The Minority Health Gap

The US Department of Health and Human Services has again declared its commitment to “accelerating health equity for the nation.”  The USDHH campaign calls attention to a complex problem with a profound impact on minority women of childbearing age and their babies.

Minority Women Have Specific Health Challenges

Young minority women in America have specific health challenges that can’t be explained simply by socioeconomic status. Education is a strong indicator for healthy prenatal outcomes. Yet, it remains a sad fact that even today, a college educated black woman in the US today is twice as likely to suffer the death of her baby within the first year of life as a white high school graduate from Appalachia.   Today, as in the early 1960s, black infants are more than twice as likely as white infants to die within their first year of life. In 2009, the infant mortality rate was 12.4 infant deaths per 1,000 live births among blacks, compared to 5.3 among whites.

This disparity cannot be explained by genetics. A review of birth record data from 27 states found that foreign non-Hispanic black women (those not born in the United States) had 28% and 26% lower odds of premature birth or giving birth to a small for gestational age (SGA) baby, respectively, when compared to U.S. born non-Hispanic black women. These rates could not be explained even after adjustment for known risk factors.

Stress Levels Are Higher for Minority Women Resulting in Premature Births

While there are numerous hypotheses for why black women continue to have higher rates of premature births, there is one area that is hard to dispute. Living as a lifelong minority in the United States is associated with an increased burden of stress. And stress has an adverse effect on maternal and infant health. The March of Dimes Foundation advises pregnant women to reduce their stress levels to reduce the risk of preterm birth. Stress can restrict blood flow to the developing fetus, increasing the risk of preterm labor. Babies that are born prematurely face increased risk of developmental delays and difficulties. Preterm birth is the most frequent cause of infant death in the United States and one of the primary contributors to racial disparities in infant mortality.

Nutrition is Key

To achieve the goal of health equity for minority women and children, we must address environmental and social realities that are wide-ranging and far more complex than what can be included in this short piece. I will focus on one small sliver of the problem: nutrition. Due to finances, access, or a combination of both, it can be a struggle to put healthy food on the table. This can be devastating during pregnancy and early childhood. Chronic stress often leads to unhealthy eating and nutrient gaps can result. While there are varying levels of evidence linking nutrient deficiencies and preterm birth, there is evidence of a greater burden of these deficiencies among African-American women than white women.  Some important nutrient deficiencies include calcium, magnesium, iron, zinc, vitamin D, iodine and an imbalance of omega-3 and omega-6 polyunsaturated fatty acids.

Essential Nutrients Needed in Pregnancy

Let’s just look at a few of these essential nutrients. Calcium has been shown to stabilize blood pressure during pregnancy and reduce the risk of pre-eclampsia, a condition in pregnancy marked by high blood pressure, swelling of the hands and feet, and protein in the urine. It is the cause of 15% of premature births. Many African Americans are lactose intolerant, putting them at risk for low dietary calcium intake. In this population, experts recommend 1,000 mg of calcium per day, taken in two divided doses, starting at 20 weeks of pregnancy. This simple intervention has the ability to reduce pre-eclampsia by almost 35%. 

Docosahexaenoic acid (DHA), a long chained omega 3 fatty acid (found in fish predominantly), is vitally important to the neurologic and retinal development of the baby during pregnancy and early childhood. But omega 3 fatty acids may also help reduce maternal stress and premature birth rates. In one interesting study of pregnant African American women, subjects given 450 mg of fish oil per day experienced both lower levels of cortisol and a lower perception of stress compared to those taking a placebo.  Again, this is important given the fact that stress increases the risk for premature birth, which disproportionately impacts black women.

The Importance of Iron, Iodine and Vitamin D

During pregnancy, there is a dramatic increase in the production of red blood cells needed to meet the needs of both the mother and the baby. Iron deficiency is strongly correlated with lower IQ and poorer neurocognitive development. However, depleted iron stores are far more common during the second and third trimesters of pregnancy in Mexican American (23.6 percent) and non-Hispanic black women (29.6 percent), compared to non-Hispanic white women (13.9 percent). African American women between the ages of 20 and 39 stand out as a population, based on Centers for Disease Control data, low in iodine. Public health warnings against excessive salt consumption have been effective—at a cost. Although high in sodium, processed and fast foods do not contain iodized salt. Low iodine during pregnancy can negatively impact a baby’s IQ and cognitive abilities. Experts recommend 150 mcg of iodine per day during pregnancy. Sadly, only half of prenatal vitamins contain iodine. 

According to the CDC, Latinas have a 30-40 percent higher risk of having babies with neural tube defects (NTDs), including spina bifida, than white or black women. Folate is known to reduce the risk of NTD by 70% and yet only 1 in 5 Hispanic women report consuming adequate amounts of folate. And to prevent birth defects, women need to be supplementing with 400 mcg per day of folate roughly six months before pregnancy.

Vitamin D is vital for healthy bones and a healthy immune system. In our age of indoor work and play, compared with past generations who spent more time out in the sunshine, vitamin D insufficiency has become alarmingly common, affecting some 90 million Americans. The American Academy of Pediatrics recommends that breastfed babies be given 400 IU per day of vitamin D3 starting with the first few days of life. The Canadian Pediatric Association recommends breastfed babies be given 800 IU of vitamin D3 per day from October-April, when there is less exposure to sunlight. However, a considerable number of breastfeeding women do not supplement their babies with vitamin D3 and few physicians advocate for higher doses (800 IU per day) during winter months, especially for dark skinned babies living in northern states.

All People Need Access to Nutritious Healthy Foods

Ensuring that families have access to nutritious healthy foods should be a national priority and allowing families to use their Supplemental Nutrition Assistance Program (SNAP, formerly known as the food stamp program) to purchase basic multivitamins, particularly for reproductive aged women and children, seems to be one sensible move towards helping to ensure against nutritional gaps that often occur in the diet. As census data affirms, the US is on its way to becoming a minority-majority nation. Achieving health equity for minority women and their children should be a year-round priority for all health providers and community health advocates.  

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References:

Cole-Lewis HJ, Kershaw TS, Earnshaw VA, et al. Pregnancy-specific stress, preterm birth, and gestational age among high-risk young women. Health Pscyhol 2014 Sep;33(9):1033-45.

Elo IT, Vang Z, Culhane JF. Variation in birth outcomes by mother’s country of birth among non-Hispanic black women in the United States. Matern Child Health J 2014 Dec;18(10):2371-81. PMID: 24756226

Latendresse G. The interaction between chronic stress and pregnancy: preterm birth from a biobehavioral perspective. J Midwifery Womens Health 2009; 54(1):8-17 PMCID: PMC2651684

Mathews TJ, MacDorman MF. Infant mortality statistics from the 2009 period linked birth/infant death data set. Natl. Vital Stat Rep. 2012; 61(8).

Mei Z, Cogswell ME, Looker AC, et al. Assessment of iron status in US pregnant women from the National Health and Nutrition Examination Survey (NHANES), 1999-2006. Am J Clin Nutr. 2011 Jun;93(6):1312-20. PMID: 21430118

Hispanic Babies are at Higher Risk of Brain and Spine Birth Defects: Mothers Who Take Folic Acid can Reduce that Risk. http://www.cdc.gov/media/subtopic/matte/pdf/CDCFolicAcidMatRelease12-22English.pdf 

African-American Women and Their Babies at a Higher Risk for Pregnancy and Birth Complications http://www.cdc.gov/media/subtopic/matte/pdf/CDCMatteReleaseInfantMortality.pdf