When Eula Owens got pregnant in 1993, she considered herself at very low risk for complications. "I don't smoke, drink, or do drugs and have always been very healthy, so why should I have a problem?" says the 30-year-old from Cincinnati, Ohio. Yet she went into labor three months early, delivering a stillborn boy. When she conceived again a year later, her doctor monitored her even more closely, but at 8 1/2 months, she developed HELLP syndrome, a potentially life-threatening complication marked by high blood pressure, liver dysfunction, and an abnormally low platelet count (the substance that makes blood clot). Although Owens went on to deliver a healthy son, Ervin, the disorder put her in serious danger after childbirth. "My blood pressure went so high, they were scared I'd have a stroke, and my platelets were so low they were afraid I'd bleed to death." After a platelet transfusion, four days of hospitalization, and treatment, she made a full recovery.
In 1996, Eula and her husband, Alexis, a high school math teacher, decided to try for one more child. "This time, the doctor had me come every two weeks for a checkup. Everything was fine until I had my third ultrasound, at six months," she says. That's when her obstetrician discovered that due to a placenta problem, intrauterine growth restriction, her baby was unusually small. She underwent an emergency c-section a few days later when the baby's heartbeat suddenly dropped. Delivered at 30 weeks, Aaron weighed barely two pounds and was 13 inches long. The tiny boy spent his first two years battling a series of ailments brought on by his prematurity, but overcame them all, except for mild cerebral palsy. Now 4, he's a bright, lively preschooler who loves to run and ride his bike. Still, there's one question that haunts his mom: "Why did all this happen? I took every precaution and got the best care."
Owens, who is African-American, also wonders if her race played a role. Black mothers have almost triple the rate of premature birth that white moms do, and are at increased risk for other pregnancy disorders, says Carla Ortique, M.D., staff ob-gyn at Austin Diagnostic Center in Texas and vice-speaker of the National Medical Association, an advocacy group for African-American doctors and patients. "Studies show a higher rate of pregnancy-induced high blood pressure -- including HELLP syndrome -- as well as gestational diabetes and intrauterine growth restriction," she explains.
The health disparities don't stop there. Black babies are almost two and a half times more likely than white, Hispanic, or Asian children to die before their first birthday, according to a recent study published in Pediatrics. Although medical advances are saving more kids in every group, the mortality gap between the races has actually widened over the past century. In 1915, the study reported, out of every 1,000 American children born, about 100 white and almost 200 black babies didn't survive their first year. Today, of every 1,000 born, only 6 Caucasian babies die during infancy, compared to 14.3 African-Americans. Health care inequities likely affect other minorities as well: However, while a number of studies have looked at the health of African-Americans, less is known about minority moms and babies of other heritages.
Deadly disparities
What's behind this glaring health divide? Experts used to blame poverty alone, which affects three times more African-Americans than whites. New research, however, reveals that even affluent black mothers and babies fare poorly in our medical system. A 1999 study by Greg R. Alexander, M.P.H., Sc.D., chair of the department of maternal and child health at University of Alabama at Birmingham, found a dramatic racial divide among healthy college-educated women who didn't smoke or drink and received good prenatal care. Even in this extremely low-risk group, the survival gap persisted: Babies born to the African-American moms had a 60 percent higher death rate.
A major reason for this was that black babies in the study were 2.6 times more likely to have a low birth weight (any weight under five pounds, eight ounces). Other research shows that African-American babies are also at very high risk for perilously premature birth -- and, therefore, very low birth weight. A recent study from the Centers for Disease Control (CDC) showed that, compared to white children, African-American babies are five times more likely to be born during the 20th to 28th week of pregnancy. Being born too small ups the risk of many life-threatening disorders, including breathing problems, bleeding in the brain, heart failure, and necrotizing enterocolitis, a potentially fatal inflammation of the intestines. All this explains why complications of low birth weight are now the leading cause of death in African-American babies, according to a government study published last year.
Yet until recently, the tiniest black babies actually appear to have had a marked survival advantage over white preemies of the same gestational age -- even though the African-American babies weighed less. When Dr. Alexander compared the outcomes for extremely premature babies of both races in a study published last year, he discovered a troubling trend. Twenty-five years ago, a minority mom who gave birth prematurely had much better odds of bringing home a living child than a Caucasian mother did. According to Dr. Alexander, that's partly because those black babies' lungs seem to have matured earlier in pregnancy than those of white infants, cutting their risk for dangerous breathing disorders. Fragile black preemies today, however, no longer have this edge, since outcomes for both groups are now about the same. "White mothers and babies may have disproportionately benefited from advances in high-risk prenatal and newborn care," resulting in an even greater overall racial gap than in the past, speculates Dr. Alexander.
Patterns of prejudice
Minority moms and babies are often the victims of subtle but potentially dangerous medical bias. Although almost all pregnant women in the U.S. now receive prenatal care -- and 75 percent of blacks and 89 percent of whites start seeing the doctor during their first trimester -- African-American women are still shortchanged on high-tech tests: Studies have shown that far fewer black moms-to-be receive ultrasound exams to track their baby's development or amniocentesis to check for genetic abnormalities like Down syndrome.
A pregnant woman's race or ethnicity can also have a powerful influence on what delivery method her doctor uses if her baby is in the breech (legs-first) position, according to a study published in the March issue of Obstetrics and Gynecology. While white women were most likely to undergo c-sections for a breech birth, the rate of vaginal deliveries was up to six times higher for Hispanic moms and 11 times higher for blacks. "This concerns me," says Bruce Shephard, M.D., clinical associate professor of obstetrics/gynecology at the University of South Florida School of Medicine in Tampa, and medical advisor to BabyTalk. "Cesarean section is preferable because it's safer. Since a baby's head is wider than its body, the big risk of a vaginal breech birth is head entrapment, which can lead to neurological damage and other complications." Most physicians are not well-trained in the complexities of this type of birth, he adds.
More shocking still, given that black women have more than twice the rate of premature birth, they are less likely to receive a therapy that could save their premature child's life. A 1998 University of Alabama at Birmingham study of 34,000 women showed that doctors prescribe cortico-steroid therapy (given to pregnant women to hasten their baby's lung development and protect against breathing complications) less frequently for minority patients who go into early labor than for white patients -- even when the women are treated at the same medical facilities.
Racial differences aren't only found for expensive procedures, says Michael Kogan, Ph.D., director of the office of data and information management at the Maternal and Child Health Bureau, in Rockville, MD. African-American women are less likely to recieve interventions that cost nothing: information on avoiding behavior that puts babies in danger. When Kogan analyzed prenatal advice given to 8,300 women of both races, he discovered that white moms reported receiving advice not to smoke or drink more frequently from their physicians than black women did. "Fewer black women were urged to quit, so they weren't getting advice that could reduce their risk of a poor outcome for their baby." Smoking during pregnancy has been linked to low birth weight and increased danger of placenta previa and sudden infant death syndrome, while the hazards of drinking include a higher risk of birth defects and miscarriage.
And, like most pregnant women, minority women are not screened for bacterial vaginosis (BV) unless they are deemed "high-risk," a category that includes women with a history of multiple sex partners and sexually active teenagers. This policy, recommended by the American College of Obstetricians and Gynecologists, can negatively impact black women and imperil their pregnancies. The condition is a vaginal infection that strikes African-American women three times more often than white women, according to a recent study from Johns Hopkins University. While the reason for this difference is unknown, some researchers believe that douching -- a practice that's more common among black women -- may be a contributing factor. What doctors do know, however, is that BV, which causes a heavy, odorous discharge in some women -- and no symptoms at all in 50 percent of those who have it -- is one of the major triggers of premature labor. Although gynecologists can detect the infection by examining a sample of vaginal fluid and cure it with antibiotics, this test is not a routine part of prenatal care. The CDC, however, advises doctors to check all pregnant women who have previously had a premature baby for BV.
Angela Peters, R.N., a 35-year-old African-American nurse who works at the University of Mississippi Medical Center in Jackson, wasn't aware of this advice when she got pregnant last year. Although she'd had an extremely premature son, Hollis, in 1995 and one bout of BV in the past, she says that she was never checked for this infection -- probably because she wasn't considered high-risk. Her first clue that something was wrong came when she suddenly developed cramps and vaginal bleeding in her second trimester. She rushed to the hospital, where she was diagnosed with BV and put on antibiotics. That didn't help, she says. "The infection spread to the amniotic fluid and I went into labor twice." The first time, doctors were able to stop the contractions, but the second time, they weren't. Her daughter, Jordan, was born sixteen weeks premature, weighing one pound, three ounces, and was on a ventilator in the neonatal intensive care unit for 4 weeks. "I wish I'd been tested for BV," she adds. "If I'd been treated sooner, maybe I could have carried Jordan longer."
Deep-rooted stereotypes
Not only are some black women's medical needs neglected, but doctor prejudice can result in substandard care for those who do get treated, charges Dr. Ortique. "I don't think the majority of white physicians are overtly racist, but they may have biases they're not aware of. They may associate African-Americans with low socioeconomic status. Or they may not feel comfortable with people of color and spend less time talking to them, which can lead to problems not being investigated to the same extent that they would be in a white patient."
Dr. Ortique also finds that some physicians aren't as knowledgeable about black women's health as they should be. "I have white colleagues who aren't aware that African-Americans are much more likely to deliver prematurely and have a higher risk of infant mortality." A 1999 survey by the Kaiser Family Foundation also shows that a majority of Americans are equally uninformed about the longstanding racial gaps in health care. A surprising 54 percent of white people and 58 percent of blacks mistakenly believe that infant survival rates are the same for both races. The study also found that more than a third of African-Americans and Hispanics polled reported that they had experienced discrimination by a health care provider or knew someone who had.
One of the researchers who conducted the survey, Marsha Lillie-Blanton, Dr.PH., Kaiser's vice president in health policy, says she was surprised to learn that such a large percentage perceived the health care system to be biased. "African-American people I talked to said their doctors don't treat them with respect. Some felt they were told what to do, often in a condescending tone, as opposed to being actively involved in decisions about their health. So, their perception is that health care is one negative experience after another, which makes them reluctant to go to the doctor."
This could be why African-Americans make fewer visits to their doctor during the last two months of pregnancy, adds Audrey Saftlas, Ph.D., associate professor of epidemiology at University of Iowa in Iowa City. "Some researchers theorize that many pregnant minority women have had negative encounters in the medical care system in their past and they may decide that the difficulties of seeing a doctor -- such as arranging child care, getting transportation, and taking time off work -- exceed the benefits. But the tragedy is that they're not coming in at the most critical time, since the end of pregnancy is when many complications occur."
Saftlas's most recent study highlights an even graver danger: Black women are three times more likely to die of such pregnancy complications as blood clots, severe bleeding, and extremely high blood pressure than white women are. "At least half of these deaths could have been prevented with the knowledge and technology we already have," she says.
Babies in danger
It's not just pregnant women and preemies who are in jeopardy, Dr. Alexander reports. "Minority babies of normal or even heavy birth weight also fare worse." A major threat to these children is sudden infant death syndrome (SIDS), a condition in which newborns die in their sleep for no apparent reason. While the causes of SIDS are not fully understood, it is two and a half times more common in African-American infants.
These grim numbers are all too familiar to Janeen Jones, a 25-year-old African-American nursing assistant from Toledo, OH. In 1994, she found her 9 1/2-week-old baby, Michael, limp and unresponsive in his crib. "He'd just had a well-baby visit two days before and everything was fine. I put him down for a nap, and when I went in to check on him, he wasn't breathing. He died in his sleep." None of the known SIDS risk factors were present, she asserts: Michael had been sleeping on his back without any covers or toys in the crib, and Jones does not smoke. Tragedy struck again in 1996, when her third child, Daniel, also succumbed to SIDS. "The doctors had no explanation -- all they could tell me was that sudden infant death was more common in African-Americans." Jones says the stress of losing two children destroyed her marriage.
Although the rate of SIDS has dropped more than 40 percent since the American Academy of Pediatrics (AAP) started advising that babies be put to bed on their backs, some parents aren't getting the message. Before the "Back to Sleep" campaign began, 70 percent of American babies slept on their stomachs -- the most dangerous position for SIDS. Now, only 20 percent do. African-American babies, however, are twice as likely to be put to sleep in this position. To find out why, Eve Colson, M.D., director of the well-newborn nursery at Yale New Haven Hospital in Connecticut, conducted a study of inner city parents, many of whom were African-American. Only 42 percent said they always put their baby to bed on his back, while about 40 percent worried, mistakenly, that their baby might choke in this position. "We needed to do more to convince parents that the back is best," she says.
To combat SIDS among African-American babies across the country, the National Center on Minority Health and Health Disparities and the National Black Child Development Institute launched a campaign in 1999. More good news: Several government agencies have recently announced ambitious new steps to close racial and ethnic gaps. The 2001 budget of the Department of Health and Human Services (HHS) calls for nearly $5 billion in funding for programs to improve the health of African-Americans, Hispanics, Native Americans, and other medically disadvantaged groups. The department also plans to create a $20 million center for research on minority health and has targeted infant mortality as one of its most urgent priorities.
That's not all. The CDC and the National Institutes of Health have awarded $24 million to community programs in 15 states aimed at erasing health disparities, while the HHS has allocated another $35 million toward this goal. But these initiatives can be doubly effective if women themselves help alert doctors to bias in treatment and recognize that their racial and ethnic backgrounds may be affecting their health -- and that of their children.
Lisa Collier Cool is an award-winning medical writer from Westchester, New York, and a mother of three.
