Modifier of mediator effect Confounder of mediator effect Social supports or deprivation Socioeconomic discrimination Access to health care Vulnerabilities: Distress Anxiety Depression Adaptation: Coping Self-esteem Mastery or control Behaviors: Health behaviors Use of health care Endocrine Cardiovascular Fetal growth Immune Neural Preconception: Maternal weight at birth Hypertension Diabetes Prenatal: Complications of pregnancy Perinatal: Preterm birth Small for gestational age Low birthweight Congenital anomalies Postnatal: Neonatal or infant mortality Race or Ethnicity Ethnic Origins Nativity Acculturation Residential segregation Racial discrimination Community characteristics
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Promoting Health: Intervention Strategies from Social and Behavioral Research comes at birth (Grason et al., 1999; Minkovitz and Baldwin, 1999). We address race and ethnicity with an emphasis on the national origins and acculturation of different groups, highlighting similarities and differences across groups. Sociocultural factors associated with SES and ethnicity influence health and health choices (Link and Phelan, 1995). While we recognize the crucial influence of women's psychosocial characteristics and behaviors on infant health at birth, our emphasis in this section is on “upstream” sociodemographic antecedents. Socioeconomic Disparities Socioeconomic indicators such as education, income, and occupation have been consistently associated with low-birthweight, preterm birth, and infant mortality (Rutter and Quine, 1990; Savitz et al., 1996). SES captures “living conditions and life chances, skill levels and material resources, relative power and privilege” (Williams and Collins, 1995). This very capturing of so many aspects of life history and everyday experience makes SES a powerful and persistent antecedent of many pregnancy outcomes, though it has rarely been measured by more than education in most epidemiological studies (Williams, 1990; Feinstein, 1993; Moss, 2000a). Effects of SES on health at birth are not confined to the lowest-SES groups; as with many other health indicators, there is a gradient of effects across SES strata (Adler et al., 1994). The incidence of low-birthweight, for example, decreases as levels of maternal education increase, with progressively better outcomes for women who have completed high school, had some college, or graduated from college (Figure 3). The gradient implies FIGURE 3. Percentage of low-birthweight live births among mothers 20 years of age and over by mother's education, United States, 1996. Less than 12 years includes persons with 12 years of schooling but no high school diploma. Twelve years includes persons with a high school diploma or GED. Thirteen to 15 years includes persons without a degree and persons with associate's degrees. Sixteen years or more includes all persons with a baccalaurate degree or higher.
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Promoting Health: Intervention Strategies from Social and Behavioral Research that it is not only poverty, the severe deprivation of social and material resources, socioeconomic discrimination, and exposure to health risks that contribute to SES disparities. Rather, the relative deprivation and adverse exposures are mediating factors that affect women over a range of SES levels (Carstairs, 1995; Robert and House, 2000). Gender, social, and economic roles and hierarchies may also contribute to gradients in pregnancy outcomes by determining the relative risks and resources to which women are differentially exposed prior to and during the reproductive period (Table 1) (Wilkinson, 1997; Weisman, 1998; Minkovitz and Baldwin, 1999). A clear understanding of the relative effects of these mediators is important in designing effective policies and programs. For example, if status in a social hierarchy is detrimental to health, then merely increasing cash assistance and food vouchers for those in poverty, without simultaneously reducing inequality, may afford little health benefit (Adler et al., 1994). On the other hand, deprivation of material assets such as car and home ownership that affect the everyday conditions of life may be as important a dimension of social class as education or income in predicting health outcomes, particularly for women (Arber, 1991). We will need to better understand why socioeconomic gradients in health at birth develop in order to reduce disparities. The health of reproductive-age women is shaped beginning with their own health at birth and continuing through childhood and adolescence with conditions that develop prior to becoming pregnant (Power et al., 1997; 1998). Lower-SES women are at greater risk for the illnesses and conditions that complicate pregnancy (Pamuk et al., 1998). For example, hypertension exhibits a steep socioeconomic effect. Poor women are 1.6 times as likely as high-income women to be hypertensive (Pamuk et al., 1998). Diabetes is also more prevalent among women of low SES, and the death rate for diabetes among low-income women is three times that for high-income women (Pamuk et al., 1998). Even behavior change is socioeconomically structured. Cigarette smoking among adults 25 and over declined between 1974 and 1995, but rates were down 49% for college-educated women, compared with a drop of 13% among those who did not finish high school (Pamuk et al., 1998). In 1995 the least educated women were twice as likely to smoke as the most educated. Risks of nutritional deficiencies are higher in lower-SES groups and nutrition prior to and during pregnancy, including folic acid intake, is linked to higher rates of congenital anomalies (Centers for Disease Control and Prevention, 1998). Often, these socioeconomically-structured behaviors have their roots in women 's everyday experiences (Moss, 2000a). The life span perspective suggests how social factors in maternal health over generations contribute to the SES gradient in health and disease of subsequent generations during infancy, childhood, and beyond (Elo and Preston, 1992; Barker, 1998). The dependence of offspring health on the health of the prior generation is clearly shown in birthweights. Women who were themselves low-birthweight, are more likely to give birth to low-birthweight babies (Sanderson et al., 1995).
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Promoting Health: Intervention Strategies from Social and Behavioral Research Gender-Based Roles and Hierarchies As women make the transition to pregnancy, many of the gender-based issues that they find problematic are magnified by SES and could contribute to SES gradients in outcomes (Benderly, 1997). Social constructs of masculinity and femininity are arguably nowhere more pronounced than around issues of sexuality and reproduction (Lane and Cibula, 2000). Assumptions about what is natural, biologically determined, or even divinely ordained, for men and women shape the views and experiences women have of sex, contraception, and pregnancy, as well as their health behaviors and interactions with the health care system (Ruzek et al., 1997; Weisman, 1997). They also affect the power and effectiveness women have in implementing their views, whether in bedrooms or the workplace. Unintended pregnancies, for example, occur at higher rates in low-SES women (Institute of Medicine, 1995) and lead to a complex array of situations that women must deal with before they decide whether or not to accept the pregnancy (U.S. Department of Health and Human Services, 1991; Institute of Medicine, 1995). An unintended pregnancy does not necessarily mean that the child is unwanted, but it does mean that many of the transitions required of women are not anticipated or planned. As a result, the pregnancy may be more stressful, particularly if there are limited resources to overcome competing demands. Low SES may be associated with more traditional and conservative views of women's roles: that sex is man's business and child rearing is woman's work, as well as the socially and culturally sanctioned hierarchical dominance by men over women. Some men use traditional views of masculinity and femininity to exert power over women that may be harmful to the health and well-being of women in pregnancy. This can result in forced sex, lack of condom use, domestic violence, and little sharing in care giving for children (Amaro, 1995; Weisman, 1997). When women become pregnant, hierarchical views and behaviors may be responsible for the increase in exposure to domestic violence and emotional abuse (O'Campo et al., 1995; Crowell and Burgess, 1996). While domestic violence is found in all socioeconomic strata, the traditional view that it is a man's job to support his spouse and children economically can backfire on lower-SES women if their partners face more frustrations than men in upper-SES strata in succeeding in the role. Abuse of women has serious ramifications because of the greater risk for homicide, effects on children in the household, and the long-term emotional and physical consequences for women and their families. Social and Economic Roles and Hierarchies Failure to consider role demands in women's lives unnecessarily limits our understanding of maternal health in pregnancy and childbirth and the impact on pregnancy outcomes (Benderly, 1997; Zapata and Bennett, 1997). Becoming a mother increases the role demands for women, which in turn may strain material and social resources in ways that vary across socioeconomic strata. Each role,
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Promoting Health: Intervention Strategies from Social and Behavioral Research including that of mother-to-be, is associated with normative expectations in women, partners, families, and communities, although there are cultural as well as socioeconomic variations. When expectations of a particular role are not fulfilled or demands are particularly heavy, stress or “strain” arises (Pritchard and Teo, 1994). Strain increases proportionally to the number of roles a woman must play as well as to the role transitions she makes during her childbearing years (Young, 1996; Weisman, 1997). For women, the roles of education, work, and motherhood interact in complex ways. In the United States and other western industrialized nations, the actual period of childbearing in a woman's life is much shorter than the duration of her potential childbearing, although countries vary in the expectation that women will work outside the home and participate actively in community affairs. The trend in the United States in recent decades has been for women to obtain high school and post-high school college degrees, enter the workforce, delay or forgo marriage, and delay or forgo child rearing (Minkovitz and Baldwin, 1999). The proportion of women with high school and college degrees now exceeds that of men (Grason et al., 1999). There has been a substantial increase in the proportion of women 20 to 30 years of age in the labor market, the prime years for healthy childbearing (Grason et al., 1999). The decline in labor force participation that used to occur between ages 20 and 24 when women left the labor force for motherhood, has progressively disappeared with women born since 1945. Yet, despite concerns that rising participation in the labor force would expose pregnant women to more stress, employed women generally report better health status and birth outcomes than do women who are not employed (Moss and Carver, 1993; Pugliesi, 1995). This can be a reflection of selection of healthier women into the labor force (the “healthy worker effect”) or of the psychosocial and material benefits that accrue from employment. Still, long work weeks of physically demanding work have been found to lead to fetal growth reductions (Hatch et al., 1997). Women working in higher-status occupations during pregnancy may obtain psychosocial and material benefits that protect against any strain of work or multiple roles (Landsbergis and Hatch, 1996). The ability to control work pace, physical demands, generosity of sick and maternity leave, and other factors may all affect how healthy a woman is when she becomes pregnant and how much care a working woman can give her pregnancy (Brett et al., 1997; Wergeland and Strand, 1998). Effects on gestational hypertension have been associated with low-decision latitude and job complexity among women in lower-status jobs (Landsbergis and Hatch, 1996). In contrast to the United States, in some European countries (e.g., France) substantial research programs have led to equitable social policies that protect the mother and fetus from work that is detrimental to their health (DiRenzo et al., 1998). In addition to role demands of school, work, and motherhood, women are likely to be primarily responsible for housework and caregivers for a child, partner, or family member. Because there has been little progress in gender equity in household responsibilities, women, especially low-SES women, continue to be responsible for most “second shift” household work and caregiving for children
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Promoting Health: Intervention Strategies from Social and Behavioral Research FIGURE 4 Percentage of women 20–29 years of age who had a teenage birth, by respondent's mother's education and respondent's race and Hispanic origin: United States, 1995. NOTE: Education level is for the infant's maternal grandmother. SOURCE: 1995 National Survey of Family Growth (Pamuk et al., 1998). and adults in the household. Women's traditional role in caring for the home must be juggled along with other roles. Studies have shown that household work for women who have had a child can have its own measurable strains on subsequent birth outcomes (Pritchard and Teo, 1994). The issue of caregiving for children is of particular importance for low-SES women because they have fewer material resources to pay for child care, available child care is usually of poor quality (Fuller and Kagan, 2000), and they are more likely to depend on family and friends. The recent change in social policy that is moving mothers on welfare into paid employment while there is limited access to affordable, quality child care in many communities will be an important change for low-SES women and may potentially affect pregnancy outcomes (O'Campo and Rojas-Smith, 1998; Wise et al., 1999). In every major ethnic group, there is an SES gradient in the percentage of women who have had teen births (Figure 4) (Pamuk et al., 1998). Birth rates to teens are particularly high in the United States, relative to other industrialized nations, and the extent to which poorer women give birth at younger ages be-
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Promoting Health: Intervention Strategies from Social and Behavioral Research cause of lack of options in social and economic roles is of particular concern. At the same time, the demands of balancing schooling, work, and motherhood are likely to place greater strain on teenagers than on older women. Socioeconomic variations in communities and neighborhoods, independent of individual socioeconomic characteristics, are associated with differences in pregnancy outcomes. For example, living in wealthier communities than expected after adjustment for parental education and marital status has been associated with lower odds of very low-birthweight babies for both black and white women in Chicago (Collins et al., 1997). Similarly, living in neighborhoods in Chicago with large proportions of unemployment and poverty has shown greater association with individual low-birthweight outcomes than individual education, even after adjustment for other community and individual factors (Roberts, 1997). Others have shown interactions of neighborhood-level per capita crime rates, unemployment, average wealth, and income with individual low-birthweight outcomes in Baltimore (O'Campo et al., 1997). A household class measure (based on working class and non-working class characteristics of employment) at the level of census block group in California served as a better predictor of individual birth outcomes than did the mother 's own social class (Krieger, 1991). The woman's socioeconomic context may provide additional information about SES gradients not captured by individual-level factors. We have suggested that socioeconomically structured roles and material conditions, along with gender hierarchies, partially explain differential demands and resources of childbearing women. The fewer the resources —social and material—the more likely they are to be overwhelmed by demands, contributing to a socioeconomic gradient in health for mothers and their infants. Most public health policies and programs are predicated upon deficit models of the high-risk conditions and behaviors of women and families in poverty, without attention to antecedent socioeconomic structural factors and without strategies for building on the strengths and resilience of those low-SES women (Hogue and Hargraves, 1993; Edin and Lein, 1997; Stack, 1997). We turn now to ethnic disparities, which provides a further opportunity to examine the strengths of adaptation and maximization of resources as well as the negative effects of stress and deprivation. “Racial” and Ethnic Disparities Public health research has focused on the concept of race, largely believing that physical differences between groups of people are important in determining health and disease (Polednak, 1989; Osborne and Feit, 1992; Centers for Disease Control and Prevention with the National Institute of Child Health and Human Development, 1993; Bennett and Kotelchuck, 1997). The terms race and ethnicity are frequently used in public health without regard to social and cultural biases of researchers that obscure the social origins of disease and support the status quo, rather than stimulate change (Williams, 1994). In fact, race is an illdefined, socially agreed-upon mixed measure of ethnicity, skin color, and nationality, without regard to genetics and lacking in scientific rigor. There is
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