Preventing Premature Birth Disparities
According to the March of Dimes, in 2003-2005 an average of 10,056 babies a week were born prematurely in the United States—i.e., before 37 completed weeks of gestation. Of these preterm infants, 1,604 were very preterm (born before 32 weeks gestation); 6,511 had a low birth weight (2,500 grams or less) and 1,188 had a very low birth weight (1,500 grams or less). African American infants had the highest rates of preterm birth (18.1%), followed by Native Americans (13.8%), Hispanics (12%), non-Hispanic whites (11%) and Asian Americans (10.5%).1
By 2006 the nation’s overall premature birth rate had risen to 12.8%, a 36% increase. In particular, there was an increase in preterm births to Hispanic women, while rates for non-Hispanic whites and blacks were relatively unchanged. However, black women continue to have the highest preterm birth rate at 18.5%. Of even more concern is the “very preterm” rate for blacks. Nearly 4% of black babies are born at less than 32 weeks of pregnancy—almost two-and-a-half times the rate for white infants.2 Dr. Jennifer L. Howse, president of the March of Dimes, has stated that “the health consequences for babies who survive an early birth can be devastating, and we know that preterm birth exacts a toll on the entire family—emotionally and financially.” Babies who are born prematurely are at high risk for serious lifelong health problems, such as learning disabilities, cerebral palsy, blindness, hearing loss and asthma. Even late preterm infants (those born at 34-36 weeks of gestation) have a greater risk of breathing problems, feeding difficulties, hypothermia, jaundice and delayed brain development.1
Premature birth is also the leading cause of death in newborns. Babies who died from preterm-related causes accounted for 36.5% of infant deaths in 2005, up from 34.6% in 2000, the March of Dimes reports. Mortality rates for infants born even a few weeks early were three times higher than those for full-term infants.
“Essentially, there has been no improvement in the infant death rate since 2000, and the increase in the proportion of infants who die from preterm-related causes is troubling,” says Joann Petrini, PhD, director of the March of Dimes’ Perinatal Data Center. “Preventing preterm birth is crucial to reducing the nation’s infant mortality rate and giving every baby a healthy start in life.”
As for the economic impact, in 2005 preterm birth cost the nation more than $26.2 billion in medical care, educational costs and lost productivity. Average first-year medical costs were about 10 times greater for preterm than for full-term infants.
On November 12, 2008, after comparing preterm birth rates for each state to the National Healthy People 2010 goal of 7.6%,3 the March of Dimes issued its first-ever Premature Birth Report Card. The nation as a whole received a grade of “D.” Of the 50 states, not even one received an “A.” Vermont was the only state to earn a “B,” eight states received a “C,” 23 states got a “D” and 18 states plus Puerto Rico and the District of Columbia received a grade of “F.”1
These grim statistics underscore an urgent need for a sustained, comprehensive plan to address this growing crisis. “It is unacceptable that our nation is failing so many preterm babies,” says Howse. “[The March of Dimes is] determined to find and implement solutions to prevent preterm birth, based on research, best clinical practices and improved education for [pregnant women].”
Why the Disparities?
While any pregnant woman can be at risk for preterm delivery, researchers have identified several factors that may increase the risk for some women. Women at the greatest risk for having a premature baby include those with a previous history of preterm birth, those carrying twins or multiples and those with certain abnormalities of the cervix.
Some researchers have explored a possible connection between the general increase in premature births and the increase in cesarean deliveries. The March of Dimes’ analysis suggests that the growing reliance on C-sections and induced labor has contributed to the problem of rising preterm delivery rates. Between 1996 and 2004 there was an increase of nearly 60,000 singleton births (i.e. a single baby, rather than one of a set of multiples) and 92% of those infants were delivered by cesarean section. While singleton births increased by about 10% during this period, the C-section rate for this group increased by 36%.
The March of Dimes report notes that C-sections have become the most common major surgical procedure for women, adding that “more than 30% of the 4.1 million U.S. live births are delivered via C-section and the rate has increased dramatically since 1996.”1 The concern is that many of these babies are being delivered by C-section without medical justification, depriving the infant of vital gestational time.
Unfortunately, there is far less information available in the literature to explain why premature birth is so disproportionately prevalent in minority women compared to their white counterparts. It is imperative that more research be undertaken to help health care providers recognize and address factors that put women of color and their babies at greater risk for preterm birth.
Various studies to date have shed light on some possible factors that may contribute to these disparities. The Institute of Medicine reported in 2002 that inequities in health care treatment account for some of the gaps in health outcomes between minorities and the majority population. The IOM report found that Americans of color tend to receive lower-quality health care than white Americans, regardless of insurance status, income and severity of the condition.4
There are also certain lifestyle factors that place a woman at greater risk for preterm birth, such as late or no prenatal care, smoking, drinking alcohol, using illegal substances, domestic violence, lack of social support, extremely high levels of stress, long working hours with long periods of standing, and short time between pregnancies (less than six to nine months between birth and the next pregnancy). According to the March of Dimes, some medical conditions during pregnancy may increase the likelihood that a woman will have premature labor—e.g., infections, high blood pressure, diabetes, clotting disorders and being under- or overweight prior to pregnancy. While all of these factors could apply to any woman of any race or ethnicity, some of them—such as obesity, diabetes, hypertension and intimate partner violence—occur in disproportionately high rates among women of color.
Still other studies have found that where minority women live may have an effect on their risk for preterm delivery. One study suggests that “since over 40% of black childbearing women live in hypersegregated areas, residential segregation may be an important social determinant of racial birth disparities.”5 Another study concludes that “women living in socioeconomically deprived areas are at increased risk of preterm birth, above other underlying risk factors. Although the increase is modest, it affects a large number of pregnancies.”6
The results of these studies suggest there is indeed a relationship between environment and premature delivery. Knowing where preterm birth disparities are the greatest provides the opportunity to design and implement effective interventions where they are needed the most.
What Nurses Can Do
As nursing professionals, there is a great deal we can do to help women of color increase their chances of giving birth to healthy, full-term infants. Nursing is a well-respected and trusted profession. Nurses have a strong voice and we can use it to call for public policies that address these health disparities. We must become more involved with this issue and make our voices heard.
Public health nurses can assess communities of color and advocate for badly needed resources. They can also coordinate activities to educate minority women of childbearing age about topics that affect their health and the health of their unborn children. One recent study concluded that prenatal home visits by case management nurses seemed to provide some protection against preterm delivery in black women and could contribute to reducing racial disparities in infant mortality.7
Nurses must become familiar with the March of Dimes’ recommendations for reducing the risk of premature birth. These include encouraging pregnant women to:
- have regular and early prenatal care;
- reduce their stress levels; and
- avoid alcohol, smoking and illicit drugs.
Increasing folic acid intake is also recommended to prevent certain fetal anomalies as well as preterm birth.
Nurses who care for pregnant women can encourage and support them in their efforts to stop using drugs or alcohol. We can assess and encourage an expectant mother who is stressed and direct her to available resources. We can advocate for a pregnant woman who shows signs of domestic abuse and inform her of available options to help protect her and her baby.
Nurses can also make a difference by educating pregnant women early on about the warning signs of premature labor. If the labor is detected in time, there are medical interventions that may stop or slow it and provide opportunities for better outcomes. By providing this much-needed education, nurses can not only inform but also advocate for and empower the patient.
The March of Dimes offers many resources, in English and Spanish, for both pregnant women and health care professionals. For more information about what you can do to help prevent premature birth disparities, visit www.marchofdimes.com.