Running head: LOW-BIRTH WEIGHT BABIES 1

Health Disparities: Black Mothers and Low Birth-Weight Babies

Atoosa Benji

Midwifery College of Utah

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Introduction

If youre not outraged, youre not paying attention- author unknown.

It is the year 2017 and the Unites States is facing a crisis. It is a crisis that is affecting

mothers and babies and thus, the fabric of our entire society. What is most disturbing is that the

crisis is preventable. Like most other crises, its prevention will take a village of people who will

raise awareness to the matter, understand the mechanism by which the problem proliferates,

create an action plan, facilitate it, and revisit efforts as to where improvements need to be made.

While the darkness of racism still hangs insidiously over many parts of the US creating discord

and havoc, where racism is the driving factor of death and sickness for both mothers and babies,

as a nation, we must be outraged.

In her famous piece, White Privilege: Unpacking the Invisible Knapsack, Peggy

McIntosh analyzed the phenomenon of white privilege, writing as a white person, I can be

sure that if I need legal or medical help, my race will not work against me (McIntosh, 1989 p.2).

This is not the case for black women in the US who are 3.5 times more likely to die in childbirth

than white women (Belluz, 2017). African-American babies have more than double the chance

of dying in their first year of life, with low birth-weight (LBW) accounting for more than half of

those deaths (Collins, David, Handler, Wall, & Andes, 2004). While anemia, hypertension,

sexually transmitted infections, and smoking are key factors to babies being born with low birth

weight, the discussion in this paper will highlight that it is racial disparity that drives both its

incidence and prevalence and institutionalized racism that fuels its proliferation.
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Section 1

A low birth-weight (LBW) baby is defined as a baby born weighing less than 5lbs 8oz

(appx 2600g). A very low birth (VLBW) weight baby weighs less than 1500 grams at birth

(Collins et al., 2004). In the US, approximately 1 out of 12 babes is born with LBW. Reasons

for a baby being born with LBW include fetal growth restriction, premature birth (birth before 37

weeks of gestation), birth defects and infections. Close to 70% babies born LBW are born

preterm (www.datacenter.kidscount.org, 2017). Babies born too small carry the unfortunate fate

of severe health conditions; these include diabetes, heart disease, obesity, metabolic syndromes,

and developmental issues. Other complications may include vision impairments, autism,

respiratory distress, and brain hemorrhage. More than 13% of black babies are born with LBW

each year, while the rates are 8.4%, 7.6% and 7% for Asian, Native American, and White babies,

respectively (marchofdimes.org 2014). Statistics for LBW are gathered from birth certificate and

the Department of Health. To calculate percentage of LBW, the number or LBW babies is

divided by the number of live births for which the birth weight of the baby was known. If the

number is less than 20, the rates are not stable (www.datacenter.kidscount.org, 2017).

Preterm babies also face the risk of death due to their small size and high risk of

complications. Both small for gestational age (SGA) and congenital anomalies contribute to

preterm stillbirth risk. This rate is higher for black women than white women. For black

women, this excess stillbirth risk is greater at preterm gestations (Willinger, Ko & Reddy, 2009).

For many years researchers have concluded that socio-economic factors, mothers

educational level, preexisting disease and poor nutrition have contributed to babies being born

with LBW. This is not the etiological end-point. While it is easy to produce data that is

quantifiable, such as rates of pre-eclampsia or diabetes or infection, it is becoming more evident

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that factors such as epigenetics, allostatic load and health disparity are indispensable to analyzing

rates of both maternal and fetal morbidity and mortality. Although medical conditions and low

socio-economic status have been related to the higher risk for preterm and low birth-weight

infants, these factors do not fully explain the health disparities in negative outcomes for African-

American women (Giurgescu, Engeland & Templin, 2015 p.570).

Studies on epigenetics and a persons propensity for resilience, point to factors that

involve both biology and nature as determinants. As researchers study the intersection of nature

and nurture on birth and birth outcomes, it is believed that birth is not the end product of 9

months of pregnancy, but the entire life-course of mothers before pregnancy. Perinatal outcomes

affect the life course perspective of generations to come (Wills, McManus, Magallanes,

Johnson & Majnik, 2014 p.851).

Section 2

Several factors have been discussed as contributing to rates of preterm and LBW babies.

In this section, I will analyze risk factors, the effect of both stress and institutionalized racism-

interwoven to their core- will be the back drop of this analysis. Excellent nutrition is a

foundation for optimal health for mothers and their unborn babies. Diseases such as

hypertension, preeclampsia, anemia, and diabetes are directly correlated to poor and inadequate

nutrition. Moreover, 82% of African-American women are overweight or obese, more than 1/3

of these women are low income and were obese prior to pregnancy (Groth, Simpson &

Fernandez, 2016). Socio-economic factors cannot be ignored when analyzing nutrition within a

population. According to the US. Census Bureau, in 2015, the percentage of black people living

below the poverty line was 25.8%, compared to 14.7%, nationally (www.census.gov). More

than 1 out of 4 black people in America faces poverty, which by its very definition includes
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lower socio-economic status, access to health care, safe neighborhoods, and healthy food.

Pregnant women living under these conditions often turn to low-cost, poor nutrient, calorie-dense

food. Difficulties obtaining food due to transportation issues, coupled with limited food access

due to living with multigeneration in one household were challenges faced by low-income

pregnant women in one study. When the same women were asked what would need to happen in

order for them to make better food choices, responses included needed more money, needing

more education on nutrition and needing more rest in order to have some consistency in schedule

and behavior patterns. (Groth et al., 2016).

African-American teenagers are 1.5 times more likely than whites to give birth

prematurely and have twice the chance of having LBW babies. In a 2003 study analyzing the

risk factors faced by black teen mothers, close to 1/3 of the teens gained too little weight during

pregnancy, 40% gained more than recommended. The mothers who did not gain adequate

weight were 3 times more at risk for giving birth preterm than the women who gained

appropriate weight. In African-American teens, smoking, inadequate prenatal care, and sexually

transmitted infections were also correlated with preterm labor and LBW (www.jhsph.edu).

Anemia in pregnancy puts a woman in danger, particularly if she suffers a postpartum

hemorrhage. Folate intake when inadequate causes certain developmental defects as well as

effects the DNA and RNA cells at the epigenetic level. The term epigenetics refers to the study

of changes in gene function that are mitotically and/or meiotically heritable and that do not entail

a change in DNA sequence (Dupont, Armant & Brenner, 2009). Inadequate protein intake can

be a key factor of premature rupture of membranes, pre-eclampsia, and SGA babies. Women of

low socioeconomic status often eat enriched, white, processed carbohydrates, containing trace
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protein. Some research studies have found that when pregnant women eat dairy every other day,

they decrease their chances of having a LBW baby (Purandare, 2013).

We can quote statistics and data ad nauseum. The point is how can we provide access to

proper nutrition, nutrition education and accessibility to food when conditions are poor and

resources are limited, particularly for black women?

The role of stress and depression cannot be overlooked when discussing negative health

outcomes, particularly in relation to maternal-child health. African-American women are more

likely to experience symptoms of depression as compared to white women. Pregnant women

who suffer from depression are more likely to give birth to preterm and LBW babies. Cortisol,

produces in the adrenal glands, in response to stress, increases the bodys inflammatory response,

suppressing the immune system, and thus increasing the risk for infection and negative birth

outcomes. In African-American women, low levels of social support, poor coping strategies and

avoidance in response to stressful situations put women at higher risk for cortisol production

(Giurgescu et al., 2015).

The term allostatic load refers to the physiological consequences of adapting to repeated

or chronic stress: can accelerate disease process (www.medicaldictionary.com). Allostatic load

is higher in black women than in white women and has an adverse effect on birth outcomes,

namely preterm birth and LBW. Under the effects of chronic stress, the body experiences an

acceleration of biological aging and an increased propensity to disease and earlier heath decline.

As a measure of cumulative burden and a physical consequence of societal disadvantage,

allostatic load may yet prove to be an important contributor to the perplexing and persistent

racial disparity in birth outcomes. (Wallace & Harville, 2103 p.681).

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What contributes to chronic stress? Financial pressure, poor health, feeling unsafe, lack

of support, lack of rest, lack of healthcare, and working several jobs can contribute. Most if not,

all are factors faced by low-income black women (Groth et al., 2016). However, while the

above-mentioned factors may be easy to identify, the chronic stress caused by repeated exposure

racism cannot be overlooked.

In a 1997 study, researchers found that US-born black babies weighed less than African-

born black babies. They also found that across 3 generations of female descendants, US-born

white, European-born white, US-born black and African-born black women, in all the groups

with the exception of African-born black women, there was an increase in birth weight in first

generation babies born in the US. African-born black women giving birth in America gave birth

to smaller babies than their descendants. The researchers concluded that acculturation to the

US lifestyle is a risk factor in addition to perceived or real discriminatory practices as

contributors for adverse birth outcome among racial/ethnic groups (Willis et al., 2014 p.853).

Another interesting point is that African-American women have higher rates of premature

babies and LBW babies, despite higher educational levels and socioeconomic status, lower

alcohol and drug use and higher income as compared to white women with the same education

and socio-economic level. Interestingly, as socio-economic levels increase the disparity in heath

between black and the women increases (Molnar, 2015).

In another study, researchers concluded that the as a maternal grandmothers residential

environment during pregnancy became unsafe, LBW rates increased in subsequent generations,

as far into the 3rd generation. They also concluded that diet, stress, maternal environments, and

neighborhood locations affect epigenetic changes within populations (Willis et al., 2014).
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In a 2004 study, Collins et al. did research on the role of maternal exposure to racial

discrimination. They found that of the African-American women who delivered LBW or VLBW

babies, 40% had experienced interpersonal racial discrimination. They found that the incidence

of LBW babies rose in populations that reported finding a job and discrimination at the

workplace as being places where they would most frequently experience racism. Thus,

discrimination in the workplace places many African-American women into a chronic stress

state, contributing to racial disparity and VLBW babies (Collins et al., 2004).

Section 3

While we still have a long way to go to close health disparities among mothers in the US,

many organizations are doing remarkable work to help bridge these gaps. African-American

women need access to care, prenatal and postpartum education, measures to help them reduce

stress, improvement of their neighborhoods, and most importantly a need to be heard and

understood. As discussed, even when socioeconomic status and education was not a factor,

African-American black women still experienced higher premature birth rate sand LBW babies.

We must address health disparities and understand racism through the eyes of those who are

experiencing it. Health equality is different from health equity. While both black women and

white women in America have equality in terms of their rights to medical care, health equity may

not exist if one group has no means of accessing the care, understanding the system, and feeling

heard by the care provider. Furthermore, if one group is under such financial pressure that taking

time off from work is impossible, then how can any sort of congruency exist in health outcomes?

When depression and cortisol levels are so high that they affect pregnancy and birth outcomes in

certain populations what good is equality of care if it is neither practical nor accessible? Health

equity is a question of social justice- it means all populations are given an opportunity to be
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healthy, and resources are distributed in a way that will equalize health outcomes of disadvantaged

groups (Braveman & Gruskin, 2003).

One program in place to ensure adequate nutrition for expectant mothers and their children

is WIC- Women Infants and Children program. WIC is a supplemental nutrition program for low

income pregnant women, breastfeeding women, and infants under the age of 5. While WIC offers

nutritional supplementation, services also include some counselling and education programs.

According to the USDA, women receiving assistance from WIC are delivering less premature and

LBW babies (www.usda.gov). In another report, 6% of women receiving assistance from WIC

and 5% of African-American women experienced less rates of premature birth and LBW babies

(Carlson & Neuberger, 2017).

While WIC is a global organization that is providing invaluable help to mothers and babies,

there is still trouble with adequate funding and access to care. Many centers do not have adequate

resources to meet the demands of low income women and children. Long waiting lists and wait

times are faced by many who reach out for help (Foster, Jiang & Gibson-Davis, 2010).

The March of Dimes is an organization devoted to improving outcomes for newborns by

preventing birth defects, infant mortality, and premature birth. They do this through advocacy,

education, and outreach. They are very active at the level of legislature. This year alone, they have

written letters to Senators and Congress in support of legislation that contributes to improving

newborn outcomes. They have been instrumental in the campaign for smoking cessation in

pregnancy, prevention of neural tube defects through nutritional education, and raising both

awareness and funds to help newborns at risk (www.marchofdimes.org).

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The March of Dimes is the gold standard of public health, working toward prevention to

improve health outcomes for mothers and babies. While their efforts are extraordinary, there is

still work to be done.

As outlined in the preceding paragraphs, bridging the health disparity between African-

American women and white women is not based solely on levelling the playing fields in terms of

education and care, but also on educating care providers to be culturally competent and aware.

The National Institute of Health (NIH) is working hard to address health disparity through

cultural competency education. The National Standards for Culturally and Linguistically

Appropriate Services in Health and Health Care (the National CLAS Standards) are intended to

advance health equity, improve quality, and help eliminate health care disparities by providing a

blueprint for individuals and health care organizations to implement culturally and linguistically

appropriate services (www.nih.gov).

It is imperative that health care providers listen to the needs of black women. Humility

entails understanding that if you are not a black woman, you will never truly understand the

challenges of a black woman living in America. We can read fancy books and articles on cultural

sensitivity, but the practice of cultural humility is where change happens. Health care workers

must attend regular cultural sensitivity programs, be required to host events where advocacy and

social change are addressed and more than anything, must form task forces to address the needs of

high-risk populations. If we are to obliterate health disparities in the US, we must work at the

level of grass roots organizations where women live and work our way up to legislation. While

fancy fund-raisers and multi-million-dollar ad campaigns are vital for exposure and attention to

the cause, eradicating racism at every level is paramount.

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Section 4

While living in the United States in the 21st century brings with it many opportunities and

resources, it is important to understand that traditional practices still have a place in the maternal-

child health system. It is vital that care givers understand that while modern medicine and

practice brings with them tremendous advances to the care of mothers and babies, there is a point

where traditional and modern practices can meet to complement each other.

Women have been helping each other during the childbirth and parenting years

for as far as history goes back. In most cultures, several families live under one roof or in very

close proximity to each other. It is not unusual for women to share daily tasks and help to raise

each others children. In the US, since the development of the nuclear family, women have

become more isolated and responsible not only to work outside the home, but also to care for

home and family. In many ways, this has put women and families at a tremendous disadvantage.

Due to the fact that women lived together, traditional practices were deeply rooted

into the family. Elders shared their experiences, their knowledge and their presence brought a

confidence and sense of competence to the younger families. Traditional practices include the

use of plant and herbs, nutritional remedies, and traditional medicines, passed on from

generations. Women made salves and balms for rashes and thrush, they treated the perineum

with herbs and compresses and they helped each other with the demands of caring for babies, so

that mothers could heal after giving birth.

Traditional care included the care of a trusted midwife, often the community

elder. The midwife was respected and honored and had rapport with the family, having seen it
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through generations of children. These midwives had skills that had been passed on from

generations and knew cures to ailments we may never have heard of

The benefits of traditional care include camaraderie, emotional and physical support and

the wisdom of tried and true remedies and practices. Due to women living in close proximity to

each other, there was a built-in network of support from women who understood each other,

because they shared the culture and traditions. Remedies came from foods and herbs and many

pharmaceuticals and medical interventions were avoided by default, because there were

alternative options. Of course, today we call them alternative. The truth is, perhaps our

Western model is the alternative one!

While the tradition model carries many benefits, there are some costs. Herbal

remedies and wisdom handed down from elders is invaluable, however, there are instances in

which modern medicine can save lives. While colic and mastitis and postpartum blues can often

be cared for with herbs and foods, in cases of pathology and abnormalities, they may not be

effective. Additionally, the remedies used have anecdotal benefits, they are not evidence-based

care. Dosing is precarious and there may be contraindications for some remedies. Sterile

technique may not be as closely observed, increasing the risk of infection and some preventable

illnesses.

Historically, women birthed at home and childbirth was considered a normal

physiological phenomenon, requiring little intervention. Prenatal care was very rare. With this

came maternal and fetal morbidity and mortality due to lack of resources and adequate care. In

the book, Gender through the Prism of Difference, the author quotes civil right activist Ella

Bakers experience growing up as a black woman in the rural south. My aunt who had thirteen

children of her own, raised three more. She had become a midwife and a child was born covered
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with sores. Nobody was particularly wanting the child, so she took the child and raised himand

another mother decided she didnt want to be bothered with two children, so my aunt took one

and raised him. They were part of the family (Zinn, Hondagneu-Sotelo, Messner & Dennisen,

2016 p. 318). In the majority of African American families, women were resilient, strong, and

capable. They shared childcare responsibilities and grandmothers, aunts and cousins often cared

for each others children or adopted them to be their own (Zinn, et al., 2016).

Modern practice includes birth attendance by physicians in highly medicalized settings.

While this brings with it better prenatal care for some, for others this comes at the high price of

interventions and a fear-based, technocratic model of care. Birth is highly intervened and

pregnancy is treated as pathology by many care-providers. Many times, women are unheard and

cultural competence lacks. The Western medical model in the US has not drastically reduced

maternal and child mortality despite all of the interventions, nor is care accessible by many

women.

Health disparities exist and with the families becoming double income and isolated,

women have lost the care and wisdom of elders. Midwifery care is very rare and when available,

difficult to access. Women resort to the internet, pop-culture books and if they are lucky, attend

childbirth and breastfeeding classes. For many who are barely staying afloat financially, care is

minimal. Little education nor advocacy exists during the child birthing years. While modern

maternity care has brought with it advances such as sterile technique, mostly safe cesarean

sections and pain management for labor, training has become so specialized that we have lost the

holistic perspective of care for women and children. Many families are made to feel that if it

doesnt fit into the medical model, they are doing it wrong.
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Section 5

The United Population Fund (UNFPA) together with the International Confederation of

Midwives (ICM) and the World Health Organization (WHO) issued a report in 2014 highlighting

the need for midwifery education and training to contribute to closing the rates of maternal and

child death. According to Dr. Babatunde Osotimehin, executive Director of the UNFPA,

midwives make an enormous contribution to the health of mothers and newborns and the well-

being of entire communities. Access to quality healthcare is a basic human right. Greater

investment in midwifery is a basic human right (www.who.int).

Midwives are key to public health across the world. Midwifery has a huge impact on

both maternal and fetal health in the long and short term (Biro, 2010). The midwifery model of

care not only focuses on individualized care but also on preventative care. According to the

Ottawa Charter which was used as the basis of the Health for All initiative by the year 2000

and beyond, the health sector must move beyond clinical and curative services, they need to

move in the direction of health promotion (Biro, 2010).

While a trained midwife attends birth, midwives are responsible for education not only

through pregnancy, but before conception. The Center for Disease Control and Prevention and

the Preconception Health and Health Care Initiative have stablished goals for preconception care.

These goals are a) screening, b) health promotion, and c) intervention. It is known that when a

woman and her partner are healthy before pregnancy, both mother and baby have a better chance

of goo health (Nypaver, Arbour & Niederegger, 2016).

Because the average midwifery visit lasts an hour or more as compared to the average

obstetrician appointment which lasts approximately 13-16 minutes in the US, a lot can be learned
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about the pregnant woman (www.medscape.com). Midwives discuss nutrition, exercise, and

stress reduction measures with their clients. Midwives highlight the importance of shared

decision making and educate clients throughout pregnancy, empowering women, and families.

Breastfeeding is encouraged and follow up care is provided postpartum for 12 weeks, in many

practices. Out of hospital birth is an option made available to many women who do not want to

birth in hospitals. More midwives are becoming Medi-Cal providers in order to be able to help

women of lower socio-economic status. Many midwives offer care on sliding scale to be able to

help families who have low income. Midwives provide in-home visits through the prenatal and

postpartum period, making access to care possible for women who cannot travel to appointments

due to financial or childcare burdens.

NARM- the North American Registry of Midwives works tirelessly to promote

midwifery care as a desperately needed public health measure to increase safe maternity care for

mothers and babies. They have collaborated with the American Public Health Association and

the World Health Organization recommending that midwives be primary maternity care

providers for the majority of women (www.narm.org).

Midwives and midwifery organizations are doing excellent work and are frontrunners in

the public health system providing access to care for all women, however barrier still exist.

These barriers include access to care, paternalistic medicine that devalues midwifery care, and

financial barriers due to cost and insurance coverage.

Many women do not know that midwifery care exists. The term midwife elicits images

of an old lady showing up at the door with a tincture. Women and families must be educated on

what midwives do and how they practice and that options exist other than hospital and
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obstetrician-based care. More needs to be done to educate people about the safety of midwifery

care and all the evidence pointing to its safety.

Insurance companies are making it very difficult for women to access care. Midwives

must jump though hoop after hoop of bureaucracy in order to have insurance companies cover

care. In California, Medical covers some births but not all and has many restrictions on out of

hospital birth facilities and twin and VBAC births, making it inaccessible for many. When

midwives do accept insurance, companies pay so little for reimbursement that the midwife makes

little or no money on the care she provides, making it unsustainable to take only insurance,

When midwifery care does exist, it is not accessible by all due to geographic restrictions.

We do not have enough midwives to serve all the women that need care, and the midwives who

are practicing are often over-worked and often underpaid.

While CNMs are often respected and accepted by the medical community, direct entry

midwives are still unrecognized and their practice is still illegal in many states in the US. Many

CNMs do not wish to practice out of the hospital, thus OOH care is minimally available.

It is well known that the collaborative care approach is beneficial in increasing maternal

and fetal wellbeing. The model of collaborative care is the shared-care model of responsibility

for the organization and delivery of care. Transportation and childcare must be made available to

all women, so that they can receive adequate prenatal and postpartum care. In certain parts of

Canada, family physicians, midwives, community health nurses and doulas, with obstetric

consultation as required, provide care in a community-based, culturally appropriate, woman-

centered manner during pregnancy, birth, and the newborn period (Morgan, Carson, Gagnan &
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Blaek, 2014). In this model of care, clients have a village of care with individualized and

preventative health measures being front and center.

In Conclusion

Health disparities exist between African-American women and white woman in the US.

Black mothers and their babies are dying in staggering numbers as compared to their white

counterparts. Premature birth and LBW are responsible for many of the morbidities and

mortalities. Inadequate access to care, financial burdens, lacking education and support services

are responsible for this disparity. As we move towards the United Nations Millennium Goals to

reduce fetal death, I propose, through the evidence presented in this paper that collaborative care

is the solution to better care for our mothers and babies. When midwives provide care for low-

risk women, with physicians on stand-by for emergencies and complications, women will be

better cared for. There is a place for birth traditional and modern practice in health care.

Where there is mutual respect between the medical model and the midwifery model of

care, with each model understanding the advantage of each, our mothers and babies benefit. I

propose the formation of centers where education, prenatal and postpartum care co-exist with

educators, nurses, nutritionists, mental health counselor doulas and OBs all in attendance. Care

would be covered by insurance and no woman would be turned away for lack of funds. Shared

decision making and cultural humility training would be routine for all care providers and social

support groups would be in place for subject such as depression, stress management, and

parenting issues. As an industrialized nation, it is abominable that we are # 47 in the world in

maternal mortality and pre-term labor being the leading cause of death among American babies

(www.pphproject.org). Midwives are leading the way in their involvement with public health

promotion, but as with any other goal of this magnitude, it will take a village to make change.
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