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Identifying Health Disparities and Social Inequities Affecting Childbearing Women and Infants
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Identifying Health Disparities and Social Inequities Affecting Childbearing Women and Infants Lorraine O. Walker and Lorie W. Chesnut
Correspondence Lorraine O. Walker, EdD, MPH, RN, University of Texas at Austin, School of Nursing, 1700 Red River Street, Austin, TX 787011499. [email protected]
ABSTRACT This article presents health disparities and social inequities that may underlie adverse outcomes for childbearing women and infants in the United States. It also presents Internet-accessible databases that nurses can use to assess maternal and infant health disparities at a national or state level. Such assessments are basic to planning programs to address gaps in health care and advocating for practice and policy changes to improve the health care of childbearing women and infants.
JOGNN, 39, 328-338; 2010. DOI: 10.1111/j.1552-6909.2010.01144.x Accepted September 2009
Keywords health disparity inequity infant maternal social justice
Lorraine O. Walker, EdD, MPH, RN, is the Luci B. Johnson Centennial Professor at the University of Texas at Austin, School of Nursing, Austin, TX. Lorie W. Chesnut, MPH, is a doctoral student in the Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL and a part-time faculty member, College of Public Health, University of Kentucky, Lexington, KY.
he United States ranks 29th in the world in infant mortality (MacDorman & Matthews, 2008) and 41st in its maternal mortality (Senate Resolution 616 [110th], 2008). In this article, we present health disparities and related social inequities that may underlie these troubling outcomes for childbearing women and infants in the United States. We also identify Internet-accessible databases that nurses may use to assess maternal and infant health at a national or state level. Such assessments are basic to planning programs to address gaps in health care and advocating for practice and policy changes to improve the health care of childbearing women and infants.
T
In this article, a health disparity refers to ‘‘a signi¢cant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the [health disparity] population as compared to the health status of the general population’’ (Minority Health and Health Disparities Research and Education Act, 2000). Because a large disparity in a population subgroup may elevate the rates of health problems manifested in the general population (Carter-Pokras & Baquet, 2002), comparisons are often based on reference populations, such as those for White Americans.
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Health disparities are of concern to nurses and other health professionals because of their professional mandate to promote health, prevent disease, and reduce su¡ering related to illness. More broadly, health disparities are of concern to all health professionals and policy makers because they often are linked to underlying social inequities that may be viewed as avoidable and unjust (Carter-Pokras & Baquet, 2002; Falk-Rafael, 2005). Such social inequities may include disadvantages stemming from socioeconomic status, educational opportunity, or discrimination. For example, nearly one in ¢ve American adults was not a high school graduate, and nearly one in seven lived below the federal poverty line in 2007 (FedStats, 2009). Single women with families, especially those headed by minority women, have the highest rates of poverty (National Poverty Center, 2008). These circumstances in turn may lead to living in environmentally unhealthy conditions, such as poor housing with lead exposures. Social inequities may contribute to di¡erences in access to or quality of health care, less knowledge and skill in promoting personal and family health, and resultant poorer health outcomes. Our framework for integrating evidence-based needs assessment of disparities in maternal or in-
& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Walker, L. O. and Chesnut, L. W.
Maternal & Infant Social Characteristics: -Age -Race / ethnicity -Income -Education
Health Care: -Access -Quality of care -Timeliness -Type of services
Maternal or Infant Health Outcomes: -Unfavorable -Favorable
Individual Characteristics: -Knowledge -Attitudes -Beliefs -Health practices
Figure 1. Framework for maternal and infant evidence on health disparities.
fant health is shown in Figure 1. Four domains of commonly used evidence include social characteristics associated with health inequities, such as race or ethnicity or income; factors associated with health care, such as access to or quality of health care; characteristics of individuals, such as beliefs or health practices; and health outcomes, which may be favorable or unfavorable because of many of these antecedent factors. Each of these four domains re£ects components considered in Objective 16 related to maternal and infant health in Healthy People 2010 (U.S. Department of Health and Human Services, 2000). Arrows denote key in£uences among these four domains. Because this ¢gure is used here primarily as a heuristic, other potential mediating and moderating relationships may need to be added if the ¢gure is used for other purposes. Consistent with Healthy People 2010, we view health care broadly to include not only the care traditionally rendered by doctors, nurses, or nurse practitioners in clinics and hospitals, but also care provided in public health settings that focus on health education, nutritional counseling, and health screening.
some maternal and child health outcomes have no parallel surveillance data, so national statistics are unavailable, for example, on postpartum illnesses of women (Centers for Disease Control and Prevention [CDC], 2009). In addition, national data on certain health behaviors, such as illicit drug use during pregnancy, may be unavailable for certain population subgroups because the data are not collected or analyzed, or are deemed to be statistically unreliable.
In the next section, we emphasize population-based sources of evidence on health disparities, either ones based on whole populations or representative samples where these are available. Although data from selected clinical and community agencies may be useful within those agencies, they may over- or underrepresent certain demographic groups and consequently lead to biased conclusions about populations of childbearing women and infants. By contrast, because of the representativeness of data drawn from state and national surveillance and vital record systems (e.g., data from birth and death certi¢cates), these are widely used sources of data about the health outcomes of maternal-infant populations. A shortcoming of U.S. health data is that
Health-Related Disparities of Childbearing Women and Infants
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Similarly, data on some population subgroups may be unreported at the state level because they are statistically unreliable as a result of small numbers of cases. Finally, analysis of health disparities, such as that related to Healthy People 2010 (U.S. Department of Health and Human Services, 2000), is often limited to the social variables of maternal education, age, and race and Hispanic ethnicity. This is because other variables associated with social inequities, such as social class, income, or disability status, are less accessible. Thus, the social variables considered in the next section are limited to maternal education, age, and race and Hispanic ethnicity.
In this section we focus on major areas of national concern in Healthy People 2010 related to the health of infants and childbearing women. Infant mortality is a sensitive indicator of the health of a population. In 2005, the overall infant mortality rate was 6.9 deaths per1,000 live births in the United States and exceeded the 2010 target of 4.5 deaths per 1,000 (CDC, 2009). Non-Hispanic Black or African American populations experienced more than twice the rate of infant mortality (13.6 deaths per1,000 live births) compared to nonHispanic-White reference populations (5.8 deaths per 1,000 live births). American Indian and Alaskan Native
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NH White NH Black Hispanic Asian / Pacific Isl. 0.0
10.0 20.0 30.0 Maternal Deaths per 100,000 live births
40.0
Figure 2. Maternal deaths by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Maternal mortality ratios for American Indians are not included because the CDC classi¢ed the existing data as not meeting statistical or con¢dentiality criteria.
populations also experienced relatively high infant mortality rates (8.1 deaths per1,000 live births). Disparities in infant mortality are also associated with maternal age at the time of giving birth with mothers younger than age 20 having higher rates of infant deaths (10.2-16.4 per 1,000) than mothers age 20 or older (5.5-7.9 per 1,000). Similarly, the 2005 overall maternal mortality ratio of 15.1 deaths per 100,000 live births exceeded the 2010 target of 4.3 maternal deaths per 100,000 (CDC). Non-Hispanic Black or African American populations had more than 3 times the ratio of maternal mortality than reference White populations (Figure 2). Maternal age is also associated with disparities in maternal mortality, with mothers younger than age 20 having the lowest mortality (7.4 deaths per 100,000) and mothers 35 years or older having the highest (38 deaths per 100,000). In contrast, maternal education as classi¢ed by the CDC is not associated with large disparities in infant mortality, but women with only a high school education (or less) have twice the
maternal mortality of those with some college education (CDC). For infants, mortality rates can be further broken down in terms of deaths occurring among those fewer than 28 days of age (neonatal mortality) and those 28 days to 1 year of age (postneonatal mortality). Figure 3 reveals that non-Hispanic Black populations experience substantially higher rates of neonatal and postneonatal mortality than reference non-Hispanic White populations. Among American Indian and Alaskan Native populations, however, the postneonatal but not neonatal mortality rate is substantially elevated compared to White reference populations. Figure 4 presents infant deaths associated with birth defects and sudden infant death syndrome (SIDS). Disparities are associated with American Indian and Alaskan Native, and non-Hispanic Black populations compared to White reference populations for both of these causes of infant deaths. In addition to racial/ethnic factors, being a teen-aged mother is associated
NH White NH Black Hispanic Neonatal
Asian / Pacific Isl.
Postneonatal
Am. Indian / Al. Native 0.0
2.0
4.0 6.0 Deaths per 1000 Live Births
8.0
10.0
Figure 3. Neonatal and postneonatal mortality by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native.
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with elevated rates of neonatal and postneonatal mortality, whereas lower maternal education levels are associated with elevated SIDS mortality rates (CDC, 2009). The conditions of low-birth-weight (o2,500 g) and preterm birth (o37 weeks gestation) are of widespread concern because of their association with infant mortality and morbidities (Goldenberg & Culhane, 2007). Although low birth weight may be the result of either preterm birth or inadequate fetal growth, it continues to be used in the United States and globally because of its ease and reliability of measurement (Kramer, 2003). As Figure 5 shows, disparities in the percentage of low-birth-weight infants are approximately double for non-Hispanic Black populations in 2005 compared to percentages for non-Hispanic White reference and other populations; however, all populations exceeded the 2010 target of 5.0%. Mothers younger than age 15 had the highest percentage of low-birth-weight infants (13.3%), but minimal di¡erences in the proportion of low birth weight are associated with maternal education level (CDC, 2009). In the case of preterm birth (Figure 5), all population groups exceed the 2010 target of 7.6% preterm births. Although non-Hispanic Black populations have a higher percentage of preterm births than White reference populations, the relative disparities are less extreme than those associated with low birth weight. These di¡erences in the patterning of disparities related to low-birth-weight and preterm birth in part may re£ect the di¡erent underlying determinants of these two morbidities (Kramer). Except for mothers in the youngest age groups, di¡erences in maternal age or maternal education
Infant mortality is a sensitive indicator of the health of a population.
were not associated with large disparities in preterm births (CDC). Receiving recommended prenatal care visits is an important component of promoting health during pregnancy and preventing or managing morbidities at an early stage. With regard to prenatal care, no population subgroup met the 2010 target that 90% of pregnant women receive early and adequate prenatal care (Kotelchuck, 1994). Although there were racial and ethnic disparities in prenatal care with only 59% of American Indian and Alaskan Native women receiving early and adequate prenatal care, the most extreme disparities were associated with maternal age (CDC, 2009). The proportion of women receiving early and adequate prenatal care increased incrementally from the youngest mothers (younger than age 15) through women age 30 years or older (Figure 6). Although health disparities are usually associated with the incidence or prevalence of unfavorable health outcomes, such as mortality and morbidity, social inequities related to educational opportunities and social resources may also in£uence health behaviors or practices that are associated with maternal and infant health (Figure 1). In this review, we focus on three practices that are widely recognized as important to maternal and infant health: smoking abstinence during pregnancy, breastfeeding to at least 6 months, and putting
NH White NH Black Hispanic
Birth Defects SIDS
Asian / Pacific Isl. Am. Indian / Al. Native 0
0.4 0.8 1.2 1.6 2 Deaths per 1000 live births, infants age younger than 1 year
Figure 4. Infant deaths from birth defects and sudden infant death syndrome (SIDS) by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native.
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NH White NH Black Hispanic
LBW Preterm
Asian / Pacific Isl. Am. Indian / Al. Native 0%
5% 10% 15% Low-Birth-Weight (LBW) and Preterm Births
20%
Figure 5. Low birth weight and preterm births by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native; LBW 5 low birth weight.
infants to sleep on their backs (American Academy of Pediatrics, Task Force on infant Positioning and SIDS, 1992; American Academy of Pediatrics, Work Group on Breastfeeding, 1997; U.S. Department of Health and Human Services, 2004). With regard to smoking abstinence during pregnancy, although racial and ethnic disparities exist with American Indian and Alaskan Native populations having the lowest rates of abstinence (82%), no racial or ethnic group meets the 2010 target of 99% abstinence (CDC, 2009). The largest disparities for smoking abstinence during pregnancy are associated with maternal education (see Figure 7), with only college graduates meeting the 2010 target.
education is also associated with substantial disparities: women with 9th- to 11th-grade education are least likely to breastfeed to 6 months, whereas women with college degrees are most likely to do so as well as to report ever breastfeeding with the most recent birth (see Figure 8). Surveillance data (2006) related to whether populations are meeting the 2010 goal of 70% of infants being put to bed in the back-sleeping position are limited to race and ethnicity. Black infants are less likely (61%) to be put to bed in the back-sleeping position than White (77%) or Hispanic (72%) infants, and the latter two groups both exceed the 2010 target (CDC, 2009).
With regard to breastfeeding, Asian and Paci¢c Islander populations are most likely to breastfeed to at least 6 months (52%) and the only racial or ethnic group to exceed the 2010 target of 50%. NonHispanic Black women are the least likely to breastfeed to 6 months (26%). However, maternal
Identi¢cation of health disparities is important in setting priorities for research to improve health of childbearing women and children, and in critically examining existing health care services for relevance to the key challenges to maternal and infant health. Equally important, knowledge of health
<15 yr. 15-19 yr. 20-24 yr. 25-29 yr. 30-34 yr. >34 yr. 0%
20%
40% 60% Early and Adequate Prenatal Care
80%
100%
Figure 6. Early and adequate prenatal care by maternal age: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009).
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disparities provides an evidence base for nurses and others to advocate for, or to take action to improve, the health of maternal and infant populations. Substantial disparities and gaps exist in meeting most 2010 targets for mortality, morbidity, health care, and some health practices important to the health and well-being of childbearing women and infants. Disparities are associated with the social variables of race, education, and maternal age, but these associations may di¡er across health outcomes, health care received, and health practices. Even widely publicized health practices, such as use of the back-sleeping position for infants, are only met by certain demographic groups.
No population subgroup met the 2010 target that 90% of pregnant women receive early and adequate prenatal care.
The preceding section provided a broad picture of maternal and infant health disparities from a national perspective and focused on areas emphasized in Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and its associated national database CDC Wonder Data 2010 (CDC, 2009). In this section we emphasize a variety of Internet-based data resources that nurses and others may use in their e¡orts to assess maternal and infant health disparities. In many cases, state data of su⁄cient size are available for reliable population estimates. For nurses in Canada, similar data sources may be found at the website for Statistics Canada (http://www.statcan.gc.ca/). This website has an option for either French or English.
Control and Prevention (CDC), or its subunit the National Center for Health Statistics (NCHS). Key federal databases related to maternal and infant health are presented in Table 1. VitalStats is a new NCHS system that o¡ers Internet users either prebuilt or customized analyses based on birth certi¢cate information. The Pregnancy Risk Assessment and Monitoring System (PRAMS) is a population-based postpartum survey of new mothers that is linked to birth certi¢cate data. PRAMS covers a number of behavioral, health care, and health status variables from preconception to the postpartum period. Its primary limitation is that PRAMS data are only available for selected states. The Pediatric Nutrition Surveillance System (PedNSS) and Pregnancy Nutrition Surveillance System (PNSS) are two national databases focused on participants in public health programs. As a result PedNSS and PNSS contain primarily nutritionrelated data pertaining to low-income women and children. The Maternal and Child Health Bureau (MCHB) is the lead federal agency for maternal and child health. It also disperses Title V funds to states to support health services to mothers and children. As a result, MCHB maintains a database on key maternal and child health indicators of each state, and Internet-searchable reports on each state’s maternal and child priorities. Additional federal databases that may contain some data on mothers and infants are presented in a comprehensive listing provided by Zeni and Kogan (2007).
The U.S. government maintains a number of healthrelated databases within the Centers for Disease
Table 2 presents databases available through nonpro¢t sources. An advantage of these is that they
Evidence Sources on Health Disparities of Childbearing Women and Infants Federal and Nonprofit Sources of National and State-Level Data
Grades 9 - 11 High School Graduate Some College or AA Degree College Graduate or above 100% 0% 25% 50% 75% Abstinence from Cigarette Smoking During Pregnancy Figure 7. Abstinence from cigarette smoking during pregnancy by maternal educational attainment: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009).
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Grades 9 - 11 High School Graduate Some College or AA Degree College Graduate or above 0%
25% 50% 75% Breastfeeding Ever and at 6 Months
100%
Figure 8. Breastfeeding ever and at 6 months by maternal educational attainment: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. AA 5 Associate Degree.
Table 1: Federal Data Sets Related to Childbearing Women and Infants Population-Based
Data-Base
Database Name
Federal Agency
Years Available
or Sample
Featuresa
Pregnancy Risk
Centers for
Year-to-Year
State-level sample
Prebuilt tables from http://www.cdc.gov/prams/
Assessment &
Disease
variation.
survey drawn
(1995^2002) (go
Standardized data
Monitoring
Control and
States begin to
from birth
to ‘‘surveillance
collection procedures
Systems (PRAMS)
Prevention
participate in
certi¢cate ¢les.
report’’ on right).
and instruments allowing
(CDC)
1988. By 2005,
Data can be
state-to-state
26 states
requested
comparisons. Scope of
participating.
through the CDC
data is from
for ¢le download.
preconception to early
Website and Data Overview
postpartum period. Includes data for health care access and individual characteristics. Pediatric Nutrition
CDC
1998 to 2007
Public Health
Prebuilt reports.
http://www.cdc.gov/
Surveillance
Surveillance
(go to ‘‘Current
PEDNSS/ Low income
System (PedNSS)
System. A⁄liated
National PedNSS
include women and
WIC agencies
data tablesç
children participating in
voluntarily submit
health
federal nutrition and
dataçnot
indicators’’)
public health programs.
representative of
Data on birthweight,
the general
short stature, under^
population.
overweight, anemia, breastfeeding. Some health behaviors including smoking, WIC enrollment.
Pregnancy
CDC
Varies. As early as
Public Health
Prebuilt reports.
http://www.cdc.gov/
Nutrition
1983 for selected
Surveillance
(go to ‘‘Current
PEDNSS/index.htm
Surveillance
indictors to 2007.
System. A⁄liated
National PNSS
Same as above. Data on
System (PNSS)
Most early 1990s
WIC agencies
data tablesç
maternal health
to present.
voluntarily submit
Health
indicators, health
data. Not
indicators’’).
behaviors and infant
representative of
outcomes.
the general population
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Table 1. Continued Federal Database Name
Agency
Data 2010 (Healthy CDC
Population-Based
Data-Base
Years Available
or Sample
Featuresa
Website and Data Overview
1998^2007
Population-based.
Prebuilt tables.
http://wonder.cdc.gov/
People 2010)
National and
Graphs. Data
data2010/obj.htm
State-level data.
download to
Interactive data base
Excel available.
system tracking Health People 2010 objectives (467) from baseline to target.
U.S. Birth Data and National
Births (1990
Population-based.
Prebuilt tables and
http://www.cdc.gov/nchs/
Statistics (Vital
Center for
through 2006).
National, state
reports or create-
VitalStats.htm More than
Stats)
Health
Perinatal
and some
your-own reports
100 demographic and
Statistics
mortality (2003^
county-level data
(query systems)
health variables available
(NCHS)
2005). Deaths
available (for
or tables. Maps,
for birth data ¢les. Parts
under
populations of 4
charts, graphs.
of this system are still
development.
100,000).
under development as of May 2009.
Title V MCH Block
Maternal and
Current Year for
Population-based.
State Narratives
https://perfdata.hrsa.gov/
Grant Annual
Child Health
Annual Report,
State-level
and Data Forms
mchb/mchreports/
Report and
Bureau
and 2005 MCH
annual reports.
including
Search/search.asp
Needs
(MCHB)
Needs
¢nancial and
System allows the user to
Assessment
program data.
query the state narrative
Assessment
by keyword or view individual application sections. Trend data by state is available for MCH select performance and outcome measures. Note. a
Database features refers to having a user-select query system and the ability to download data, tables, and graphs.
bring together data from a variety of sources that pertain to their mission. Foremost among these is Peristats, a database of perinatal data at the state and U.S. national levels maintained by the March of Dimes Birth Defects Foundation. By contrast, the Statehealthfacts database maintained by the Kaiser Family Foundation focuses on a variety of health indicators at the state level of which a number pertain to health of mothers and infants as well as other population subgroups. Other key nonpro¢t databases in Table 2 focus on children’s health or women’s reproductive health.
An Example of Using Available Databases to Assess Maternal and Infant Health Needs To illustrate how nurses might use various databases, we provide a ¢ctitious example of how nurses in three statesçAlabama, Florida, and Texasçjoined together through their Association of Women’s Health, Obstetric and Neonatal Nurses
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(AWHONN) organizations to assess the health needs of childbearing women and infants. We selected these states because of their diverse populations. The nurses in our example were interested in what areas they might target for campaigns or advocacy to improve maternal and infant health within their speci¢c state. To begin, the nurses felt is was important to have an overall picture of the demographic characteristics of each state so they accessed the U.S. government portal FedStats (http://www.fedstats.gov/) and printed out key social and economic indicators for each state using the MapStats option. The demographic data revealed that there were substantial Hispanic populations in Texas (36%) and Florida (21%), whereas African Americans were a substantial minority population in Alabama (27%) and also in Florida (16%). They also noted that Alabama had a lower per-capita income then Texas and Florida, although Alabama and Texas had a higher percent
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The U.S. government maintains a number of Internetaccessible databases related to maternal and infant health. of persons living below the federal poverty level than Florida. From the CDC Wonder Data 2010 website (Table 1), they found that Alabama had a higher infant mortality rate (9.5 deaths per 1,000 live births) compared to Texas (6.5 deaths) or Florida (7.2 deaths). From the Peristats website (Table 2), they sought data on access to health care among women of childbearing age and found that Alabama had a lower overall number of uninsured women of childbearing age (20%) compared to Florida (27%) or Texas (31%). The nurses then decided they wanted to focus their campaign on early and adequate prenatal care (Kotelchuck, 1994) in state populations with patterns of health disparities and turned again to the CDC Wonder Data 2010 website. They found that in Alabama the infants of African American and teen mothers had higher infant mortality rates; these two groups also faced disparities related to early
and adequate prenatal care. Thus, Alabama nurses selected these disparity groups as their focus. In Florida, nurses found that less than one half of teen mothers were getting early and adequate prenatal care so decided to focus on this disparity. In Texas, the nurses found that less than one half of Hispanic women received early and adequate prenatal care so decided to focus on this disparity group. Nurses in each state then turned to the MCHB website (Table 1) to examine each state’s maternal and child health priorities to see how their own e¡orts might be coordinated with those of each state. Although this example is ¢ctitious and simplistic (but the ¢ndings for the states are real), it illustrates how nurses might use Internet-accessible data to assess areas of need in their state to improve the health of mothers and infants.
Concluding Perspective Key maternal and infant health disparities in the United States and related Internet-accessible databases are presented in this article. The purpose of monitoring health disparities is to provide an evi-
Table 2: Nonprofit Sources and Other Informational Resources Database
Population-
Name
Agency
Years Available
Based or Sample Database Features Website and Data Overview
PeriStats
March of Dimes
Varies. As early as
Population-
Birth Defects
1990 for select
based.
Foundation
User-select query
http://www.marchofdimes.
system, graphs,
com/peristats/ Data from 12
indicators through
maps, tables. U.S.,
government agencies and
2006.
regional and state
organizations are
summaries
combined to provide an
available. Select
exceptionally user-friendly
county-level and
tool. Perinatal data
city-level data
primarily from the National
available.
Center for Health Statistics. Features also include literature search capabilities, calculations, de¢nitions, and updates.
Statehealthfacts
Kaiser Family Foundation
Current. Some older
Varies by topic.
Interactive maps,
http://www.statehealthfacts.
data may be
tables, graphs,
org/ Data provided on more
available upon
downloadable as
than 500 health topics, very
request.
.pdf ¢les. U.S. and
user friendly. Sources
state-to-state
include various federal
comparisons.
agencies, Kaiser Family Foundation reports, and more. Includes special reports, ¢nancial expenditures for health services, and more.
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Table 2. Continued Database
Population-
Name
Agency
Years Available
Based or Sample Database Features Website and Data Overview
KIDS COUNT
The Annie E.
Current with
Population
Data Center
Casey
multiyear option for
Foundation
select indicators.
Interactive maps,
based.
http://datacenter.kidscount.
tables, graphs,
org/ Data provided on more
pro¢les, rankings.
than 100 indicators,
Includes
including economic status,
community-level
health, safety, and risk
data for some
factors. Very user friendly.
indicators. Raw
All data from government
data available for
sources. Includes special
download.
reports, publications associated with child wellbeing, and more.
Guttmacher Institute State
Guttmacher Institute
Varies.
Population
Interactive maps,
based.
http://www.guttmacher.org/
build-your-own
statecenter/ Data from
Center, State
tables for select
published reports/materials
Table Maker
indicators.
created by the Guttmacher Institute (specializing in sexual and reproductive health) and from other sources including select federal agencies. Includes information on abortion, adolescents, contraception, pregnancy, and services/ ¢nancing. Links to statespeci¢c prebuilt reports, research articles, and policy analyses.
dence base for changes in practice, policy, or programs, or for setting priorities related to resources to reduce or eliminate the disparities. Failure to monitor health disparities carries the inherent risk of assuming that all groups in the overall population are fairing equally well when this may not be the case. There is also the inherent risk that populations found to be at higher risk of certain disparities will be stereotyped in ways that marginalize them still further. As a result, it is essential that nurses partner with representatives of the disparities populations for whom they wish to advocate or seek to better serve. Such partnering allows nurses and other professionals to more deeply understand the context of disparities and work collaboratively with representatives of disparities populations. Models for such partnering and community involvement may be found in sources such as Healthy Start programs (PolicyLink, 2000). Understanding where disparities exist and partnering with disparities populations enable nurses to take action to pro-
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mote social justice for childbearing women and infants.
Acknowledgments Partially funded by MCHB Leadership for Education in Public Health Training Grant #T76MC00008, Education for MCH Leadership at UAB.
REFERENCES American Academy of Pediatrics, Task Force on infant Positioning and SIDS. (1992). Positioning and SIDS. Pediatrics, 89,1120-1126. American Academy of Pediatrics, Work Group on Breastfeeding. (1997). Breastfeeding and the use of human milk. Pediatrics, 100, 10351039. Carter-Pokras, O., & Baquet, C. (2002). What is a ‘‘health disparity’’? Public Health Reports, 117, 426-434. Centers for Disease Control and Prevention. (2009). Data 2010 . . . the Healthy People 2010 database. Retrieved from http://wonder.cdc. gov/data2010/OBJ.HTM Falk-Rafael, A. (2005). Speaking truth to power: Nursing’s legacy and moral imperative. Advances in Nursing Science, 28, 212-223.
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FedStats. (2009). MapStats. Retrieved from http://www.fedstats.gov/qf/ states/01000.html Goldenberg, R. L., & Culhane, J. F. (2007). Low birth weight in the United States. American Journal of Clinical Nutrition, 85, 584S-590S. Kotelchuck, M. (1994). An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. American Journal of Public Health, 84, 1414-1420. Kramer, M. S. (2003). The epidemiology of adverse pregnancy outcomes: An overview. Journal of Nutrition, 133,1592S-1596S. MacDorman, M. F., & Matthews,T. J. (2008, October). Recent trends in infant mortality in the United States (NCHS Data Brief, No. 9). Retrieved from http://www.cdc.gov/nchs/data/databriefs/db09.htm Minority Health and Health Disparities Research and Education Act.
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National Poverty Center. (2008). Poverty in the United States. Retrieved from http://npc.umich.edu/poverty/ PolicyLink. (2000). Community involvement in the federal Healthy Start program. New York: Author. Retrieved from http://www.policylink. org/pdfs/HealthyStartBrief.pdf. Senate Resolution 616 [110th]. (2008). A resolution reducing maternal mortality both at home and abroad. Retrieved from http://www. govtrack.us/congress/billtext.xpd?bill=sr110-616 U.S. Department of Health and Human Services. (2000). Healthy people 2010 (conference edition, in two volumes). Washington, DC: Author. U.S. Department of Health and Human Services. (2004). The health consequences of smoking: A report of the surgeon general. Atlanta, GA: Author.
Public Law 106-525 (2000). Retrieved from http://frwebgate.
Zeni, M. B., & Kogan, M. D. (2007). Existing population-based health da-
access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106__cong__public__
tabases: Useful resources for nursing research. Nursing Outlook,
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55, 20-30.
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Identifying Health Disparities and Social Inequities Affecting Childbearing Women and Infants Lorraine O. Walker and Lorie W. Chesnut
Correspondence Lorraine O. Walker, EdD, MPH, RN, University of Texas at Austin, School of Nursing, 1700 Red River Street, Austin, TX 787011499. [email protected]
ABSTRACT This article presents health disparities and social inequities that may underlie adverse outcomes for childbearing women and infants in the United States. It also presents Internet-accessible databases that nurses can use to assess maternal and infant health disparities at a national or state level. Such assessments are basic to planning programs to address gaps in health care and advocating for practice and policy changes to improve the health care of childbearing women and infants.
JOGNN, 39, 328-338; 2010. DOI: 10.1111/j.1552-6909.2010.01144.x Accepted September 2009
Keywords health disparity inequity infant maternal social justice
Lorraine O. Walker, EdD, MPH, RN, is the Luci B. Johnson Centennial Professor at the University of Texas at Austin, School of Nursing, Austin, TX. Lorie W. Chesnut, MPH, is a doctoral student in the Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL and a part-time faculty member, College of Public Health, University of Kentucky, Lexington, KY.
he United States ranks 29th in the world in infant mortality (MacDorman & Matthews, 2008) and 41st in its maternal mortality (Senate Resolution 616 [110th], 2008). In this article, we present health disparities and related social inequities that may underlie these troubling outcomes for childbearing women and infants in the United States. We also identify Internet-accessible databases that nurses may use to assess maternal and infant health at a national or state level. Such assessments are basic to planning programs to address gaps in health care and advocating for practice and policy changes to improve the health care of childbearing women and infants.
T
In this article, a health disparity refers to ‘‘a signi¢cant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the [health disparity] population as compared to the health status of the general population’’ (Minority Health and Health Disparities Research and Education Act, 2000). Because a large disparity in a population subgroup may elevate the rates of health problems manifested in the general population (Carter-Pokras & Baquet, 2002), comparisons are often based on reference populations, such as those for White Americans.
328
Health disparities are of concern to nurses and other health professionals because of their professional mandate to promote health, prevent disease, and reduce su¡ering related to illness. More broadly, health disparities are of concern to all health professionals and policy makers because they often are linked to underlying social inequities that may be viewed as avoidable and unjust (Carter-Pokras & Baquet, 2002; Falk-Rafael, 2005). Such social inequities may include disadvantages stemming from socioeconomic status, educational opportunity, or discrimination. For example, nearly one in ¢ve American adults was not a high school graduate, and nearly one in seven lived below the federal poverty line in 2007 (FedStats, 2009). Single women with families, especially those headed by minority women, have the highest rates of poverty (National Poverty Center, 2008). These circumstances in turn may lead to living in environmentally unhealthy conditions, such as poor housing with lead exposures. Social inequities may contribute to di¡erences in access to or quality of health care, less knowledge and skill in promoting personal and family health, and resultant poorer health outcomes. Our framework for integrating evidence-based needs assessment of disparities in maternal or in-
& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Walker, L. O. and Chesnut, L. W.
Maternal & Infant Social Characteristics: -Age -Race / ethnicity -Income -Education
Health Care: -Access -Quality of care -Timeliness -Type of services
Maternal or Infant Health Outcomes: -Unfavorable -Favorable
Individual Characteristics: -Knowledge -Attitudes -Beliefs -Health practices
Figure 1. Framework for maternal and infant evidence on health disparities.
fant health is shown in Figure 1. Four domains of commonly used evidence include social characteristics associated with health inequities, such as race or ethnicity or income; factors associated with health care, such as access to or quality of health care; characteristics of individuals, such as beliefs or health practices; and health outcomes, which may be favorable or unfavorable because of many of these antecedent factors. Each of these four domains re£ects components considered in Objective 16 related to maternal and infant health in Healthy People 2010 (U.S. Department of Health and Human Services, 2000). Arrows denote key in£uences among these four domains. Because this ¢gure is used here primarily as a heuristic, other potential mediating and moderating relationships may need to be added if the ¢gure is used for other purposes. Consistent with Healthy People 2010, we view health care broadly to include not only the care traditionally rendered by doctors, nurses, or nurse practitioners in clinics and hospitals, but also care provided in public health settings that focus on health education, nutritional counseling, and health screening.
some maternal and child health outcomes have no parallel surveillance data, so national statistics are unavailable, for example, on postpartum illnesses of women (Centers for Disease Control and Prevention [CDC], 2009). In addition, national data on certain health behaviors, such as illicit drug use during pregnancy, may be unavailable for certain population subgroups because the data are not collected or analyzed, or are deemed to be statistically unreliable.
In the next section, we emphasize population-based sources of evidence on health disparities, either ones based on whole populations or representative samples where these are available. Although data from selected clinical and community agencies may be useful within those agencies, they may over- or underrepresent certain demographic groups and consequently lead to biased conclusions about populations of childbearing women and infants. By contrast, because of the representativeness of data drawn from state and national surveillance and vital record systems (e.g., data from birth and death certi¢cates), these are widely used sources of data about the health outcomes of maternal-infant populations. A shortcoming of U.S. health data is that
Health-Related Disparities of Childbearing Women and Infants
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Similarly, data on some population subgroups may be unreported at the state level because they are statistically unreliable as a result of small numbers of cases. Finally, analysis of health disparities, such as that related to Healthy People 2010 (U.S. Department of Health and Human Services, 2000), is often limited to the social variables of maternal education, age, and race and Hispanic ethnicity. This is because other variables associated with social inequities, such as social class, income, or disability status, are less accessible. Thus, the social variables considered in the next section are limited to maternal education, age, and race and Hispanic ethnicity.
In this section we focus on major areas of national concern in Healthy People 2010 related to the health of infants and childbearing women. Infant mortality is a sensitive indicator of the health of a population. In 2005, the overall infant mortality rate was 6.9 deaths per1,000 live births in the United States and exceeded the 2010 target of 4.5 deaths per 1,000 (CDC, 2009). Non-Hispanic Black or African American populations experienced more than twice the rate of infant mortality (13.6 deaths per1,000 live births) compared to nonHispanic-White reference populations (5.8 deaths per 1,000 live births). American Indian and Alaskan Native
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NH White NH Black Hispanic Asian / Pacific Isl. 0.0
10.0 20.0 30.0 Maternal Deaths per 100,000 live births
40.0
Figure 2. Maternal deaths by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Maternal mortality ratios for American Indians are not included because the CDC classi¢ed the existing data as not meeting statistical or con¢dentiality criteria.
populations also experienced relatively high infant mortality rates (8.1 deaths per1,000 live births). Disparities in infant mortality are also associated with maternal age at the time of giving birth with mothers younger than age 20 having higher rates of infant deaths (10.2-16.4 per 1,000) than mothers age 20 or older (5.5-7.9 per 1,000). Similarly, the 2005 overall maternal mortality ratio of 15.1 deaths per 100,000 live births exceeded the 2010 target of 4.3 maternal deaths per 100,000 (CDC). Non-Hispanic Black or African American populations had more than 3 times the ratio of maternal mortality than reference White populations (Figure 2). Maternal age is also associated with disparities in maternal mortality, with mothers younger than age 20 having the lowest mortality (7.4 deaths per 100,000) and mothers 35 years or older having the highest (38 deaths per 100,000). In contrast, maternal education as classi¢ed by the CDC is not associated with large disparities in infant mortality, but women with only a high school education (or less) have twice the
maternal mortality of those with some college education (CDC). For infants, mortality rates can be further broken down in terms of deaths occurring among those fewer than 28 days of age (neonatal mortality) and those 28 days to 1 year of age (postneonatal mortality). Figure 3 reveals that non-Hispanic Black populations experience substantially higher rates of neonatal and postneonatal mortality than reference non-Hispanic White populations. Among American Indian and Alaskan Native populations, however, the postneonatal but not neonatal mortality rate is substantially elevated compared to White reference populations. Figure 4 presents infant deaths associated with birth defects and sudden infant death syndrome (SIDS). Disparities are associated with American Indian and Alaskan Native, and non-Hispanic Black populations compared to White reference populations for both of these causes of infant deaths. In addition to racial/ethnic factors, being a teen-aged mother is associated
NH White NH Black Hispanic Neonatal
Asian / Pacific Isl.
Postneonatal
Am. Indian / Al. Native 0.0
2.0
4.0 6.0 Deaths per 1000 Live Births
8.0
10.0
Figure 3. Neonatal and postneonatal mortality by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native.
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with elevated rates of neonatal and postneonatal mortality, whereas lower maternal education levels are associated with elevated SIDS mortality rates (CDC, 2009). The conditions of low-birth-weight (o2,500 g) and preterm birth (o37 weeks gestation) are of widespread concern because of their association with infant mortality and morbidities (Goldenberg & Culhane, 2007). Although low birth weight may be the result of either preterm birth or inadequate fetal growth, it continues to be used in the United States and globally because of its ease and reliability of measurement (Kramer, 2003). As Figure 5 shows, disparities in the percentage of low-birth-weight infants are approximately double for non-Hispanic Black populations in 2005 compared to percentages for non-Hispanic White reference and other populations; however, all populations exceeded the 2010 target of 5.0%. Mothers younger than age 15 had the highest percentage of low-birth-weight infants (13.3%), but minimal di¡erences in the proportion of low birth weight are associated with maternal education level (CDC, 2009). In the case of preterm birth (Figure 5), all population groups exceed the 2010 target of 7.6% preterm births. Although non-Hispanic Black populations have a higher percentage of preterm births than White reference populations, the relative disparities are less extreme than those associated with low birth weight. These di¡erences in the patterning of disparities related to low-birth-weight and preterm birth in part may re£ect the di¡erent underlying determinants of these two morbidities (Kramer). Except for mothers in the youngest age groups, di¡erences in maternal age or maternal education
Infant mortality is a sensitive indicator of the health of a population.
were not associated with large disparities in preterm births (CDC). Receiving recommended prenatal care visits is an important component of promoting health during pregnancy and preventing or managing morbidities at an early stage. With regard to prenatal care, no population subgroup met the 2010 target that 90% of pregnant women receive early and adequate prenatal care (Kotelchuck, 1994). Although there were racial and ethnic disparities in prenatal care with only 59% of American Indian and Alaskan Native women receiving early and adequate prenatal care, the most extreme disparities were associated with maternal age (CDC, 2009). The proportion of women receiving early and adequate prenatal care increased incrementally from the youngest mothers (younger than age 15) through women age 30 years or older (Figure 6). Although health disparities are usually associated with the incidence or prevalence of unfavorable health outcomes, such as mortality and morbidity, social inequities related to educational opportunities and social resources may also in£uence health behaviors or practices that are associated with maternal and infant health (Figure 1). In this review, we focus on three practices that are widely recognized as important to maternal and infant health: smoking abstinence during pregnancy, breastfeeding to at least 6 months, and putting
NH White NH Black Hispanic
Birth Defects SIDS
Asian / Pacific Isl. Am. Indian / Al. Native 0
0.4 0.8 1.2 1.6 2 Deaths per 1000 live births, infants age younger than 1 year
Figure 4. Infant deaths from birth defects and sudden infant death syndrome (SIDS) by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native.
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NH White NH Black Hispanic
LBW Preterm
Asian / Pacific Isl. Am. Indian / Al. Native 0%
5% 10% 15% Low-Birth-Weight (LBW) and Preterm Births
20%
Figure 5. Low birth weight and preterm births by race/ethnicity: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. NH 5 Non-Hispanic; Asian/Paci¢c Isl. 5 Asian or Paci¢c Islander. Am. Indian 5 American Indian; Al. Native 5 Alaskan Native; LBW 5 low birth weight.
infants to sleep on their backs (American Academy of Pediatrics, Task Force on infant Positioning and SIDS, 1992; American Academy of Pediatrics, Work Group on Breastfeeding, 1997; U.S. Department of Health and Human Services, 2004). With regard to smoking abstinence during pregnancy, although racial and ethnic disparities exist with American Indian and Alaskan Native populations having the lowest rates of abstinence (82%), no racial or ethnic group meets the 2010 target of 99% abstinence (CDC, 2009). The largest disparities for smoking abstinence during pregnancy are associated with maternal education (see Figure 7), with only college graduates meeting the 2010 target.
education is also associated with substantial disparities: women with 9th- to 11th-grade education are least likely to breastfeed to 6 months, whereas women with college degrees are most likely to do so as well as to report ever breastfeeding with the most recent birth (see Figure 8). Surveillance data (2006) related to whether populations are meeting the 2010 goal of 70% of infants being put to bed in the back-sleeping position are limited to race and ethnicity. Black infants are less likely (61%) to be put to bed in the back-sleeping position than White (77%) or Hispanic (72%) infants, and the latter two groups both exceed the 2010 target (CDC, 2009).
With regard to breastfeeding, Asian and Paci¢c Islander populations are most likely to breastfeed to at least 6 months (52%) and the only racial or ethnic group to exceed the 2010 target of 50%. NonHispanic Black women are the least likely to breastfeed to 6 months (26%). However, maternal
Identi¢cation of health disparities is important in setting priorities for research to improve health of childbearing women and children, and in critically examining existing health care services for relevance to the key challenges to maternal and infant health. Equally important, knowledge of health
<15 yr. 15-19 yr. 20-24 yr. 25-29 yr. 30-34 yr. >34 yr. 0%
20%
40% 60% Early and Adequate Prenatal Care
80%
100%
Figure 6. Early and adequate prenatal care by maternal age: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009).
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disparities provides an evidence base for nurses and others to advocate for, or to take action to improve, the health of maternal and infant populations. Substantial disparities and gaps exist in meeting most 2010 targets for mortality, morbidity, health care, and some health practices important to the health and well-being of childbearing women and infants. Disparities are associated with the social variables of race, education, and maternal age, but these associations may di¡er across health outcomes, health care received, and health practices. Even widely publicized health practices, such as use of the back-sleeping position for infants, are only met by certain demographic groups.
No population subgroup met the 2010 target that 90% of pregnant women receive early and adequate prenatal care.
The preceding section provided a broad picture of maternal and infant health disparities from a national perspective and focused on areas emphasized in Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and its associated national database CDC Wonder Data 2010 (CDC, 2009). In this section we emphasize a variety of Internet-based data resources that nurses and others may use in their e¡orts to assess maternal and infant health disparities. In many cases, state data of su⁄cient size are available for reliable population estimates. For nurses in Canada, similar data sources may be found at the website for Statistics Canada (http://www.statcan.gc.ca/). This website has an option for either French or English.
Control and Prevention (CDC), or its subunit the National Center for Health Statistics (NCHS). Key federal databases related to maternal and infant health are presented in Table 1. VitalStats is a new NCHS system that o¡ers Internet users either prebuilt or customized analyses based on birth certi¢cate information. The Pregnancy Risk Assessment and Monitoring System (PRAMS) is a population-based postpartum survey of new mothers that is linked to birth certi¢cate data. PRAMS covers a number of behavioral, health care, and health status variables from preconception to the postpartum period. Its primary limitation is that PRAMS data are only available for selected states. The Pediatric Nutrition Surveillance System (PedNSS) and Pregnancy Nutrition Surveillance System (PNSS) are two national databases focused on participants in public health programs. As a result PedNSS and PNSS contain primarily nutritionrelated data pertaining to low-income women and children. The Maternal and Child Health Bureau (MCHB) is the lead federal agency for maternal and child health. It also disperses Title V funds to states to support health services to mothers and children. As a result, MCHB maintains a database on key maternal and child health indicators of each state, and Internet-searchable reports on each state’s maternal and child priorities. Additional federal databases that may contain some data on mothers and infants are presented in a comprehensive listing provided by Zeni and Kogan (2007).
The U.S. government maintains a number of healthrelated databases within the Centers for Disease
Table 2 presents databases available through nonpro¢t sources. An advantage of these is that they
Evidence Sources on Health Disparities of Childbearing Women and Infants Federal and Nonprofit Sources of National and State-Level Data
Grades 9 - 11 High School Graduate Some College or AA Degree College Graduate or above 100% 0% 25% 50% 75% Abstinence from Cigarette Smoking During Pregnancy Figure 7. Abstinence from cigarette smoking during pregnancy by maternal educational attainment: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009).
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Grades 9 - 11 High School Graduate Some College or AA Degree College Graduate or above 0%
25% 50% 75% Breastfeeding Ever and at 6 Months
100%
Figure 8. Breastfeeding ever and at 6 months by maternal educational attainment: United States, 2005.
Source: Centers for Disease Control and Prevention. (2009). Note. AA 5 Associate Degree.
Table 1: Federal Data Sets Related to Childbearing Women and Infants Population-Based
Data-Base
Database Name
Federal Agency
Years Available
or Sample
Featuresa
Pregnancy Risk
Centers for
Year-to-Year
State-level sample
Prebuilt tables from http://www.cdc.gov/prams/
Assessment &
Disease
variation.
survey drawn
(1995^2002) (go
Standardized data
Monitoring
Control and
States begin to
from birth
to ‘‘surveillance
collection procedures
Systems (PRAMS)
Prevention
participate in
certi¢cate ¢les.
report’’ on right).
and instruments allowing
(CDC)
1988. By 2005,
Data can be
state-to-state
26 states
requested
comparisons. Scope of
participating.
through the CDC
data is from
for ¢le download.
preconception to early
Website and Data Overview
postpartum period. Includes data for health care access and individual characteristics. Pediatric Nutrition
CDC
1998 to 2007
Public Health
Prebuilt reports.
http://www.cdc.gov/
Surveillance
Surveillance
(go to ‘‘Current
PEDNSS/ Low income
System (PedNSS)
System. A⁄liated
National PedNSS
include women and
WIC agencies
data tablesç
children participating in
voluntarily submit
health
federal nutrition and
dataçnot
indicators’’)
public health programs.
representative of
Data on birthweight,
the general
short stature, under^
population.
overweight, anemia, breastfeeding. Some health behaviors including smoking, WIC enrollment.
Pregnancy
CDC
Varies. As early as
Public Health
Prebuilt reports.
http://www.cdc.gov/
Nutrition
1983 for selected
Surveillance
(go to ‘‘Current
PEDNSS/index.htm
Surveillance
indictors to 2007.
System. A⁄liated
National PNSS
Same as above. Data on
System (PNSS)
Most early 1990s
WIC agencies
data tablesç
maternal health
to present.
voluntarily submit
Health
indicators, health
data. Not
indicators’’).
behaviors and infant
representative of
outcomes.
the general population
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Table 1. Continued Federal Database Name
Agency
Data 2010 (Healthy CDC
Population-Based
Data-Base
Years Available
or Sample
Featuresa
Website and Data Overview
1998^2007
Population-based.
Prebuilt tables.
http://wonder.cdc.gov/
People 2010)
National and
Graphs. Data
data2010/obj.htm
State-level data.
download to
Interactive data base
Excel available.
system tracking Health People 2010 objectives (467) from baseline to target.
U.S. Birth Data and National
Births (1990
Population-based.
Prebuilt tables and
http://www.cdc.gov/nchs/
Statistics (Vital
Center for
through 2006).
National, state
reports or create-
VitalStats.htm More than
Stats)
Health
Perinatal
and some
your-own reports
100 demographic and
Statistics
mortality (2003^
county-level data
(query systems)
health variables available
(NCHS)
2005). Deaths
available (for
or tables. Maps,
for birth data ¢les. Parts
under
populations of 4
charts, graphs.
of this system are still
development.
100,000).
under development as of May 2009.
Title V MCH Block
Maternal and
Current Year for
Population-based.
State Narratives
https://perfdata.hrsa.gov/
Grant Annual
Child Health
Annual Report,
State-level
and Data Forms
mchb/mchreports/
Report and
Bureau
and 2005 MCH
annual reports.
including
Search/search.asp
Needs
(MCHB)
Needs
¢nancial and
System allows the user to
Assessment
program data.
query the state narrative
Assessment
by keyword or view individual application sections. Trend data by state is available for MCH select performance and outcome measures. Note. a
Database features refers to having a user-select query system and the ability to download data, tables, and graphs.
bring together data from a variety of sources that pertain to their mission. Foremost among these is Peristats, a database of perinatal data at the state and U.S. national levels maintained by the March of Dimes Birth Defects Foundation. By contrast, the Statehealthfacts database maintained by the Kaiser Family Foundation focuses on a variety of health indicators at the state level of which a number pertain to health of mothers and infants as well as other population subgroups. Other key nonpro¢t databases in Table 2 focus on children’s health or women’s reproductive health.
An Example of Using Available Databases to Assess Maternal and Infant Health Needs To illustrate how nurses might use various databases, we provide a ¢ctitious example of how nurses in three statesçAlabama, Florida, and Texasçjoined together through their Association of Women’s Health, Obstetric and Neonatal Nurses
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(AWHONN) organizations to assess the health needs of childbearing women and infants. We selected these states because of their diverse populations. The nurses in our example were interested in what areas they might target for campaigns or advocacy to improve maternal and infant health within their speci¢c state. To begin, the nurses felt is was important to have an overall picture of the demographic characteristics of each state so they accessed the U.S. government portal FedStats (http://www.fedstats.gov/) and printed out key social and economic indicators for each state using the MapStats option. The demographic data revealed that there were substantial Hispanic populations in Texas (36%) and Florida (21%), whereas African Americans were a substantial minority population in Alabama (27%) and also in Florida (16%). They also noted that Alabama had a lower per-capita income then Texas and Florida, although Alabama and Texas had a higher percent
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The U.S. government maintains a number of Internetaccessible databases related to maternal and infant health. of persons living below the federal poverty level than Florida. From the CDC Wonder Data 2010 website (Table 1), they found that Alabama had a higher infant mortality rate (9.5 deaths per 1,000 live births) compared to Texas (6.5 deaths) or Florida (7.2 deaths). From the Peristats website (Table 2), they sought data on access to health care among women of childbearing age and found that Alabama had a lower overall number of uninsured women of childbearing age (20%) compared to Florida (27%) or Texas (31%). The nurses then decided they wanted to focus their campaign on early and adequate prenatal care (Kotelchuck, 1994) in state populations with patterns of health disparities and turned again to the CDC Wonder Data 2010 website. They found that in Alabama the infants of African American and teen mothers had higher infant mortality rates; these two groups also faced disparities related to early
and adequate prenatal care. Thus, Alabama nurses selected these disparity groups as their focus. In Florida, nurses found that less than one half of teen mothers were getting early and adequate prenatal care so decided to focus on this disparity. In Texas, the nurses found that less than one half of Hispanic women received early and adequate prenatal care so decided to focus on this disparity group. Nurses in each state then turned to the MCHB website (Table 1) to examine each state’s maternal and child health priorities to see how their own e¡orts might be coordinated with those of each state. Although this example is ¢ctitious and simplistic (but the ¢ndings for the states are real), it illustrates how nurses might use Internet-accessible data to assess areas of need in their state to improve the health of mothers and infants.
Concluding Perspective Key maternal and infant health disparities in the United States and related Internet-accessible databases are presented in this article. The purpose of monitoring health disparities is to provide an evi-
Table 2: Nonprofit Sources and Other Informational Resources Database
Population-
Name
Agency
Years Available
Based or Sample Database Features Website and Data Overview
PeriStats
March of Dimes
Varies. As early as
Population-
Birth Defects
1990 for select
based.
Foundation
User-select query
http://www.marchofdimes.
system, graphs,
com/peristats/ Data from 12
indicators through
maps, tables. U.S.,
government agencies and
2006.
regional and state
organizations are
summaries
combined to provide an
available. Select
exceptionally user-friendly
county-level and
tool. Perinatal data
city-level data
primarily from the National
available.
Center for Health Statistics. Features also include literature search capabilities, calculations, de¢nitions, and updates.
Statehealthfacts
Kaiser Family Foundation
Current. Some older
Varies by topic.
Interactive maps,
http://www.statehealthfacts.
data may be
tables, graphs,
org/ Data provided on more
available upon
downloadable as
than 500 health topics, very
request.
.pdf ¢les. U.S. and
user friendly. Sources
state-to-state
include various federal
comparisons.
agencies, Kaiser Family Foundation reports, and more. Includes special reports, ¢nancial expenditures for health services, and more.
336
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IN FOCUS
Walker, L. O. and Chesnut, L. W.
Table 2. Continued Database
Population-
Name
Agency
Years Available
Based or Sample Database Features Website and Data Overview
KIDS COUNT
The Annie E.
Current with
Population
Data Center
Casey
multiyear option for
Foundation
select indicators.
Interactive maps,
based.
http://datacenter.kidscount.
tables, graphs,
org/ Data provided on more
pro¢les, rankings.
than 100 indicators,
Includes
including economic status,
community-level
health, safety, and risk
data for some
factors. Very user friendly.
indicators. Raw
All data from government
data available for
sources. Includes special
download.
reports, publications associated with child wellbeing, and more.
Guttmacher Institute State
Guttmacher Institute
Varies.
Population
Interactive maps,
based.
http://www.guttmacher.org/
build-your-own
statecenter/ Data from
Center, State
tables for select
published reports/materials
Table Maker
indicators.
created by the Guttmacher Institute (specializing in sexual and reproductive health) and from other sources including select federal agencies. Includes information on abortion, adolescents, contraception, pregnancy, and services/ ¢nancing. Links to statespeci¢c prebuilt reports, research articles, and policy analyses.
dence base for changes in practice, policy, or programs, or for setting priorities related to resources to reduce or eliminate the disparities. Failure to monitor health disparities carries the inherent risk of assuming that all groups in the overall population are fairing equally well when this may not be the case. There is also the inherent risk that populations found to be at higher risk of certain disparities will be stereotyped in ways that marginalize them still further. As a result, it is essential that nurses partner with representatives of the disparities populations for whom they wish to advocate or seek to better serve. Such partnering allows nurses and other professionals to more deeply understand the context of disparities and work collaboratively with representatives of disparities populations. Models for such partnering and community involvement may be found in sources such as Healthy Start programs (PolicyLink, 2000). Understanding where disparities exist and partnering with disparities populations enable nurses to take action to pro-
JOGNN 2010; Vol. 39, Issue 3
mote social justice for childbearing women and infants.
Acknowledgments Partially funded by MCHB Leadership for Education in Public Health Training Grant #T76MC00008, Education for MCH Leadership at UAB.
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JOGNN, 39, 328-338; 2010. DOI: 10.1111/j.1552-6909.2010.01144.x
http://jognn.awhonn.org