Tuesday, November 1, 2011

March of Dimes Preterm Birth Scorecard and Racial Disparities

The March of Dimes has released an interactive scorecard for the latest U.S. premature birth statistics.

The good news is that we're moving in the right direction, receiving a C for a premature birth rate of 12.2%, which is better than the D we'd previously received (the premature birth rate for 2006 was 12.8%). The bad news is we're still pretty far away from the 2020 goal of 9.6% and 1 in 8 babies are still being born too soon.

The even worse news is that the U.S. is a big place and that can skew the data. While we received a C overall, three states (Louisiana, Mississippi, and Alabama) and Puerto Rico all received F's. Only one state (Vermont) received an A.

The March of Dimes identifies three contributing factors that are also analyzed for each state: uninsured women, women who smoke, and late preterm births.

Late preterm births are defined as births between 34 and 36 weeks (preterm birth is defined as a birth before 37 weeks, but studies have shown that even babies born at 38 or 39 weeks have higher risks than those born at 40). This number is particularly important because it's where the March of Dimes focused a lot of attention, calling "on hospitals and health care professionals to establish quality improvement programs that ensure consistency with professional guidelines regarding c-sections and inductions prior to 39 weeks gestation."

The overall rates for these three factors: 
  • Slight increase in uninsured women- 20.7% to 20.8%
  • Decrease in women smoking- 19.6% to 17.6%
  • Slight decrease in late preterm birth- 8.8% to 8.7%

Digging a little deeper into the March of Dimes results, this is what we find for the states that failed:

The premature birth rate here held steady at 18%. In the analysis of contributing factors, the number of who are smoking and are uninsured both rose. The number of late preterm births dropped slightly (from 12.9 to 12.6%).

The premature birth rate here remained virtually unchanged at 15.6%. Again, the number of uninsured women rose (though smoking dropped!) The rate of late preterm births remained the same (10.7%).

The premature birth rate here dropped from 15.4% to 14.7%. The number of uninsured women rose slightly and the number of smoking and late preterm births (10.2%) dropped.

I can't help but notice that the three states who failed are also three states with very high African American populations. In fact, Mississippi and Louisiana are the number one and two states for highest percentage of African American population, respectively. Alabama comes in at number 6.

This data from the Kaiser Family Foundation demonstrates that preterm birth rates are higher (in some cases, a lot higher) among non-Hispanic blacks than among non-Hispanic whites or Hispanics. In Mississippi, the rates look like this: blacks 22.3%, whites 14.8%, Hispanics 12.8%. In Louisiana: blacks 20%, whites 12.4%, Hispanics 12.8%. In Alabama: blacks 20.5%, whites 13.6%, Hispanics 14.2%.

Since we know that income disparity is certainly exacerbated among racial lines, and since the March of Dimes connects health insurance to premature birth rates, I first thought that might have something to do with it.

However, that doesn't seem to be the case. Ziba Kashef's article from ColorLines explains "Research has debunked the notion that socioeconomic status and related factors are the source of the problem." Kashef's articles and others (like this one by Mark Johnson) suggests that the disparity may be attributed to stress and that stress may be attributed to racism on the societal level.

I commend the March of Dimes efforts to reduce premature birth rates. I am also interested in the three factors they're singling out to examine because they represent different types of impacts: personal, societal, and a combination of the two.

Smoking represents a wholly personal decision (granted, one that can be affected by social mores, marketing, and addiction). Whether or not a woman smokes is influenced by society, but it is a choice that woman makes for herself.

Insurance is a combination of societal and personal factors. Economic status and employment go a long way toward determining access to health insurance, and those factors aren't always controllable on an individual level. However, some individuals who have access to insurance make a choice not to use it.

Late preterm births are, as the March of Dimes points out in their campaign, largely determined by societal factors. A medical culture that is quick to induce and opts for elective c-sections is one that goes far beyond individual choices. While a woman may make these individual choices for herself, she only does so as part of a medical community that allows (and even encourages) those options. This is definitely a place where a top-down approach can be effective.

However, none of these factors looks at the complicated relationship between black women and preterm births. If researchers like Kashef and Johnson are right and racism is a direct contributor to preterm births among black women, reducing the preterm birth rate in the U.S. is much, much more complicated. In addition to looking at factors of individual choice, medical practices, and economic factors, we must also look at the way our very culture creates hostile environments through prejudices and negativity.

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