Back to Maternal and Infant Health

The Social Context of Pregnancy for African-American Women

Source: Maternal and Child Health Journal, 5(2) 67–140 (2001).
http://www.kluweronline.com/issn/1092-7875/contents*

Foreword: The Social Context of Pregnancy for African American Women: Implications for the Study and Prevention of Adverse Perinatal Outcomes
Vijaya K. Hogan, Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Cynthia D. Ferré, Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia

Prologue: Closing the Gap, Opening the Process: Why Study Social Contributors to Preterm Delivery Among Black Women
Diane L. Rowley, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia

In the United States, the excess rates of infant mortality, VLBW, and preterm delivery among African American families relative to white families are known as “the gap.” A group of researchers in the Division of Reproductive Health at the Centers for Disease Control and Prevention proposed that the study of causes of the gap in preterm delivery and the potential interventions to eliminate this disparity required a multidisciplinary approach to elucidate the biologic pathways, stressors, and social environment associated with preterm birth. They encouraged studies that examined the social and political impact of being an African American woman in the United States, racism, and the combined effects of gender, racism, and relative social position, as potential unmeasured etiologic factors that contribute to the gap. The studies conducted represent the expertise of anthropologists, sociologists, medical researchers, and epidemiologists who study both individual and social causes and then also provide a theoretical interpretation by those who lived the experience, (e.g., the study participants) rather than just the researchers' interpretation of the causes of and prevention strategies for the gap.

The Prevalence of Socioeconomic and Behavioral Characteristics and their Impact on Very Low Birth Weight in Black and White Infants in Georgia
Cynthia J. Berg, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Lynne S. Wilcox, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Philip J. d'Almada, Battelle Memorial Institute, Columbus, Ohio

Objectives: We examined possible reasons for the disparity in the rate of very low birth weight (VLBW) delivery (<1500 g) in the United States between black women and white women. Methods: Using data from a population-based, case–control study of very low birth weight infants, we compared the prevalence of sociodemographic and behavioral characteristics between black and white mothers of normal birth weight infants; the difference in these characteristics between case and control mothers; and, using logistic regression, calculated odds ratios for VLBW for black versus white infants, adjusting for these characteristics. Results: Although black women were disadvantaged on every variable examined, they did not report more behavioral risk factors. Among white women, several traditional risk factors were associated with VLBW, while among black women, only marital status, cigarette smoking, and vitamin nonuse were associated with VLBW delivery. Controlling for the socioeconomic and behavioral factors reduced the odds ratio for VLBW delivery among black mothers from 3.7 to 3.3. Conclusions: Racial disparity in socioeconomic status may be greater than our current ability to adjust for it in epidemiologic studies. The fact that traditional risk factors were not associated with VLBW delivery in black women may be due to the very high prevalence of these risk factors among black women or to different or additional risks or stresses experienced by black women.

Qualitative Methodologies and Community Participation in Examining Reproductive Experiences: The Harlem Birth Right Project
Leith Mullings, Department of Anthropology, Graduate School and University Center, City University of New York, New York, New York
Alaka Wali, The Field Museum of Natural History, Chicago, Illinois
Diane McLean, Montefiore Medical Center, New York, New York
Janet Mitchell, Lincoln Medical and Mental Health Center, New York, New York
Sabiyha Prince, Department of Anthropology, Graduate School and University Center, City University of New York, New York, New York
Deborah Thomas, Department of Anthropology, Graduate School and University Center, City University of New York, New York, New York
Patricia Tovar, Colombian Institute of Anthropology and History, National University, Bogotá, Colombia

Objectives: Racial disparities in health present a challenge to public health because of the complexity of interacting social forces. The Harlem Birth Right Project sought to improve understanding of these forces by using qualitative and community participatory methods. In this paper we 1) describe the process of qualitative inquiry and community involvement, 2) evaluate the impact of community participation, and 3) present a brief summary of the findings on social context as it relates to pregnancy outcomes of women in Harlem. Methods: We operationalized the qualitative method by combining participant observation, longitudinal case studies, and focus groups. An ethnographic survey was used to verify and triangulate findings across methods of data collection. We involved the community in the design, implementation, and analysis by collaborating with community-based organizations, setting up a community advisory board, and the use of dialogue groups and community meetings. Results: The use of qualitative methods and community partnership uncovered important aspects of the social context of women's lives that may not have emerged through traditional epidemiologic research. We found that pregnancy may serve as a catalyst to increase perception of the magnitude of preexisting social stressors. Several stressors and chronic strains associated with structural forces were identified. For example, the high percentage of households headed by women is seen as one consequence of larger structural forces. While social support networks serve as an important coping mechanism to buffer against the stress caused by these structural forces, the types of support women seek differs by social strata, and some strategies were identified as being substantially more effective than others. Conclusions: Qualitative and community participatory research can be successfully conducted to support public health goals and can derive important new information on the social context of women's lives.

Examining the Burdens of Gendered Racism: Implications for Pregnancy Outcomes Among College-Educated African American Women
Fleda Mask Jackson, Rollins School of Public Health, Emory University, Atlanta, Georgia
Mona Taylor Phillips, Spelman College, Atlanta, Georgia
Carol J. Rowland Hogue, Rollins School of Public Health, Emory University, Atlanta, Georgia
Tracy Y. Curry-Owens, Rollins School of Public Health, Emory University, Atlanta, Georgia

Objectives: As investigators increasingly identify racism as a risk factor for poor health outcomes (with implications for adverse birth outcomes), research efforts must explore individual experiences with and responses to racism. In this study, our aim was to determine how African American college-educated women experience racism that is linked to their identities and roles as African American women (gendered racism). Methods: Four hundred seventy-four (474) African American women collaborated in an iterative research process that included focus groups, interviews, and the administration of a pilot stress instrument developed from the qualitative data. Analysis of the qualitative and quantitative data from the responses of a subsample of 167 college-educated women was conducted to determine how the women experienced racism as a stressor. Results: The responses of the women and the results from correlational analysis revealed that a felt sense of obligations for protecting children from racism and the racism that African American women encountered in the workplace were significant stressors. Strong associations were found between pilot scale items where the women acknowledged concerns for their abilities to provide for their children's needs and to the women's specific experiences with racism in the workplace (r = 0.408, p < .001). Conclusions: We hypothesize that the stressors of gendered racism that precede and accompany pregnancy may be risk factors for adverse birth outcomes.

Pregnancy Discovery and Acceptance Among Low-Income Primiparous Women: A Multicultural Exploration
Nadine R. Peacock, Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois. Department of Anthropology, University of Illinois at Chicago, Chicago, Illinois
Michele A. Kelley, Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois. Health Research and Policy Centers, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
Colleen Carpenter, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, North Carolina
Margaret Davis, Southside Health Consortium, Chicago, Illinois
Glenda Burnett, Mile Square Health Center, University of Illinois at Chicago, Chicago, Illinois
Noel Chavez, Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
Verónica Aranda, Health Research and Policy Centers, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
Members of the Chicago Social Networks Project

Objectives: As part of a larger study exploring psychosocial factors that influence self-care and use of health care services during pregnancy, we investigated the process of pregnancy discovery and acceptance among a culturally diverse group of women who had given birth to their first child in the year preceding data collection. Methods: Eighty-seven low-income women from four cultural groups (African American, Mexican, Puerto Rican, and white) participated in eight focus groups held in their communities. The focus groups were ethnically homogenous and stratified by early and late entry into prenatal care. A social influence model guided the development of focus group questions, and the study followed a participatory action research model, with community members involved in all phases of the research. Results: Issues that emerged from the focus groups as possible influences on timing of pregnancy recognition include the role of pregnancy signs and symptoms and pregnancy risk perception in the discovery process, the role of social network members in labeling and affirming the pregnancy, concerns about disclosure, “planning” status of the pregnancy, and perceived availability of choices for resolving an unintended pregnancy. Conclusions: The pregnancy discovery process is complex, and when protracted, can potentially result in delayed initiation of both prenatal care and healthful pregnancy behaviors. Enhancing our understanding of pregnancy discovery and acceptance has clear implications for primary and secondary prevention. Future research is needed to further explain the trajectory of pregnancy discovery and acceptance and its influence on health behaviors and pregnancy outcome.

Stress and Preterm Birth: Neuroendocrine, Immune/Inflammatory, and Vascular Mechanisms
Pathik D. Wadhwa, Departments of Psychiatry & Human Behavior and Obstetrics & Gynecology, College of Medicine, Irvine, University of California, Irvine, California
Jennifer F. Culhane, Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
Virginia Rauh, Mailman School of Public Health, Columbia University, New York, New York
Shirish S. Barve, Department of Medicine, University of Louisville College of Medicine,
Louisville, Kentucky

A growing literature suggests that maternal psychological and social stress is a significant and independent risk factor for a range of adverse reproductive outcomes including preterm birth. Several issues remain to be addressed about stress and vulnerability to stress during pregnancy. Of these, perhaps one of the most important questions relates to biologic plausibility. Parturition, the process that results in birth, is a biological phenomenon. Very little empirical research to date, however, has examined the role of biological processes, if any, as mediators of the relationship between stress and preterm birth. In this paper we discuss the maternal, placental, and fetal neuroendocrine, immune/inflammatory, and vascular processes that may bridge the experience of social adversity before and during pregnancy and the biological outcome of preterm birth.

Jennifer F. Culhane, Jefferson Medical College, Thomas Jefferson University, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania
Virginia Rauh, Columbia University, Mailman School of Public Health, NYC, New York
Kelly Farley McCollum, The Health Federation of Philadelphia, Philadelphia, Pennsylvania
Vijaya K. Hogan, Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, Georgia
Kathy Agnew, University of Washington, Department of Obstetrics and Gynecology, Seattle, Washington
Pathik D. Wadhwa, Departments of Psychiatry & Human Behavior, and Obstetrics & Gynecology, College of Medicine, University of California, Irvine, California. UC Irvine Behavioral Perinatology Research Program, Irvine, California

Objectives: Maternal infection, particularly bacterial vaginosis (BV) in pregnancy, is one of the leading causes of adverse perinatal outcomes. The determinants of individual differences in susceptibility, or vulnerability, to maternal infections are poorly understood. This study examines whether chronic maternal stress predisposes women to infection during pregnancy, and if so, whether the effects of chronic stress on infection are independent of other established risk factors. Methods: We conducted a cross-sectional, clinical prevalence study of chronic maternal stress and BV status in a sample of 454 pregnant women at 14.3 ± 0.3 weeks gestation (±SEM). BV was diagnosed by Gram-stain of vaginal fluid samples; chronic maternal stress was assessed using the Cohen Perceived Stress Scale. Other established risk factors for BV, including maternal age, race/ethnicity, marital status, SES, and behaviors related to feminine hygiene, sexual practices, and substance use, were measured using a structured interview. Results: Of the 454 women enrolled in this study, 224 (49%) were BV positive (Nugent score 7–10), 64 (14%) had intermediate vaginal flora (Nugent score 4–6), and 166 (37%) were BV negative (Nugent score 0–3). BV+ women had significantly higher chronic stress levels than BV- women (24.6 ± 0.5 vs. 22.2 ± 0.6 units (±SEM), respectively; t = 3.19; p < .01). Maternal sociodemographic variables (African-American race/ethnicity) and behavioral characteristics (vaginal douching, number of lifetime sexual partners, and use of illicit drugs) also were significantly associated with the presence of BV. After controlling for the effects of these variables, using a multivariable logistic regression model, chronic maternal stress remained a significant and independent predictor of BV status. Women in the moderate-stress group (third quartile) and high-stress (fourth quartile) group were 2.3 times (95% CI = 1.2–4.3) and 2.2 times (95% CI = 1.1–4.2) more likely to be BV+ than women in the low-stress group (bottom quartile). Conclusions: High levels of chronic stress during pregnancy are associated with bacterial vaginosis. The effect of chronic maternal stress is independent of the effects of other established sociodemographic and behavioral risk factors for BV.

Commentary: Eliminating Disparities in Perinatal Outcomes—Lessons Learned
Vijaya K. Hogan, Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Terry Njoroge, Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Tonji M. Durant, Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Cynthia D. Ferre , Pregnancy and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia

The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.

Back to Maternal and Infant Health

Date last reviewed: 03/21/2006
Content source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion