By Tiff
Introduction
Fifty years ago, being able to deliver a successful pregnancy at twenty-two weeks and the neonate survives was extremely rare. The technology that we have now was only imagined in movies then. In the United States, a country with ground-breaking medical treatments and unparalleled medical technology, “preterm births are on the rise” (Varney, 2023). Mental and emotional strains are placed on the families of many different cultures and backgrounds of preterm neonates who are enduring physical trauma to stay alive. Underdeveloped lungs, cardiac abnormalities, and neurological deficits are among some of the issues most preterm neonates face.
Although a generous number of preterm births are due to a lack of prenatal care and drug use, genetic and physiological abnormalities found before birth are also to blame. IVF is also a contributing factor to the rise in preterm births (Thinking about Fertility Treatment, n.d.). Intrauterine growth restriction is another little-known contributing factor to the rise in preterm births. “Many factors such as age, health, and behavioral habits of the mother affect the growth of the fetus and are responsible for causing IUGR” Sharma (2016). The stress of the mother and the environment they spend the most time in has a major impact in the development of IUGR. Lucinda “Looch” Brzozowski, RN, a certified NICU nurse at Thomas Jefferson University Hospital in Philadelphia explains, “Sometimes the in-utero environment is unsafe, so the need to deliver early is crucial. Not that they’re better off out here, but at least they’ll have a chance being a preterm delivery.” These little humans endure so much to live. Unsafe environments due to socioeconomic disparities of the mother, congenital defects, stress from the mother, and other variables impact the well-being of these neonates. These little people with gargantuan problems have been hidden behind world-wide public health concerns for years. They have a story to tell.
Factors
Preterm birth is a little-known public health concern compared to gun violence or disease. It is a significant concern when it comes to neonatal mortality in the United States. Preterm birth has once been thought to be the result of drug and alcohol abuse only. Now with advanced technology and in-depth research, we understand the many causes of preterm birth. However, we do not know what triggers preterm birth for all babies and how to prevent it (Burris et al. 2011). With research being conducted within the community, more and more contributing factors are found.
The social factor of this issue begins with how the expecting mother perceives the reactions of her peers and family. For example, a young teen is pregnant and has every intention of seeking education and guidance from medical providers and community programs to do what’s right for her child and help her carry her baby to term, with hopes of it being healthy. The social determinant comes into play and changes the goal. Due to the presence and negative input from her peers and family, she declined the care that she sought. People project their negative views of healthcare on those who admire and seek guidance from them. Because of this bias, a new young impressionable mother-to-be is deterred from receiving proper care.
Cultural factors may play a huge role when it comes to preterm birth. Cultural determinants could range from immediate and extended family to the community one has grown up. People in tight-knit neighborhoods often raise their children together, and share stories, advice, habits, and biases passed down from generation to generation. This does not consist of race and ethnicity alone, there are variables as there are with every issue. The culture of a generation can be a determinant. The increase of social platforms that are plagued with propaganda spread false truths to young impressionable parents-to-be. Care is not taken seriously and the lack of participants in urban community programs for childbirth has decreased.
How a group or individual responds to information is a part of the behavioral factor in preterm birth. Information that is received and rejected by expectant mothers predicts negative behavior during the pregnancy. Smoking, alcohol consumption, drug abuse, and high-risk sexual behavior, stand a great chance of increasing preterm birth. Personal lifestyle choices, good or bad, can alter the outcome for a safe and healthy birth. Not being compliant with medications, office visits, and medical advice are pieces of the problem within the problem.
Local Initiatives
Community-based organizations have been and are being created to assist moms-to-be who live in high-risk areas of low socioeconomic groups. Programs to educate soon-to-be mothers on the importance of prenatal care, abstinence from drug and alcohol use during pregnancy, and healthy eating are created specifically for those in low socioeconomic neighborhoods. The goal of these programs is to encourage healthy and safe habits during pregnancy. Developing healthy habits may decrease the chances of a baby being born preterm. Although these programs have been developed to help those in need, there are barriers created by those in need that prevent receiving help.
State Sponsored Programs
State-sponsored programs like Medicaid, have the potential to provide pregnant women and teens with low socioeconomic statuses with quality prenatal care to help prevent preterm birth. Medicaid, unlike commercial health insurance, provides care with very little to no cost for the recipients. Those unable to attain commercial insurance due to lack of education and employment are able to receive care without the stress of not knowing how they will receive care and treatment if needed. Those who utilize the programs through Medicaid are less likely to deliver their child preterm than those who do not receive care. Removing stressors of pregnancy can lower the number of risks (Sonchak, 2016).
Effectiveness
Community programs are a major factor and the first line of defense when it comes to preventing preterm birth. The community-based programs help a sample of the population, whereas state and national programs help the population. In the United States, expectant mothers in poverty can participate in the WIC (Supplemental Nutrition Program for Women, Infants and, Children) program to receive vouchers for healthy food. When compared to expectant mothers in poverty who did not receive assistance from WIC, mothers who received WIC decreased their chances of delivering preterm. They developed healthier habits and were committed to following guidelines and safe practices by their medical providers. The WIC program is shown to decrease preterm birth rates. “The odds of preterm birth compared with normal term birth were lower among expectant mothers covered by Medicaid who received WIC benefits during pregnancy compared with their counterparts who did not receive WIC benefits during pregnancy” (Soneji & Beltrán-Sánchez, 2019).
Disparities
No matter the goal, how much research was conducted, or how much of a financial contribution was made to achieve the goal, something will always be in the way of reaching that goal. Social disparities have been growing, making huge negative impacts on communities across the country. People with good intentions are steered in the wrong direction by people who spread propaganda on social media platforms. Bashing the healthcare systems, instilling fear of childbirth, or downplaying prenatal care and healthy eating are tactics being broadcast by those who experienced an unfavorable outcome during pregnancy or after the delivery of a preterm baby. These people project their fears, anger, and bias onto the public to satisfy their need to tear down others. As the old saying goes, “misery loves company” and these people will do anything to make those who seek to do right by their unborn child, rethink their choices and follow their mission to fail society.
Reducing Disparity
More programs, more resources, and education. Ensuring that everyone knows of the available help within the communities, that is free, may help reduce some of the disparities. Social media helps spread propaganda worldwide for almost every public health issue, so why not use it to broadcast and shine light on positive outcomes? If hospital systems worked together to show positive outcomes instead of competing with one another, people in the communities would share that. People would have positive things to say instead of negative. For now, community and state programs are doing what they can to encourage healthy lives for expectant mothers and babies. Sadly, it’s not enough to go up against famous social media influencers who don’t have faith in the healthcare system for pregnant women. That is dangerous for mothers-to-be living in poverty. State programs need to collaborate with community programs that have an influential stand in these communities. Then, and only then will a change be seen.
The MCC was created in 1980 by seven local organizations to decrease the number of preventable infant deaths. The Philadelphia Welfare Rights Organization, Childbirth Education Association of Greater Philadelphia, Health Law Project, University of Pennsylvania Law School, CHOICE, Institute of Social Medicine and Community Health, and American College of Nurse Midwives, Pennsylvania Chapter, formed the MCC. This collaboration was started to decrease the number of infant mortalities in Philadelphia, it grew into a well-known, respected, and mimicked organization. No one wants to feel the pain of a child dying. Education is the best way if possible to prevent it. With programs running and increasing since 1980, the MCC has helped over 100,000 families in Philadelphia and the surrounding counties. A better understanding of what “high-risk pregnancy” is and how it can be prevented was accepted. Risk factors for preterm birth are now being taken seriously by communities that once dismissed them. Although all services aren’t available in every area of the city, those that have reached and helped, have better outcomes than those who share the same disparities. Sections of Philadelphia that weren’t stricken with poverty during MCC’s development but now are, will soon have the same resources and access to the life-changing programs. Now programs include MOMobile Project, Early Head Start, Family Start, Healthy Start, and Cribs for Kids (Maternity Care Coalition Records – Philadelphia Area Archives, n.d.). These programs, since their formation, have educated, nurtured, and guided thousands of scared and lost women and their families. Children receive timely primary care appointments and vaccinations. Healthy food choices and positive social habits are made and committed to. Young mothers in the programs are no longer ashamed or embarrassed to breastfeed in public. They take pride in it.
Social Factors
The last thing a person living in a lower socioeconomic group living in poverty wants to hear is that they are a product of their environment. Social disparities and determinants have greatly affected the behaviors of young people today. Most people want to do better than what they are currently doing. Some want to take steps to do better but do not move forward with it. Some take the steps and move forward to achieve better. Others who intend to do the right thing and be better for themselves will be influenced by those close to them to a negative path. These social determinants happen not only to adolescents wanting to leave the “hood” but also to soon-to-be mothers who want better for their unborn children. It seems that a large number of those in lower socioeconomic groups face more negativity not only from the environment in which they live and work but many encounter social disparities when receiving medical care. When looking at these two factors, one cannot help to think about which had the negative impact first. Was the social determinant such a negative factor, that the person in need of medical care denies it until the last possible second and approaches it with a negative attitude? Or was the social disparity in receiving medical care so negative and stressful that the positive attitude one had faded away? No matter what the cause for this social determinant and disparity, a change needs to occur to put an end to this little-known public health crisis of preterm birth.
A person’s social environment, the place they spend the most time in, with the most influential people in their lives will be heavily impacted by this. Devon Rauscher RN, a certified NICU nurse at Thomas Jefferson University Hospital in Philadelphia expresses her concern of another social determinant. Age. “We get a lot of young girls that have no guidance or positive support from family, so they look to their friends that are their age for help. It creates a cycle of kids not finishing school and having kids.” Although a person’s race, age, area code, education level, or financial status should not impact their healthcare experience, they play a great role in creating disparities (Soneji & Beltrán-Sánchez, 2019). And it goes both ways. The patient receiving medical care has fears and assumptions about what will happen during a visit. Has a negative thought process going into a visit with advice and biased thoughts from family and peers in the neighborhood or at work. The provider looks at the patient’s demographic sheet prior to a visit and forms a biased opinion. During the visit, the doctor is stoic, has poor bedside manners, and does not attempt to learn about the patient. The patient is nervous, standoffish, and afraid to trust the provider. The patient fails to communicate all problems and concerns and many questions go unanswered. Questions that could have prevented a child from being born early. This social factor has been a growing problem in the United States.
Theory
The social cognitive theory is most appropriate when assessing the behaviors of people in my chosen group. People who were born, grew up, and held residence in neighborhoods of poverty typically are influenced by the behaviors of those close to them. Not just by family, but by those near their homes or work. Decisions are made with doubt and confusion and at times fear of not fitting in with a certain group. Whether it’s going to a different doctor for prenatal care- because a popular group of peers prefers one doctor that’ll write for pain meds after delivery and the other doctor won’t but the less desired doctor is highly skilled. The influences from one’s community can be held accountable for many bad choices.
People can decide on a good safe choice one day and do a complete three-sixty and make a terrible life-altering decision the next day. The ability to change one’s mind is a gift and a curse. Nothing is one hundred percent, especially a model or theory when it comes to human behavior. It changes. Sometimes without reason. Banking on how a person will act based on a theory is okay to get an idea of what type of resolution may occur, but there are too many variables that can influence one’s behavior to guarantee a certain outcome. For any model to be flawless in getting the same result, a group of people must have the same thoughts, actions, reactions, reasoning, and goals. Like two snowflakes are never the same, why a person thinks, acts, and has the beliefs they have is never the same as the next. This theory is good for getting an idea of and using results as a guide to reach a better understanding.
Recommendations for Community Actions
Making changes to improve the community where the numbers are high for infant mortality is the first step in decreasing the number of cases of this little-known public health issue. Changing the social factors of this problem at the community level is not extremely difficult. It may also benefit more than one group of people, a group that could be proven to affect the number of infant mortality cases. In Philadelphia, one of the largest cities in the U.S., the highest number of infant mortality cases are found here. In neighborhoods of poverty, the lack of “greenspace” is considered to be a contributing factor in the number of infant deaths. “Urban areas have small amounts of vegetation and a plethora of buildings and pavements that hold heat during the day and reradiate it at night” (Schinasi et al. 2020). This, in turn, increases the sensitivity of heat to infants who reside in these areas of the city. Low socio-economic groups that live in sections of the city that lack adequate housing, do not have the resources to prevent heat-related illness, or the same greenspace as middle-class neighborhoods. Greenspace has been proven to lower noise and air pollution in urban areas. It can also reduce the heat that is retained. In recent studies, greenspace has been shown to be a natural mood elevator. Increased heart rates, anxiety, and depression, risk factors for infant mortality are reduced in neighborhoods with adequate greenspace. One study showed how a vacant lot caused tachycardia just by walking near it, while another with greenage showed to lower a heart rate.
Greenage may also have the ability to reduce stressors that can cause violence in a community. The heat can make anyone uncomfortable. Walking to the corner store on a hot day, while the sun is beaming down can be a dreaded task. Walking to the corner store in a neighborhood of poverty, where tension is high normally due to violence can be a risk-factor for preterm birth. A pregnant woman walking to the store in a poverty-stricken neighborhood on a hot day can bring on anxiety with a high heart rate. The fear of encountering violence on a hot day in an area where violence is high is almost guaranteed. The threat of violence lurks around every corner when it is hot in Philadelphia. Gun violence is higher in the summertime and innocent bystanders seem to be the more common victims. These poverty-stricken neighborhoods that lack greenspace have higher numbers of gun violence than those that have adequate greenspace. Increased greenage in these neighborhoods of poverty reports a higher median household income than those that have very little to no greenage. It is possible that increasing greenage in neighborhoods with heavy violence could decrease some of the risk factors associated with preterm birth. Local botany organizations can help by donating trees and educating community leaders on how to generate greenspace within their communities. This initiative can possibly save two lives with one plant.
Recommendations for State Actions
What works for the sample may work for the population. Community programs that have seen positive changes and achieved goals should be adopted by the state. If something has promising responses and positive outcomes, it should be shared to promote the same positivity on a larger scale. The Maternity Care Coalition is a program founded in Philadelphia that has provided services for over 100,000 people in need since the 1980’s. The MCC has created programs for breastfeeding education, provided cribs for those who could not afford them, and has the Momobile, a mobile program that allows volunteers to assist new and young mothers with understanding parenthood in their homes. “Evidence-based home visiting programs are essential for at-risk pregnant women and young families (Murusko, 2022). A better understanding of what “high-risk pregnancy” is and how it can be prevented was accepted because of this program. Risk factors for preterm birth are now being taken seriously by communities that once dismissed them. This program, if adopted by the state has the potential to educate to decrease the number of preterm births and infant mortality.
Recommendation to Reduce Disparities
Communicate without bias. Social disparities in my opinion are not one-sided. Every day, a Black woman encounters some kind of discrimination or biased opinion about them by a medical professional. That negativity comes from bringing personal bias to the workplace. It also comes with acquiring a stigma from working with a certain population. Failure to inquire about one’s lifestyle can increase the chances of preterm birth. Judging based on the demographics of a population instead of communicating with the individual is bad practice. Women living in poverty, in close-knit neighborhoods will often take on the bias of their peers. Having a negative opinion about a physician without meeting them is also bad practice. What one’s peer experienced with a provider does not mean the next person will experience the same. People in poverty tend to go into unknown situations with bad advice on top of having very little education. That makes trying to treat the soon-to-be-mother very difficult. The refusal to share a medical or family history, and a truthful social history about smoking, alcohol, or drugs has an extremely high chance of causing preterm birth. It takes two people to have a conversation. If both parties are open-minded, listen to each other, and are truthful, the odds of having a healthy and safe delivery can increase. Bias assumptions towards a population and taking on the opinions of others can not produce a healthy pregnancy. Talking and listening….having open and honest conversations is how this disparity will become a thing of the past.
Recommendations for Improvement
Removing pregnant women in poverty from the social determinants. Difficult? Yes. Impossible? No. Pregnant women who want to be good mothers and deliver term babies will work hard to accomplish that goal. Others say they want the same but won’t act on it, although, they may luck up and deliver a term baby without complications. The objective is to prevent all preterm births caused by the stressors and social determinants of poverty, but the realistic goal is to help those who seek help. Developing programs where at-risk pregnant women can if they choose, opt to reside in homes geared towards helping those at-risk soon-to-be mothers reduce those risk factors and receive an education. Program participants would have to follow the guidelines and fit the criteria. The goal is to carry the pregnancy to term without worrying about, safety, food, or shelter while receiving education (a trade), and learning how to successfully parent their child/ren. This plan is possible to be put into action. Sadly, in Philadelphia, there aren’t a great number of at-risk mothers wanting to change their social disparities and determinants. Many would rather keep the same bad unhealthy habits that endanger their unborn child’s life they have yet to experience.
Not all preterm births come from poverty. Other cases come from the exact opposite. Healthier habits and more greenspace are seen in areas with middle-class homes and they provide better outcomes. IVF (in-vitro fertilization) contributes to a large number of preterm births and mortality as well. “In vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is associated with an increased risk of preterm (33rd-37th gestational week) and early preterm birth (20th-32nd gestational week)” (Li et al., 2022). This method of reproduction is used by those in a higher socioeconomic group when they are unable to conceive. Intrauterine growth restriction is a less-than-desired growth rate of the fetus. IUGR can be caused by a large number of health problems. Women conceiving over the age of 35 years and assisted reproductive technologies (ART) are two risk factors in preterm birth. These women typically live in middle to upper-class areas. In cases like this, programs for understanding these risk factors could be implemented during the course to reach conception. Learning ways to have successful births despite those risk factors would be the goal of women around the world.
Reflection
Preterm birth in the United States is higher than any other country with wealth (Varney, 2023). This little problem has grown to become a little-known public health issue. The rate at which babies are being born prematurely is alarming. Although there are resources and programs to assist and try to prevent it, there isn’t enough noise being made about it. The seriousness of preterm birth is being overshadowed by gun violence and suicide. Greenspace in high-risk areas may help decrease these tragedies. Social disparities, determinants, and biased opinions have prevented appropriate care for the little ones. That can change by learning good listening techniques, asking questions, and engaging in conversation with each other. Doctors and patients have to communicate to reach a common goal. A healthy baby.
References
Burris, H. H., Collins, J. W., & Wright, R. O. (2011). Racial/ethnic disparities in preterm birth: clues from environmental exposures. Current Opinion in Pediatrics, 23(2), 227–232. https://doi.org/10.1097/mop.0b013e328344568f
Home : Maternity Care Coalition. (n.d.). Marternity Care Coalition. https://maternitycarecoalition.org/
Li, J., Shen, J., Zhang, X., Peng, Y., Zhang, Q., Hu, L., Reichetzeder, C., Zeng, S., Li, J., Tian, M., Gong, F., Lin, G., & Hocher, B. (2022). Risk factors associated with preterm birth after IVF/ICSI. Scientific Reports, 12(1), 7944. https://doi.org/10.1038/s41598-022-12149-w
Murosko, Daria. (2022, September 21). Addressing Risk Factors to Improve Infant Mortality Rates in 200 Words. https://policylab.chop.edu/blog/addressing-risk-factors-improve-infant-mortality-rates-200-words
Sharma, D. (2016). Intrauterine Growth Restriction: Antenatal and Postnatal Aspects. Clinical Medicine Insights: Pediatrics, 10, CMPed.S40070. https://doi.org/10.4137/cmped.s40070
Sonchak, L. (2016). The Impact of WIC on Birth Outcomes: New Evidence from South Carolina. Maternal and Child Health Journal, 20(7), 1518–1525. https://doi.org/10.1007/s10995-016-1951-y
Varney, S. (2023, March 16). The US Remains a Grim Leader in Preterm Births. Why? And Can We Fix It? KFF Health News. https://kffhealthnews.org/news/article/america-premature-birth-rates-maternal-infant-mortality/
Thinking about fertility treatment. (n.d.). http://Www.marchofdimes.org. https://www.marchofdimes.org/find-support/topics/planning-baby/thinking-about-fertility-treatment
Brzozowski, Lucinda 2023, Thomas Jefferson University Hospital, Philadelphia PA
Rauscher, Devon 2023, Thomas Jefferson University Hospital, Philadelphia PA
