Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution C: Preconception, Prenatal, Perinatal, and Postnatal Influences on Health
Paper Contribution C: Preconception, Prenatal, Perinatal, and Postnatal Influences on Health
Pages 125-169
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From page 125... ...
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~.
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From page 126... ...
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.
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From page 127... ...
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~.
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From page 128... ...
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.
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129 Ct .s no o a' o .
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From page 130... ...
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~.
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From page 131... ...
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~.
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From page 132... ...
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~.
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From page 133... ...
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~.
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From page 134... ...
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)
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From page 135... ...
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 Felt, 1992, Centers for Disease Control and Prevention with the National Institute of Child Health and Human Development, 1993, Bennett and Kotelchuck, 1997~.
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From page 136... ...
Low-birthweight, while a poor indicator of the impact of prenatal care, is still a robust indicator of sociodemographic characteristics of different populations. There is a marked socioeconomic gradient in lowbirthweight for white and black ethnic groups, but there is no gradient for Latino and Asian American or Pacific Islanders (Figure 5~.
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From page 137... ...
While African Americans are disproportionately represented in lower socioeconomic groups, not all of the differential in birth outcomes for African Americans is explained by SES (Starfield et al., 1991, Williams and Collins, 1995, Roberts, 1997~. One potential explanation for the disparity is that education does not have the same social or economic returns (salary, benefits, or occupational status)
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From page 138... ...
Using evidence from black/white neonatal mortality ratios that increase with age of the mother, the theory helps to explain ethnic disparities in health at birth by showing that black and white women "weather" at different rates (Geronimus, 1986, 1987~. This occurs because different life circumstances undermine or promote health through a cascade of advantages and disadvantages throughout the life course.
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From page 139... ...
Data from the most segregated metropolitan areas show that a high black infant mortality rate persisted from 1980 to 1990, contributing substantially to the black/white disparity in overall mortality (Polednak, 1996~. Besides residential segregation, other community features are associated with health disparities.
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From page 140... ...
Latinos and Asian Americans or Pacific Islanders As with African American women born outside the United States, foreignborn Latina and Asian American or Pacific Islander women have better birth outcomes than those of their U.S.-born peers (Table 2~. One potential reason is because of the healthy migrant or nativity effect described above.
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From page 141... ...
Similarly, Mexican Americans had fewer years of education than Puerto Ricans or Cubans, but better birthweight outcomes. When adjusted for sociodemographic factors including education, there remain systematic ethnic differences in odds of lowbirthweight and preterm birth, increasing from Chinese to Japanese and Filipino groups, and with the odds highest among the U.S.-born (Singh and Yu, 1996b)
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143 ~ ~ oo r~ .
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From page 144... ...
(Cohen et al., 1997~. While studies have not yet documented SES gradients in stress and adaptation, and are only beginning to investigate ethnic differences in stress and adaptation, there is growing evidence that these factors are associated with reproductive health and pregnancy outcomes, and need to be better understood (Hogue, 1999~.
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From page 145... ...
African American women who had more respect for themselves, believed they did things the same as most people, and had more people in their social networks all had higher-weight babies, and term delivery was associated with positive self-attitude (Edwards et al., 1994~. Among African American women, social support, life events the year prior to
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From page 146... ...
Nearly all have been with poor women, several with Latinas, and one with African American women. Beneficial effects on birthweight have been documented for social support, but not as a buffer to high levels of stress.
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From page 147... ...
there is no reliable effect of psychosocial support services during pregnancy in clinical encounters. POLICY AND PROGRAM STRATEGIES Since reducing infant mortality in the United States became a prime public health policy goal in the mid-1980s, the evidence that any of the policy or program changes have lead to measurable improvements in the health of infants at birth is modest at best.
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From page 148... ...
Studies evaluating the impact of Medicaid improvements found variable effects on prenatal care use and little impact on pregnancy outcomes (Piper et al., 1990, 1994a, 1994b, California Department of Health Services, 1996, Haas et al., 1996, Epstein and Newhouse, 1998~. Nationwide, vital statistics revealed that the early and continuous use of prenatal care improved, without associated impact on birth outcomes (Figures 1-3~.
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From page 149... ...
during pregnancy have better birthweight and infant mortality rates than women who do not, even after adjustment for a number of characteristics to reduce selection bias (Stockbauer, 1987, Moss and Carver, 1998~. Psychosocial Services for Low-Income Women Enhanced prenatal care services that include nutrition, psychosocial, and health education services along with obstetric care have developed in the public health sector of the nation's health care system largely through the efforts of the Bureau of Maternal and Child Health in HRSA.
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From page 150... ...
The program was started in 1990 to assist communities with high infant mortality rates in developing innovative, multidimensional community approaches to reducing infant mortality. Community-level consortia at most sites developed collaborative partnerships of local and state agencies, the private sector, schools, and other community and social organizations, sharing people and resources in the efforts.
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From page 151... ...
The Aiken County experience, like that of some Healthy Start and other FIMR projects, is illustrative of case studies that lead to theories of community interventions that develop multilevel and multidimensional policies and strategies over time, involving community partnerships that potentially could begin to reverse disparities in health at birth. Reducing Ethnic Health Disparities at Birth National public health interventions addressing the reduction in ethnic disparities in maternal and infant health have been developed largely as research demonstration projects, rather than government policy or program initiatives.
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From page 152... ...
, together with the National Institutes of Health (NIH) , held a conference to announce research demonstration projects to determine what could be done to reduce the ethnic disparities in preterm birth rates for black and white women (Centers for Disease Control and Prevention with the National Institute of Child Health and Human Development, 1993~.
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From page 153... ...
The analyses contrast the expectations of public health professionals with the life experiences of African American women with regards to pregnancy and prenatal care. The findings illustrate the gap in mutual understanding to be closed before there can be effective behavior change on the parts of both professionals and women participants.
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From page 154... ...
We have much to learn about how stress, depression, and social support, which are shaped by social class, racism, and gender roles
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From page 155... ...
The reigning paradigms of different disciplines shape the research questions that are asked and identify research issues that are often neglected outside disciplinary boundaries. The concepts and data relevant to pregnancy outcomes and infant mortality require a scrutiny of values and expansion of meaning systems as they relate to class, gender, ethnicity, and other forms of social differentiation, as well as psychological stress and adaptation in different sociocultural and sociopolitical settings.
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From page 156... ...
The vast majority of babies are healthy, the challenge to public health research is whether it can move from a focus on risk toward a better understanding of resources and resilience. Documenting Causal Mechanisms Additional work is needed on the concepts and measures that are used to track socioeconomic effects on pregnancy outcomes.
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From page 157... ...
There were unexpectedly low rates of low-birthweight, for example, in some samples of African American and Mexican American women that raise issues about participation bias among cautious respondents. To have more women participate will take greater efforts to build trust in research.
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(19954. The role of prenatal care in preventing low birth weight.
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(1991~. Randomized controlled trial of antenatal social support to prevent preterm birth.
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American Journal of Public Health, 86, 394396. The Cochrane Collaboration.
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American Journal of Public Health, 76, 14161421. Geronimus, A
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American Journal of the Diseases of Children, 145, 194-199. Kogan, M
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American Journal of Preventive Medicine, 9, 82-122. Krieger, N
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(1990~. Factors associated with smoking in low-income pregnant women: Relationship to birth weight, stressful life events, social support, health behaviors and mental distress.
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urban black infant mortality, by degree of residential segregation. American Journal of Public Health, 86, 723-726.
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(1994~. Pregnancy outcomes among Asian Americans.
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American Journal of Public Health, 84, 1444-1449. Smith, P
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From page 168... ...
American Journal of Public Health, 84, 1511-1514. Wilkinson, D
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From page 169... ...
, Maternal and Child Health: Programs, Problems and Policy and Public Health (pp.
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