Maternal health disparities: Economic & psychosocial hardships

during pregnancy

May 18-19, 2005Jacob’s Institute For Women’s Health

Paula Braveman, MD, MPHProfessor 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)

Poor:at or under the

poverty line33%

High income:over 400% of poverty

22%

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

0

4

8

12

16

20

24

28

% o

f w

om

en

Overall 0-100% 101-200% 201-300% 301-400% >400%% of Federal Poverty Level

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

0

4

8

12

16

20

24

Afr Amer API - US API - notUS

EuroAmer

Latina US Latina notUS

AmerIndian

% o

f w

om

en

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

0

2

4

6

8

10

12

14

16

18

20

% o

f w

om

en

Overall 0-100% 101-200% 201-300% 301-400% >400%

% of Federal Poverty Level

Separated or divorced: racial/ethnic disparities (2003 only, n=3,728)

0

2

4

6

8

10

12

14

16

18

Afr Amer API - US API - notUS

EuroAmer

Latina US Latina notUS

AmerIndian

% o

f w

om

en

Partner lost his job: disparities by income (2003 only, n=3,728)

0

2

4

6

8

10

12

14

16

18

20

% o

f w

om

en

Overall 0-100% 101-200% 201-300% 301-400% >400%

% of Federal Poverty Level

Partner lost his job: racial/ethnic disparities (2003 only, n=3,728)

0

2

4

6

8

10

12

14

16

18

20

22

Afr Amer API - US API - notUS

EuroAmer

Latina US Latina notUS

AmerIndian

% o

f w

om

en

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

0

2

4

6

8

10

12

14

16

18

20

% o

f w

om

en

Overall 0-100% 101-200% 201-300% 301-400% >400%

% of Federal Poverty Level

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

0

2

4

6

8

10

12

14

Afr Amer API - US API - notUS

EuroAmer

Latina US Latina notUS

AmerIndian

% o

f w

om

en

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

0

4

8

12

16

20

24

28

32

36

40

% o

f w

om

en

Overall 0-100% 101-200% 201-300% 301-400% >400%% of Federal Poverty Level

Food insecurity: racial/ethnic disparities,2002-2003

0

4

8

12

16

20

24

28

32

Afr Amer API - US API - notUS

EuroAmer

Latina US Latina notUS

AmerIndian

% o

f w

om

en

Total Number of Hardships* Women Had During Pregnancy: by Income, MIHA 2003

0102030405060708090

100

Family income as a % of federal poverty level

% o

f p

reg

nan

t w

om

en

Five or more

Four

Three

Two

One

*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

0

20

40

60

80

100

% o

f p

reg

nan

t w

om

en Five or more

Four

Three

Two

One

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.

3 4 3 4

Race/Ethnicity

2

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