By Anna Maria Barry-Jester, Kaiser Health News
The turning point for Dr. Paula Braveman arrived when a long-time patient of hers at a community clinic in the Mission District of San Francisco slipped past the front desk and knocked on her office door to say goodbye. He would not come back to the clinic, he told her, because he could no longer afford it.
It was a pivotal moment for Braveman who decided to not only cure sick patients, but also to advocate guidelines that will help them be healthier when they arrive at their clinic. In the nearly four decades since then, Braveman has been dedicated to researching the “social determinants of health” – how the spaces we live, work, play, and study in and the relationships we maintain there affect our health.
As director of the Center on Social Disparities in Health at the University of California-San Francisco, Braveman studied the relationship between neighborhood wealth and child health, and how access to insurance affects prenatal care. A long-time advocate of translating research into policy, she has worked on key health initiatives with the San Francisco Department of Health, the Federal Centers for Disease Control and Prevention, and the World Health Organization.
Braveman has a special interest in maternal and child health. she latest research reviews what is known of the persistent gap in preterm birth rates between black and white women in the United States. Black women are about 1.6 times more likely to give birth more than three weeks before their due date than white women. These statistics have alarming and costly health implications, as premature babies are at greater risk of respiratory, heart, and brain abnormalities, and other complications.
Braveman co-authored the review with an expert group convened by the March of Dimes that included geneticists, clinicians, epidemiologists, biomedical experts, and neurologists. They examined more than two dozen suspected causes of preterm birth – including the quality of prenatal care, environmental toxins, chronic stress, poverty, and obesity – and found that direct or indirect racism best explains racial differences in preterm birth rates.
(Note: In the review, the authors use the terms “upstream” and “downstream” to describe what determines human health. A downstream risk is the condition or factor most directly responsible for a health outcome while an upstream factor of what causes or increases the downstream risk – and often what needs to be changed to prevent someone from getting sick – for example, a person who lives near drinking water contaminated with toxic chemicals could benefit from drinking the Water Sick Use Filters. The upstream solution would be to stop the disposal of toxic chemicals.)
KHN spoke to Braveman about the study and its results. The extracts have been edited in terms of length and style.
Q: You have been concerned with premature birth and racial differences for so long. Was there anything from this review that surprised you?
The process of systematically going through all of the risk factors that are written about in the literature and then seeing how the history of racism has been an upstream determinant for practically everyone. That was kind of amazing.
The other one was very impressive: When we looked at the idea that genetic factors could be the cause of the black and white disparity in premature birth. The geneticists in the group, and there were three or four of them, concluded from the evidence that genetic factors might affect the disparity in premature birth, but at best the effect would be very small, very small in fact. This could not explain the higher rate of premature birth in black women compared to white women.
Q: In addition to finding out what causes premature birth, you wanted to explain racial differences in the rate of premature birth. Are there examples of factors that can affect premature birth that do not explain the racial differences?
It looks like there are genetic components to premature birth, but they don’t explain the black and white disparity in premature birth. Another example is an early elective caesarean section. This is one of the problems that contribute to preventable preterm birth, but it doesn’t look like it really adds to the black and white gap in preterm birth.
Q: You and your colleagues have identified exactly one upstream cause of premature birth: racism. How would you characterize the certainty that racism is a key upstream cause of higher preterm birth rates in black women?
The following saying comes to mind: A randomized clinical trial would not be necessary to be certain of the importance of parachuting when jumping out of an airplane. For me it is currently close.
When we go through this paper – and we worked on this paper for three or four years and there was plenty of time to think about it – I don’t see how the evidence we have could be explained otherwise.
Q: What did you learn about how a mother’s broader life experience of racism could affect childbirth outcomes compared to what she experienced in the medical facility during pregnancy?
There were many ways that the experience of racial discrimination affected a woman’s pregnancy, but one of the most important ways would be the pathways and biological mechanisms involved in stress and the physiology of stress. It is clear in neuroscience that a chronic stressor appears to be more damaging to health than an acute stressor.
So there is little point in searching only during pregnancy. But this is where most of that research has been done: Stress During Pregnancy and Racial Discrimination and Its Role in Birth Outcomes. Very few studies have examined life-course experiences of racial discrimination.
My colleagues and I published a paper asking African American women about their experiences of racism and we didn’t even define what we meant. Women didn’t talk much about their experiences of racism during pregnancy from their doctors; They talked about the life experience and especially about experiences that go back to childhood. And they talked about having to worry and be constantly vigilant so that their antennas have to be ready even when they are not experiencing an incident, in order to be prepared in the event of an incident.
Combined with what we know about stress physiology, I’d bet my money on the fact that life experiences are so much more important than experiences during pregnancy. Not enough is known about premature birth, but for all that is known, there is inflammation involved, immunodeficiency and that is exactly what leads to stress. Neuroscientists have shown us that chronic stress causes inflammation and dysfunction of the immune system.
Q: What measures do you consider most important at this stage to reduce premature births in black women?
I wish I could just give a guideline or two, but I think it goes back to the need to reduce racism in our society. In all its manifestations. It’s a shame not to be able to say, “Oh, here I have this magical sphere. And if you just let yourself into it, the problem will be solved. “
If you take the conclusions of this study seriously, you are saying, well, policies that only look at these downstream factors are not going to work. It is up to the upstream investment to achieve a more equitable and less racist society. At the end of the day, I think that’s takeaway, and it’s a big, big job.
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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health topics. Along with Policy Analysis and Polling, KHN is one of the three main operational programs at KFF (Kaiser Family Foundation). KFF is a non-profit foundation that provides the country with information on health issues.
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