The overwhelming majority of babies in the U.S. are born healthy, and their growth brings joy and comfort to their parents.
But across the country, there is a whopping disparity in birth outcomes based on race. Black women fare worse than white women in almost every aspect of reproductive health.
“Any state you look at, you see the same disparities, and race is the strongest predictor of disparities,” says Dr. Deborah Ehrenthal, of Christiana Care Health System in Delaware. “So we see higher rates of infant mortality, higher rates of preterm delivery.” Black women are about 60 percent more likely than white women to deliver babies early, and black infants are about 230 percent more likely than white infants to die before their first birthdays.
In the Neonatal Intensive Care Unit at Christiana Hospital, a corridor is filled with the hum of incubators, which serve as a lifeline for fragile newborns.
Along with the large staff – including more than 100 nurses – you can’t help but notice the parents in the NICU, hovering over incubators, rocking quietly in chairs.
Tiera Carter was visiting the NICU for the first time since giving birth to her 1-day-old son. His name is David, and he weighs less than 2 pounds.
“His chances are pretty good of him gaining weight and getting better, right?” she asks Dr. David Paul, a neonatologist.
“It’s going to take him a while,” he says. “It’s going to be two to three weeks until we see him gain weight.”
Fragile lives. Fingers crossed.
‘Enormous Stressors’ Take A Toll On Black Women
The emotional toll is quite evident here, and so too is the cost of preterm birth.
In addition to seeing patients, Paul also heads up the Delaware Healthy Mother and Infant Consortium, which brings together public health officials, physicians and others in an effort to address health disparities.
Paul says the overall tab for premature births in Delaware runs as high as $80 million a year. More than half of that is paid for by Medicaid. And he says many of those premature births are due to pre-existing factors in the mothers’ lives – factors he encounters every day in the NICU.
“We see so many of the same risk factors over and over again,” he says. “Hypertension, obesity, smoking, diabetes, lack of antenatal care, drug use, alcohol use, poor maternal health.”
And in Delaware, as in other states, there is something counterintuitive going on with the race gap in birth outcomes. The gap does not narrow with age and educational attainment. In other words, white women’s health outcomes improve as they climb the socioeconomic ladder and give birth in their 20s and early 30s, rather than in their teen years. Not so for black women, whose health problems seem to compound with age.
So what explains that? Arline Geronimus, a professor at the University of Michigan School of Public Health, calls this phenomenon “weathering.” She theorizes that the cumulative impact of constantly dealing with disadvantages causes birth outcomes for black women to deteriorate with maternal age.
“Women in particular, especially in low-income communities, have enormous stressors they’re coping with,” she says. “They’re usually centrally responsible for raising children, taking care of ailing elders, working, earning money, dealing with material hardship.”
And it’s not just hardships associated with poverty. Geronimus says that for middle- and upper-class blacks, the pressure to be model minorities – or sometimes being the only minority – can also take a toll.
When Geronimus began talking about her weathering theory more than 20 years ago, she was widely pilloried. Some called her racist; others wanted her fired.
But in the years since, there’s been growing acceptance of her view that constant stress does lead to the deterioration of bodily systems: the cardiovascular system, the metabolic system and the immune system.
“This weathering process that eats at your health begins quite young. Its impact is seen as early as the 20s,” she says.
In fact, studies have found that African-American women of childbearing age in particular, in their 20s and early 30s, already suffer from chronic disease.
“In those ages, they’re suffering from hypertension at two or three times the rate of whites their own age,” she says. “African-Americans at age 35 have the rates of disability of white Americans who are 55, and we haven’t seen much traction over 20 to 30 years of trying to reduce and eliminate these disparities.”
“We’re not understanding what a broader social problem it is,” she adds, “and how much social policies, housing policies, economic policies, urban planning policies all impact health through these various roots and mechanisms.”
Doing Their Best, With Limited Funds
Back in Delaware, neonatologist David Paul agrees that addressing broader social issues would solve problems before patients land in the NICU. But he says that at the moment, there’s not enough research to convince those holding the purse strings that such a strategy would work.
“I think if we had data to show that, yeah, if we build more sidewalks, if we build more soccer fields, if we put more money into physical education at school, we’ll improve those outcomes later on, we’d be able to go to the legislators and have a lot more power to say, let’s put money upfront.”
For now, they are doing what they can, with limited funds.
One floor down from the NICU, Dr. Vanita Jain puts a fetal heart rate monitor to Dana Thurn’s big belly. Ideally, the public health system would have reached Thurn much earlier – long before she became obese, long before her gastric bypass surgery, long before she began suffering from depression.
But in Delaware, the thinking is, nine months of pregnancy is an ideal time to reach women they may not otherwise reach.
Thurn is one of more than 10,000 women enrolled in the state’s Healthy Women, Healthy Babies program, which provides women with extra resources beyond standard medical care. So, when she comes in for a traditional OB-GYN visit, she also meets with dietitian Maureen O’Brien, who goes over which foods to eat and which to avoid.
Thurn will also hear from breast-feeding counselors and social worker Karen Spring, who screens for depression and also helps families find resources, such as food pantries or job placement agencies. She’ll also help women enroll in WIC – the government’s Special Supplemental Nutrition Program for Women, Infants and Children.
In Delaware, the good news is that preterm births are down. The state’s infant mortality rate has also dropped – by about 10 percent since the early 2000s. However, it’s still higher than the national average.
Since 2006, the state has spent about $4 million a year on an assortment of programs aimed at eliminating stress, promoting healthier living and improving birth outcomes.
Is $4 million is adequate? “It’s been enough to make a difference in Delaware,” says Paul. “It’s not enough to eliminate the problem.”
And so for the foreseeable future, Paul will have additional duties – doing rounds with his patients at the NICU, and also convincing those in power that spending money upfront is an investment that could save millions in the long run.