Maternal health outcomes differ significantly between racial groups within the United States. The American College of Obstetricians and Gynecologists describes these disparities in obstetric outcomes as "prevalent and persistent." Black, indigenous, and people of color are disproportionately affected by many of the maternal health outcomes listed as national objectives in the U.S. Department of Health and Human Services's national health objectives program, Healthy People 2030. The American Public Health Association considers maternal mortality to be a human rights issue, also noting the disparate rates of Black maternal death. Race affects maternal health throughout the pregnancy continuum, beginning prior to conception and continuing through pregnancy (antepartum), during labor and childbirth (intrapartum), and after birth (postpartum). There are multiple explanations for racial disparities in maternal health. Biological factors, such as higher rates of preexisting chronic disease prior to pregnancy, fail to fully account for differences in outcomes. There is a lack of evidence to support a genetic difference between racial groups as a cause of maternal health disparities such as preterm birth. Social factors, such as structural racism, have been suggested as a contributory cause of the wide racial disparities in maternal health in the United States. Experiences of racism and discrimination may also contribute to hypertension indirectly through stress on the pregnant individual. Disparities in adverse pregnancy outcomes for Black women have been hypothesized to be related to higher loads of allostatic stress before and during pregnancy, epigenetic changes, and/or telomere shortening. Studies of potential biomarkers of allostatic stress have failed to date to demonstrate the racial group differences seen with self-report measures. Inequities in access and the provision of health care may also effect maternal outcomes. The effects of implicit and explicit provider bias in obstetrical care has been poorly studied and may contribute to disparate outcomes. The information health care providers share and how that information is presented affects the autonomy and decision-making of birthing women. Proposed interventions to reduce racial disparities in maternal health outcomes target changes at individual, health care system, and health care policy levels. Some states are utilizing federal block grant money for initiatives targeting reductions in maternal morbidity and mortality for Black and Hispanic women. Efforts have been made to address racial inequalities for birthing women by providing continuing education for healthcare providers. Measurement, methodological, and ethical issues arise when using race in health outcomes research. Recommendations for appropriate use of race as a research variable may limit use of white normative standards in the future, which can imply non-white people as being atypical. Proposed alternative variables for race may be genetic ancestry, socioeconomic factors, or differential opportunities.
Preconception
Unintended pregnancy Overall, approximately 50% of pregnancies in the United States are unplanned, however Black and Hispanic women are more likely to have unplanned pregnancy than white women. Unintended pregnancies are associated with increased risk of delayed entry into prenatal care, decreased rates of breastfeeding after birth, increased risk of maternal depression, and increased risk of domestic abuse. The cost of unintended pregnancy in the United States exceeded $20 billion in 2010.
Social determinants of health
Environment While limited research is available about the reproductive system effects of environmental pollutants, evidence from animal models indicates risks to humans. Black families are more likely to live in neighborhoods with poorer air quality and higher rates of heavy metal contaminants. Air pollution has been associated with increased risk of preterm birth. Heavy metals such as lead and mercury are known neurotoxins and the developing fetal nervous system may be particularly vulnerable to excessive levels. Exposure to organic pollutants prior to conception is linked to lower birth weight in infants. One study of pesticide use in New York found the highest rate of exposure in Black women; pesticide exposure in pregnancy is associated with low birth weight and smaller head circumference. The correlation between pesticide and pollutants on fetal growth restriction seen in Black women in New York City was not demonstrated among Dominican women living in the same neighborhoods, suggesting there may be a cultural modifier.
Economic status Strategies to improve pregnancy outcomes through behavioral interventions like folic acid supplementation and smoking cessation may be too little too late, as many women enter prenatal care several weeks into sensitive fetal development. Optimizing preconception health is recommended by several professional organizations to optimize maternal health prior to pregnancy, particularly for women with chronic diseases. Low income women, however, are less likely to have access to preconception and preventive health care. In general, financial disadvantages heavily impact an expecting mother’s risk for adverse outcomes at birth. Racial disparities in poverty adversely effect Black and Hispanic families.
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