[Editor's note: Yesterday, Darline Turner-Lee introduced us to a new study by Ashley Schempf, et al that looks at racial disparities in maternal mortality rates, and the socioeconomic factors that influence those disparities. Today, Darline expounds upon this issue further, including her own experiences practicing medicine in the areas described in the study.]

Discussion

This was an interesting and difficult study to read and analyze. While I appreciate the authors' desire to pinpoint causation in an effort to propose disparity-reducing interventions, the situations are far more complex than the study leads one to believe. The authors themselves admitted that,

"A comprehensive neighborhood socioeconomic index explained only half of the total neighborhood contribution to racial disparities in MPTB, suggesting an impact of racial inequalities in neighborhood environments that is not just a function of measured socioeconomic disadvantage.'

I strongly agree with this assessment. I earned my Master's Degree at Duke University and trained as a physician assistant in the very counties described. While race and neighborhood deprivation (poverty) are significant factors, there are many more that come into play. To begin with, there is little choice of providers. If you are uninsured or on Medicare in Durham County, unless you have a tertiary care medical issue, you get your care from the county regional hospital on the far north end of the county, not at the high tech, well equipped Duke University Medical Center. With the various Medicare and Planned Parenthood cuts, there is now likely little to no availability of prenatal care in local neighborhoods. If you live in one of the lower income neighborhoods, it's difficult to get to the regional hospital for services via public transit. I can only imagine trying to get to the hospital, via public transportation and you are 13 years old (the age of one of the young ladies that I delivered). Does a 13- or even 16-year-old pregnant girl know the importance of prenatal care for herself and her baby? Their concerns are the repercussions for even being pregnant! Many girls deny and/or try to hide the pregnancy, not protect and nurture it. Fear trumps care.

Fear and mistrust towards the medical community is huge amongst African Americans. The Tuskegee Experiment is well known lore in the African American community and if that isn't enough, almost everyone has a tale of healthcare gone wrong, mistreatment, humiliation and an adverse outcome for which there was no restitution. While in training, I was on rounds in a group of about 6 students. We were all instructed by the attending physician to feel a woman's adnexal mass. At no time during this interaction was she asked if she could be examined by 6 students (I just hope that the attending asked her before the fact!). At no time were we introduced to her. At no time did any of us say one word to her. We simply walked up to her perineum in the lithotomy position and one after the other performed a pelvic examination while the attending talked about 'her case' as if she were a test dummy and not a live human being. How many of us reading this would have submitted to such treatment? And with the best-selling book The Immortal Life of Henrietta Lacks, once again the flames of mistrust towards the (white) medical community are fanned.

And then there is simply life stress itself. One of my Mamas on Bedrest lost her job after 12 weeks when she was prescribed bed rest and admitted to the hospital. A single mama, her 9 year old son was left with her mother who insisted that she couldn't care for her grandson indefinitely. So there she was in the hospital, newly unemployed and now without medical benefits. (She scrambled and was able to get emergency Medicaid.) She was worried about losing her apartment because she could no longer pay her rent (we were able to get her an emergency grant.) She was worried about her son at home. She was worried about the baby she was carrying and how she would care for him. Is it any wonder she delivered him at 28 weeks? He stayed in the NICU for weeks before being discharged home, yet was denied Early Childhood Intervention by the state. Here was a newly unemployed mama of 2, whose infant likely will have lifelong special needs.

The complexities of racial and socioecomomic disparities are myriad and make huge contributions to adverse pregnancy outcomes. While I believe that Schempf and her colleagues mean well in trying to pinpoint factors that could be modified to improve birth outcomes, 'The Gap' in maternal and infant morbidity and mortality between African American and white women in the United States has so many inter-related factors, I really don't believe that you can control for them all or regard them independently-at least at this point in time as our societal and health care systems are structured. Covert and overt racism still exist in this country and its effects create 'unobserved' factors that are difficult to measure. When I had my son nearly 6 years ago, I was approached by a 'well meaning' social worker who came into my private room to present me with a binder of Medicare, WIC and Social Services information. 'Here is some information you may need,' she explained. Quickly perusing the binder of papers, my immediate response was indignation and anger.

'Why would you think I needed this information?' I asked her. 'Oh well, I just thought...' she trailed off. I politely informed her that we had private PPO insurance, that my husband would be in shortly on his way to work (at a local semiconductor corporation) and that her information was neither needed nor wanted. She turned all kinds of red, and quickly left. I quickly recovered (so I thought) from the incident, yet can vividly recall it today. How did that incident impact my health in that moment? What impact did it have on my memory of my son's birth, of my experience as a patient in that hospital and as a birthing black woman in Texas? Was my experience unique or par for the course as a black woman? Can it be measured? Should it be ignored?

The logistical analyses applied to the data from North Carolina, I believe, portray an artificial, misleading picture that race and SES, when 'leveled out' or 'controlled' really don't have a statistically significant impact on birth outcome in black women. There are just too many other factors involved, many for which there are no controls that are contributing to the disparities. While I believe that this is a plausible start, there needs to be much more research in racial disparities in maternity care, including SES and birth outcomes and examining the interactions between patients of color and white providers before we'll be able to develop effective interventions to bridge and eventually eliminate 'The Gap.'

*To read yesterday's post, go here.

Posted by: Darline Turner-Lee, BS, MHS, PA-C

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