Black Pregnant.2019
In 1986, the CDC established the pregnancy mortality
surveillance system to evaluate clinical issues surrounding
maternal death. At its inception the number of maternal deaths
was noted to be 7.2/100,000; in 2019, three decades later, the rate
has almost tripled-with Black women disproportionately affected,
no matter the socioeconomic status. The cause of this disparity
remains unclear. Extant studies have proposed myriad factors,
inclusive of prenatal infections, lack of prenatal care and medical
co-morbidities, during pregnancy as critical. While these internal
factors are important, what impact do external influences, such as
racism and implicit bias factor into the dismal perinatal outcomes
that are prevalent in 2019? This editorial will explore internal and
external forces impacting perinatal health for women of color.
Policy makers have known for years that racial and ethnic differences in health outcomes exist and multiple agencies like the Federal government have prioritized venues- like Health People 2010- the goal of which was the elimination of racial disparities in health outcomes. The final review of Healthy People 2010 was, while it was an ambitious endeavor, there was a significant lack of progress in reducing health disparities. What it did achieve was the development of more informative models and approaches to measuring disparities which serves as an information foundation for Healthy People 2020.
There are two words that need to be highlighted- difference and disparity- and the question becomes when does a difference become a disparity? There is little consensus on what constitutes a disparity or when a difference between two groups should be given the more charged term disparity. For some, disparity implies an inequity or an injustice, rather than a simple inequality. Determining when a difference becomes a disparity is not measured directly, but rather as a residual or a distinction between two groups, often after other factors might contribute to that difference have been statistically controlled for. Difference vs disparity is quite important when discussing the reproductive disadvantages seen among African American women in this country. Does a difference exist which compounds the disparities noted?
Despite improvements in obstetrical and neonatal care, Black infants and mothers still experience excess mortality. The mortality rate for Black infants is 2.5 x higher than for White infants. Black women have 4x higher pregnancy related mortality and 70% higher hospitalization rates for pregnancy related complications than do White women. Extreme preterm birth, fetal growth restriction and sepsis predominantly account for excess Black neonatal mortality; conversely vascular, hypertensive and infection related complications primarily account for disparity in maternal mortality and morbidity.
There are certain experiences embedded within the social context of African American women’s lives; exposure of lifelong stress, and genetic variables- but when stratified across a socioeconomic continuum-the same poor prenatal outcomes still persist. So, the question becomes are there certain pathophysiologic differences at hand accounting for outcomes?
Genitourinary, and to a lesser extent, non-genitourinary tract infections are implicated in preterm birth. Intrauterine infection seems to be the common denominator to racial disparities regarding preterm birth. Although the exact mechanism hasn’t been fully elucidated, intrauterine infection likely results from ascending lower genital tract infections preceding or shortly following conception. Most types of genitourinary infections, including sexually transmitted diseases like gonorrhea, trichomonas, and chlamydia and non-sexually transmitted infections such as Group B strep, UTI and bacterial vaginosis occur more frequently among Black women. Numerous studies have correlated vaginal infection with BV to the high incidence of preterm birth. There is a compelling body of evidence that racial differences exist in the vaginal flora or the vaginal microbiome of women. A healthy vagina has an abundance of lactobacillus species that work to ward off infectious entities by their production of hydrogen peroxide, lactic acid and bacteriocins- in addition they maintain an acidic vaginal pH. Research in this arena has noted that Black women affected by preterm labor show a shift, or an imbalance, of these helpful bacteria to a more diverse polymicrobial community. This variation allows for an overgrowth of pathogenic bacteria and a resultant change to a more alkaline pH-increasing the risk of ascending intrauterine infection resulting in preterm labor and endometritis in the postpartum period.
For More Information: https://irispublishers.com/wjgwh/fulltext/black-pregnant-2019.ID.000536.php
Policy makers have known for years that racial and ethnic differences in health outcomes exist and multiple agencies like the Federal government have prioritized venues- like Health People 2010- the goal of which was the elimination of racial disparities in health outcomes. The final review of Healthy People 2010 was, while it was an ambitious endeavor, there was a significant lack of progress in reducing health disparities. What it did achieve was the development of more informative models and approaches to measuring disparities which serves as an information foundation for Healthy People 2020.
There are two words that need to be highlighted- difference and disparity- and the question becomes when does a difference become a disparity? There is little consensus on what constitutes a disparity or when a difference between two groups should be given the more charged term disparity. For some, disparity implies an inequity or an injustice, rather than a simple inequality. Determining when a difference becomes a disparity is not measured directly, but rather as a residual or a distinction between two groups, often after other factors might contribute to that difference have been statistically controlled for. Difference vs disparity is quite important when discussing the reproductive disadvantages seen among African American women in this country. Does a difference exist which compounds the disparities noted?
Despite improvements in obstetrical and neonatal care, Black infants and mothers still experience excess mortality. The mortality rate for Black infants is 2.5 x higher than for White infants. Black women have 4x higher pregnancy related mortality and 70% higher hospitalization rates for pregnancy related complications than do White women. Extreme preterm birth, fetal growth restriction and sepsis predominantly account for excess Black neonatal mortality; conversely vascular, hypertensive and infection related complications primarily account for disparity in maternal mortality and morbidity.
There are certain experiences embedded within the social context of African American women’s lives; exposure of lifelong stress, and genetic variables- but when stratified across a socioeconomic continuum-the same poor prenatal outcomes still persist. So, the question becomes are there certain pathophysiologic differences at hand accounting for outcomes?
Genitourinary, and to a lesser extent, non-genitourinary tract infections are implicated in preterm birth. Intrauterine infection seems to be the common denominator to racial disparities regarding preterm birth. Although the exact mechanism hasn’t been fully elucidated, intrauterine infection likely results from ascending lower genital tract infections preceding or shortly following conception. Most types of genitourinary infections, including sexually transmitted diseases like gonorrhea, trichomonas, and chlamydia and non-sexually transmitted infections such as Group B strep, UTI and bacterial vaginosis occur more frequently among Black women. Numerous studies have correlated vaginal infection with BV to the high incidence of preterm birth. There is a compelling body of evidence that racial differences exist in the vaginal flora or the vaginal microbiome of women. A healthy vagina has an abundance of lactobacillus species that work to ward off infectious entities by their production of hydrogen peroxide, lactic acid and bacteriocins- in addition they maintain an acidic vaginal pH. Research in this arena has noted that Black women affected by preterm labor show a shift, or an imbalance, of these helpful bacteria to a more diverse polymicrobial community. This variation allows for an overgrowth of pathogenic bacteria and a resultant change to a more alkaline pH-increasing the risk of ascending intrauterine infection resulting in preterm labor and endometritis in the postpartum period.
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