Early Prenatal Care Does Not Close Racial Gaps in Perinatal Mortality
Even when they obtain early prenatal care, women who belong to racial and ethnic minority groups are more likely than white women to experience perinatal mortality—the loss of a fetus or the death of an infant within four weeks after birth. In a large, multicenter study of women who received care during their first trimester, perinatal mortality occurred in 10.0 pregnancies per 1,000 among white women, 15.9 per 1,000 among Hispanics and 42.1 per 1,000 among blacks. The racial disparities remained in analyses adjusting for a wide range of variables that may be associated with pregnancy outcomes.1
Racial disparities in perinatal mortality have been documented for decades. To assess whether they persist when women obtain early prenatal care, analysts examined data from a study of obstetric patients recruited at 10–13 weeks of gestation at 15 sites in nine states in 1999–2002. The database included detailed information about women's demographic and health characteristics, obstetric history and pregnancy complications. Racial differences in women's characteristics and pregnancy complications were assessed through chi-square tests or analyses of variance; odds ratios were calculated to estimate differences in perinatal mortality.
A total of 35,529 pregnancies were included in the analyses, of which 5% were among blacks, 22% among Hispanics, 68% among whites and 5% among women of other races or ethnicities. On average, black and Hispanic women were younger and had less education than white women and others, and significantly lower proportions were married. White women had the lowest average body mass index and the lowest levels of use of antihypertensive medication before pregnancy and of pregestational diabetes. Blacks reported the highest levels of tobacco and illicit drug use during pregnancy; whites, the highest level of alcohol consumption. Both the proportion who had ever had a miscarriage and the proportion who had had a preterm birth were highest among blacks.
The frequency of all 13 pregnancy complications examined differed significantly among racial groups. Notably, the proportions of women experiencing intrauterine growth restriction, preterm or very preterm birth (i.e., birth prior to 37 or 32 weeks' gestation) and cesarean delivery were highest among blacks and lowest among whites.
Thirteen pregnancies per 1,000 resulted in fetal losses or neonatal deaths, but the rate differed substantially by mother's race. It was 10.0 per 1,000 for white women, 15.9 per 1,000 for Hispanics, 42.1 per 1,000 for blacks and 16.6 per 1,000 for other women. According to analyses controlling for all of the background characteristics studied, women in any minority group were more likely than whites to experience perinatal mortality (odds ratios, 1.5 for Hispanics, 3.6 for blacks and 1.8 for women of other races). Separate analyses for three components of perinatal mortality yielded similar results: Compared with white women, blacks had sharply higher odds of experiencing fetal loss at fewer than 24 weeks of gestation, fetal loss later in gestation or neonatal death; Hispanic and other women had intermediate risks of these outcomes.
As the analysts point out, the data do not present a complete picture of the adequacy of patients' prenatal care; although a visit early in pregnancy was an eligibility requirement for study enrollment, neither the frequency nor the content of visits was documented. Nevertheless, they emphasize that the prospective nature of the data collection from a large, unselected population of pregnant women is a major strength of their data source.
The analysts contend that although their findings "implicate race as an independent… factor" in perinatal mortality, research on genetic diversity makes this conclusion "untenable." Rather, they suggest, the racial disparities may stem from "cultural differences [that] often parallel racial and ethnic lines," such as differences in nutritional status and use of health care services. Racial disparities in perinatal mortality, they conclude, must be further explored and addressed, because "prenatal care, although unequivocally helpful and necessary, remains insufficient…for minority women."—D. Hollander
1. Healy AJ et al., Early access to prenatal care: implications for racial disparity in perinatal mortality, Obstetrics & Gynecology, 2006, 107(3):625–631.