Researchers at the University of Michigan Health System, Ann Arbor, and the University of Pittsburgh found maternal opiate use had increased nearly five-fold between 2000–2009. Researchers call the increase an “epidemic,” and subsequent neonatal abstinence syndrome (NAS) and hospitalization costs saw substantial growth as well.
The study cites research from the Substance Abuse and Mental Health Administration showing just over 16% of pregnant teens and 7.4% of pregnant women aged 18–25 used illicit drugs. When those drugs were used during pregnancy, newborns experienced a higher risk of “adverse neonatal outcomes,” including low birth weights, as well as withdrawal symptoms such as respiratory and feeding problems, seizures and tremors, and increased irritability. Among those fetuses exposed to heroin or methadone, 60%–80% displayed these and other NAS characteristics.
The number of newborns experiencing NAS increased three-fold during this same period, from 1.2 to 3.39 per 1,000 hospital births annually—that’s roughly one birth every hour. Medicaid covered almost 80% of the infants and their mothers, and 36.3% lived in the lowest-income areas. Associated hospital costs for these newborns, who “experience longer, often medically complex and costly initial hospitalizations,” increased by 35%, from $39,400 to $53,400 per year. Total costs, as adjusted for inflation, grew from $190 million to $720 million.
The researchers called for increased public health measures, particularly regarding initial exposure to opiates, and considerably more research. Results of this study can be found in the Journal of the American Medical Association. It was presented at the Pediatric Academic Societies Annual Meeting in May. Visit http://jama.ama-assn.org for more information.
In the Fall 2009 issue of Minority Nurse, we published “Preventing Premature Birth Disparities,” an article written by Monique Blair, BSN, and Carol Eliadi, EdD, JD, APRN. The article examined the growing crisis of high preterm birth rates in women of color and noted that “unfortunately, there is [little] information available in the literature to explain why premature birth is so disproportionately prevalent in minority women compared to their white counterparts.”
In response, we received this letter from Ihsaan Alim, MSN, RN, MPA, who is currently a doctoral candidate in the School of Public Health at New York Medical College in Valhalla, N.Y.
“I applaud the article on preventing premature birth disparities,” he writes. “What I found most interesting and troubling is the question of why there is less than adequate information in the literature to explain high premature birth rates and other health disparities in minority women. I agree with the authors that more research into this complex and important issue is urgently needed. The consequences of premature birth are enormous: increased risk of infant death, slow cognitive development, hyperactivity, respiratory problems, obesity and heart disease. Perhaps paying greater attention to this singular health care problem will benefit a host of other minority health issues.
“Literature that I have reviewed does not always point to a direct cause-and-effect principle for premature births. Social and economic inequalities faced by racial and ethnic minorities are complex and cannot be fully captured by the simple means of a socioeconomic position, such as class or education.1, 2 As Ms. Blair and Dr. Eliadi point out, factors such as inadequate prenatal care, smoking, drinking, using illegal substances, domestic violence and short time between pregnancies can all increase a woman’s risk for preterm birth. Therefore, instead of a ‘linear’ cause and effect, I support the idea of a matrix of risk factors that contribute to disproportionate premature birth rates for minority women.
“As a nurse or other clinician, it is important to understand the intersecting factors that contribute to positive or negative health outcomes,” Alim continues. “Perhaps at the forefront of these issues is the availability of health care. According to the U.S. Census Bureau, roughly 47 million Americans do not have health insurance. Furthermore, in 2008 the Journal of Health Affairs reported that an additional 25 million Americans are underinsured. Having no or inadequate health insurance means little or no access to medical care, including preventive, diagnostic and treatment services for major health concerns.
“Other factors, such as education, family income, quality of employment and exposure to environmental hazards, all impact health. Where a patient lives is important. Neighborhood conditions, such as air and water quality and the availability of adequate housing, police/fire protection, transportation, stores, parks and libraries are also contributing factors. Employment conditions that affect health include exposure to toxic substances, heavy workloads and stress. And, of course, patients’ personal behaviors are determinants of the overall health outcome. Do your patients smoke, do they maintain a healthy diet, do they exercise, use alcohol or illegal drugs, do they have safe sexual practices? These are key questions for any health assessment.
“Our patients are more than just their own particular health issues or diagnoses,” Alim concludes. “We must recognize that our patients are totals and multiples of their community, family, lifestyle and socioeconomic backgrounds. Any one of these factors alone could be the tipping point to poor health outcomes, and the more they intersect, the more complex the picture becomes. It is important to incorporate this model into all levels of nursing—from academia and research to inpatient care and community health—so that we can better understand the causes of minority health disparities and develop better solutions.”
- Kaufman, J.S., Cooper, R.S. and McGee, D.L. (1997). “Socioeconomic Status and Health in Blacks and Whites: The Problem of Residual Confounding and the Resiliency of Race.” Epidemiology, Vol. 8, No. 6, pp. 621-628.
- Nazroo, J.Y. and Williams, D.R. (2006). “The Social Determination of Ethnic/Racial Inequalities in Health.” Social Determinants of Health, Second Edition, M. Marmot and R.G. Wilkinson (Eds.), Oxford University Press, Chapter 12, pp. 238-265.
Last issue, Minority Nurse addressed infant mortality in minority communities, discussing some of the disparities, research, and solutions surrounding the issue. This piece was submitted as a supplement to “A Quiet Crisis: Racial Disparities and Infant Mortality”
Aim for a healthy weight. Get enough folic acid in your diet. Find effective ways to manage stress. Talk to your doctor about your family history. All very important information to maintain good preconception health, but as nurses know all too well, people don’t always follow good advice. But how about when the message is coming from someone you can relate to and trust—like a peer?
The U.S. Health and Human Services Office of Minority Health’s Preconception Peer Educator (PPE) program taps into the power young people have to positively influence each other’s behavior, by enlisting and training college students to become health ambassadors. PPEs—many of them nursing, public health, and social work students—organize events at college campuses, K–12 schools, and in the wider community to educate teens and fellow 20-somethings about infant mortality and to deliver the simple message that now is the time to take care of your health…for life.
Born out of OMH’s A Healthy Baby Begins With You campaign, launched in 2007 with the aim of raising awareness about infant mortality in minority populations, who suffer some of the highest rates, the PPE program highlights preconception health as the less-emphasized factor to influence birth outcome and maternal and child health. Science shows that in communities of color, health disparities begin early in life, so PPEs serve as messengers—drawing attention to the critical link between healthy behaviors in youth and improved maternal and overall health in adulthood.
The information is important for other reasons too. While many adolescents and young adults may be a long way from thinking about starting a family, about half of pregnancies are unplanned, which makes preconception health all the more pertinent. Poor health in the early years can also lead to chronic disease later in life, and learning about the long-term payoff of preconception health is not only a way to catch problems early but to curb health disparities in communities as a whole.
The pilot program started in 2008 with Morgan State University, Spellman College, Fisk University, Meharry Medical College, and University of Pennsylvania School of Nursing. The general objective was to tackle the high rates of infant mortality in the African American community by addressing the root causes much earlier in life.
Today, around 90 schools and almost 1,000 students have participated in preconception health trainings. PPEs who have completed the program say their efforts are making a difference in young lives, and the program has grown in popularity mostly through word of mouth.
“We’ve always been taught in the black community that when you get married and decide to have kids—that’s when you should start thinking about your body,” says 20-year-old PPE Atalie Ashley-Gordon, a University of South Florida student in public health. “But I learned that we were very wrong.
“Peers make a big difference in driving this message home,” she adds, because “I’m just old enough to be influential but just young enough to be credible. That’s what makes peer education so important.”
Even though rates of Sudden Infant Death Syndrome (SIDS) in the U.S. have declined substantially in recent years, SIDS deaths are still disproportionately high among certain racial and ethnic minority populations. African American babies are more than twice as likely to die from SIDS as Caucasian babies, while American Indian and Alaska Native infants have the highest SIDS rates in the nation—2.6 times higher than in the general population.
Nurses can help reduce this tragic disparity by educating minority parents, families and communities about proven “safe sleep” techniques for decreasing SIDS risk. These include, among others, placing infants to sleep on their backs, avoiding the use of soft bedding materials, preventing babies from becoming overheated, using a pacifier and not smoking around infants. And now, a new research study from Kaiser Permanente has added another important item to that checklist: placing an electric fan in baby’s bedroom to improve air ventilation.
As reported in the October 2008 issue of the journal Archives of Pediatric & Adolescent Medicine, the study found that infants who slept in a bedroom with a fan ventilating the air had a 72% lower risk of SIDS than those who slept in a bedroom without a fan. In fact, use of a bedroom fan was found to be particularly beneficial for babies who were in a high-risk sleep environment, such as sleeping on their stomach or in an overheated room. However, the researchers warn, fan use by itself is not a substitute for safe sleep practices like placing babies on their backs; it must be used in conjunction with these other risk reduction methods, not instead of them.
The study also uncovered some evidence suggesting that improving room ventilation by opening a window may have some effect in protecting infants from SIDS, though it is not as helpful as turning on a fan. Opening a window in a baby’s room reduced the risk of SIDS by 36% compared to babies who slept in a room with closed windows, though this connection was not statistically significant. More studies need to be done to determine the exact relationship between different types of ventilation and the risks of SIDS, the researchers emphasize.
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.