Improved Prenatal Care Could Reduce Racial Disparity in Infant Mortality
Courtroom Mama, writing at The Unnecesarean has issued a long-overdue challenge to the birth advocacy community to take off our “birth blinders” and see the infant mortality crisis in the United States for what it is: one of the most shameful examples of health disparities in our country. Reflecting onCrisis in the Crib, a documentary released last year by The Office of Minority Health, she writes,
I care so much about unnecessary interventions and evidence-based care that it's tempting to look at our flagging position in rank for maternal and infant health and say, “see! It's the unnecesareans and the pitocin and the EFM!” But the truth, as the documentary shows, is more complicated... we live in a nation where the legacy of slavery and segregation is a permanent invisible underclass.
She's right, and the statistics are astounding:
One in six black babies are born preterm, and one in 25 are born very preterm (before 32 weeks).
In 2004, 4.1% of black infants were born very preterm, compared to 1.8% of Hispanic infants, 1.6% of white infants, 2.2% of Native American infants and 1.5% of Asian infants. Very preterm infants face the highest risk for death and serious lifelong disabilities.
The theory that has emerged to explain disparities in preterm birth states that factors such as intergenerational poverty, racism, and social isolation cause chronic stress that triggers changes in women's immune and vascular systems, making them more vulnerable to having a baby that is born too soon and too small. When the problem runs this deep, is it any wonder that essentially nothing that doctors and midwives do to women -- whether it's medications, bed rest, ultrasounds, or fetal fibronectin tests -- has any meaningful impact on preterm birth rates? With no effective tools in their toolbox, maternity care providers work in vain to prevent babies from filling up costly, high-tech neonatal intensive care units, fighting for their lives.
But what if we changed the tools and the toolbox? Maybe prenatal care -- totally reimagined, could help women counteract or manage the stress and prevent its devastating physiological, emotional, and behavioral effects.
It turns out it can. CenteringPregnancy is the first innovation in prenatal care in approximately 100 years. This redesign brings women out of the exam room into a group setting where they receive basic prenatal checkups, build community with other women, and gain knowledge and skills in pregnancy, childbirth and parenting. Two healthcare providers facilitate groups of 8-12 women of similar gestational ages. Instead of short visits alone with a provider, CenteringPregnancy has ten 120-minute sessions from about week 14 of pregnancy through one-month postpartum. That is, 20 hours of prenatal care across pregnancy, compared to about 2 hours -- at no additional cost.
A large, multi-center randomized controlled trial documented a 33 percent reduction in preterm birth for women in Centering groups conducted in two public clinics. The benefit was pronounced among African American women, who experienced a 41 percent reduction in preterm birth (10 percent vs. 16 percent). Other outcomes include improvement in breastfeeding rates, satisfaction with care, return for postpartum visits, and pregnancy spacing.
Many of us who come to birth advocacy through positive, empowering experiences, treasure the prenatal care we received. For those of us who had home births, hour-long (or longer) appointments are the norm, and it's time spent forming meaningful relationships based on mutual trust and shared responsibility with our midwives. My own midwives for my first pregnancy spent time to help me problem-solve and plan so I could improve my nutrition, avoid overexhaustion at work, and prepare for birth and motherhood. They checked in with me often to make sure I had adequate support from my partner, my family, and my community. I could ask questions not just about my back soreness or fatigue, but the big questions like “What do people mean when they say having a baby changes everything?” and “How will I be able to go back to work and still nurse and mother my child the way I want to?” and my midwives shared their wisdom from their own journeys as mothers and from the thousands of families they collectively had cared for before me. I made informed decisions with their guidance, and I entered labor feeling confident in my body, my choices, and my care providers.
THIS is how prenatal care should be. Right? Well, not necessarily. Unless and until there is a major upheaval in healthcare financing and staffing patterns, having this kind of prenatal care is a privilege. And I don't mean privilege like “I'm so lucky.” I mean privilege in the sense that I can't have that kind of care unless others are deprived of it.
If everyone woke up tomorrow and realized that they deserved to have every question answered, every fear and concern explored, every test/procedure/diagnosis explained, we would quickly run out of midwives to provide that care. That is, if our solution was to provide one-to-one care on the traditional prenatal schedule. In short, that kind of prenatal care, however great it is, is not scalable to levels that could benefit all women and babies.
The Centering model of prenatal care has been implemented in more than 300 sites throughout the U.S., Canada and other countries and is highly replicable. A hospital or provider practice that decides today to start Centering could be enrolling women in their first groups in just a matter of months. It is appropriate for all prenatal populations -- whether teens, military, community health centers, private practices, Indian Health Services and so on. It has also been adapted to provide well-woman and well-baby care throughout the baby's first year of life, a stark contrast to the traditional fragmented mother-baby care that drops women's wellbeing out of the picture after the 6-week postpartum visit. (A randomized controlled trial of this adaptation is in progress.)
If the birth advocacy community is serious about making childbearing safe, healthy, transformative, and joyful, and connecting mothers in a network of supporting community, we need to broaden our view of what constitutes optimal care. Yes, there are critical problems with how labor and birth are “managed” in this country, and we need to continue to work on that front. But how can we justify not fighting for the widespread implementation of programs that are proven to avert preterm births and close the gap between blacks and whites?
Thank you, Courtroom Mama, for pushing us all out of our comfort zones a little to talk about the bigger reality about birth in this country. I want to issue a challenge to my fellow birth advocates to look at the models of prenatal care, not just birth care, and rally behind those that are effective and empowering.