High Premature Birth Rate: A Maternal and Infant Health Crisis

What Can We Learn from the U.S. 2020 Premature Birth Rate?

The 2020 prematurity birth rate results are in and, for the fifth year in a row, the rate has increased. The March of Dimes Report Card gives the United States a grade of C- based on the preterm birth rate of 10.2% (10.0% last year). The report also appraises the national preterm birth rate by percentage of live births in 2016 - 2018 (average) born pre-term for each of the five bridged racial and ethnic groups:

• Asian/Pacific Islander: 8.7%
• American Indian/Alaska Native: 11.6%
• Black: 13.8%
• White: 9.1%
• Hispanic: 9.6%

This report also looks at national data into preterm birth rates and provides a grade by state. In the U.S., the preterm birth rate for black women outpaces the rate among all other women resulting in a 50% higher rate.

Included in the March of Dimes Report (MOD) is the infant mortality rate both nationally and by state. The 2018 infant mortality rates indicates that 5.7 of every 1,000 live births do not survive, and prematurity is one of the leading causes of death for these infants. Preterm birth ethnicity is described in each of the linked racial and ethnic groups, with the highest rate of infant mortality seen for non-Hispanic Black women.

The 2020 March of Dimes Report collected data that informs on race and ethnicity disparity in the U.S by state. The ratio indicates progress towards the eradication of racial disparities in preterm birth.  Sadly, the disparity ratio in the report worsened from baseline.

Preterm birth globally impacts 15 million babies every year. More than 1 in 10 babies die each year related to complications of preterm birth. It is the leading cause of death for children under 5 years of age worldwide.

This is unacceptable!  Nevertheless, it is accepted, tolerated, and far too often overlooked.

Last year, in mid-November while awaiting the release of the March of Dimes prematurity report card, I read a quote that resonated with me. Stacey Stewart, CEO for the March of Dimes, recognizes the impact of prematurity and said “every American should be alarmed about the state of maternal and infant health in this country, because it is an issue that touches each one of us. This is one crisis, not two! The health of moms and babies is powerfully linked and we need to start treating it as such.”

More Must Be Done Regarding Premature Birth!

The World Health Organization offers solutions: “More than three quarters of premature babies can be saved with feasible, cost-effective care, such as essential care during child birth and in the postnatal period for every mother and baby, provision of antenatal steroid injections (given to pregnant women at risk of preterm labor and under set criteria to strengthen the babies’ lungs), kangaroo mother care (the baby is carried by the mother with skin-to-skin contact and frequent breastfeeding), and antibiotics to treat newborn infections.”

Breastfeeding and human milk has proven results to improve outcomes for both mothers and babies. Breast milk provides both nutrition and bioactive components that work synergistically to optimize short and long term outcomes. The benefits of breastfeeding and mothers providing their own milk protects against a range of diseases and conditions in the infants, including acute otitis media, gastroenteritis, lower respiratory tract infections, SIDS, atopic dermatitis, asthma, diabetes (types I and II), obesity (childhood and adult), childhood leukemia, and neurocognitive outcomes.

Benefits of breastfeeding extends to maternal health, including decreased postpartum bleeding, more rapid uterine involution, decreased menstrual blood loss, increased child spacing (lactational amenorrhea), earlier return to pre-pregnancy weight, and decreased risk of breast and ovarian cancers.

This past year, the coronavirus pandemic along with other challenges has brought a lot of uncertainty.  One thing that remains and is important during this global crisis is that breast milk continues to a protective benefit for both mothers and infants. It would be erroneous if I did not recognize the disparity identified in MOD Report Card.

Inequity prevails, and the March of Dimes Report Card reflects the reality of healthcare in the U.S. for minority women and infants.  Race alters access to healthcare, quality of care, and life-saving provisions. As a result, the incidence for poorer outcomes and death increases for black and brown women and infants.

Several years ago, a colleague, professional, and experienced nurse said that she was not going to provide a double breast pump kit to a black mother because she was not going to breastfeed her baby and it was a waste of a higher cost kit. Instead, she offered the mother a single breast pump kit. In her mind, she genuinely thought that, based on the mother’s skin color, she would not commit to breastfeeding her baby. I understand where her thought process was coming from - if one reviews the breastfeeding rates by race alone, one could make an assumption that a black mother may not breastfeed her baby. However, it is difficult to say – and none of us have a working crystal ball to know for sure – which mothers are going to breastfeed. Instead, wouldn’t it be prudent to offer all mothers and families the same information, products, equipment, and education so they are set up to have the best chance for meeting their breastfeeding goals and providing breast milk for their baby?

We all have biases and may not recognize them when they are present. The key here is to begin recognizing our own biases and how they alter the opportunity for equity.  NICHQ published insights on “The Impact of Institutional Racism on Maternal and Child Health”, which advocates on the importance of understanding history as a vital step toward developing policy. NICHQ also reports on steps to address racism in their latest article, “Four steps to address racism’s impact on maternal and child health.” Start with acknowledging our own bias, transition from cultural competence to cultural humility, from awareness to practice, understand the effects of stress on black women, and finally be an ally and not a savior.

Addressing Maternal and Infant Racial and Ethnic Inequities

How do we start decreasing the divide and improving maternal and infant health as it relates to race and ethnicity disparity?  Three of the top recommended solutions:

• Access to Care:  CDC Vital Signs (2017) reported on data in their article titled “African American Health: Creating equal opportunities for health” which strongly indicates health differences are often due to economic and social conditions that are more common among African Americans than whites.  Black adults are more likely to report that they could not see a medical doctor because of cost. Connect patients with community organizations and resources that can help with working across sectors to connect people, and services that impact health, such as transportation, housing, refilling prescriptions on time, and getting to follow-up visits.
• Medicaid Expansion: This may be the number one and most significant way to improve essential health for women of childbearing age, as doing so improves access to comprehensive and affordable insurance coverage.
• Delayed or Inadequate Care: Women living in rural areas are reported to have the highest rate of delayed care or no medical care due to cost and no health insurance coverage. Many are poor and unable to cover costs of care and, as a result, instances of home births are higher. Additional factors that cause challenges to access include out of pocket costs, provider availability, and logistical issues related to transportation and finding time or work conditions to make medical appointments.  Access challenges have a higher impact on women and children, because far too often when specialty care is cut or consolidated within medical systems then maternal and/or pediatric care is the first to go.
  
  Centers for Medicare and Medicaid reports on this critical issue, “Improving Access to Maternal Health Care in Rural Communities”, regarding health disparities for women in rural and urban areas and by race and ethnicity. Their research provides background information on the scope of this problem and the attention needed for national, state, and community- based organizations to collaborate on developing an action plan to improve access to maternal health care in rural communities. The brief outlines vital opportunities that exist on state and national levels to improve access to maternal healthcare in rural communities before, during, and after pregnancy.

The preterm rate is has not decreased in more than five years, the infant mortality rate has made little change, and the progress towards improving racial and ethnic disparity in preterm birth rate has worsened. If these maternal and infant health outcomes are going improve, significantly more support is required now.

References

1. March of Dimes: 2020 March of Dimes Report Card. November 15, 2020. March of Dimes Report Card
2. World Health Organization. Preterm birth. 2018. Retrieved from Preterm birth (who.int)
3. Centers for Disease Control and Prevention. (CDC). African American Health. Retrieved from African American Health | VitalSigns | CDC
4. American Academy of Pediatrics. Benefits of Breastfeeding. Benefits of Breastfeeding (aap.org)
5. National Institute for Children’s Health and Quality (NICHQ). Four Steps to Address Racism’s Impact on Maternal and Child Health. Four Steps to Address Racism’s Impact on Maternal and Child Health (nichq.org)
6. Center for Medicare and Medicaid Service. CMS. Improving Access to Maternal Health Care in Rural Communities: Issue Brief. Improving Access to Maternal Health Care In Rural Communities: An Issue Brief (cms.gov)
7. March of Dimes. 2019 March of Dimes 2019 Report Card Shines Spotlight on the U.S Maternal and Infant Health Crisis. November 4, 2019.  March of Dimes 2019 Report Card Shines Spotlight on the U.S. Maternal and Infant Health Crisis