EDITORʼS NOTE: This article originally appeared in the Milwaukee Journal Sentinel. It is being reprinted as part of a partnership between the Community Journal and Journal Sentinel to help address a critical issue in our community.
by Mark Johnson and Tia Ghose–(Milwaukee Journal Sentinel, Publication Date: April 17, 2011)
A tight, persistent pain in the lower abdomen chased Jasmine Zapata from class that morning, forcing her upstairs to rest on a couch at the University of Wisconsin School of Medicine and Public Health in Madison.
It was Sept. 20, and Zapata was in her 25th week of pregnancy, just past the midpoint.
She neither smoked nor drank. She knew the importance of proper prenatal care and had followed the doctor’s orders to the letter. Zapata, after all, was in her second year of medical school. The 23-year-old Milwaukee native had carried her first pregnancy to term and had a beautiful son to show for it: MJ, now 18 months old.
At her last doctor visit the week before, all had been fine. But on this morning when Zapata rose from the couch and went into the bathroom, she saw she was bleeding. By the time the ambulance got to the hospital, she was completely dilated and in fear for her baby daughter.
“When they were doing an ultrasound, I was mentally preparing myself,” Zapata said. “What if they tell me she’s dead?”
Educated, married, with no chronic illnesses or family history of prematurity, Zapata was not, in most respects, a high risk for premature delivery, the No. 1 cause of infant mortality in Milwaukee.
Only one factor suggested risk: Zapata is African-American.
Her case highlights an ongoing mystery in medicine. For decades, researchers have found that African-Americans across this country had double or even triple the rates of prematurity, low birth weight and infant mortality of their white counterparts. A married, college-educated African-American woman faces worse odds than a white, unmarried woman who dropped out of high school.
The trend can’t be explained away by genetic differences. Researchers have looked at the difference in the birth outcomes of African immigrants to this country and those of their American-born children.
“When they first come (to the U.S.), their birth outcomes are outstanding, and then after one generation, they’re bad,” said James J. Collins, an epidemiologist and neonatologist at Northwestern University. “That’s pretty frustrating, but it’s clear there’s some social phenomenon that goes on in this country.”
Years of research and well-intentioned efforts have led to improvements in the overall mortality rates, but the gap between African-Americans and whites has widened. Milwaukee’s black infant mortality rate stood at 15.7 deaths per 1, 000 live births between 2005 and 2008, among the worst in the nation and more than double the rate for the city’s white infants.
Dozens of factors can lead to premature births: chronic diseases such as high blood pressure and diabetes; behaviors such as smoking and drinking alcohol; and history, including previous premature deliveries. Even when these are accounted for, there’s still a stark difference between how well African-American and white babies fare.
One point, however, has become increasingly clear: Prematurity is a primary cause of infant mortality, defined as the death of a child before age 1. In 2006, more than two-thirds of the infants who died in the United States were born preterm.
“Preterm birth is the most problematic and leading cause of infant mortality,” said Cynthia Ferre, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta, who has studied infant mortality for 25 years. Increasingly, medical researchers are focusing on stress as the trigger for a complex cascade inside a woman’s body that leads to preterm labor, in effect signaling the fetus to leave the womb.
Social scientists have spent decades investigating many external factors that appear to power the stress machine: poverty, unhealthy environments, racism. Others have spent years studying the internal, or biological, factors: genes, biology, chemistry.
So far, solutions have tackled prematurity and infant mortality from one direction or the other, and as a result have had limited success. Research that drills into both internal and external factors – and interplay between the two – remains scarce.
Several studies have shown that some of the strongest factors fueling prematurity are ones a woman has little control over – the air she breathes, the neighborhoods she walks through every day, the way she is treated in her community and society.
African-Americans who live in segregated neighborhoods are likelier to have their babies prematurely, according to a December study in the journal Social Science and Medicine. In Milwaukee where Zapata grew up, the African-American population predominantly lives in segregated neighborhoods, and the metropolitan area was ranked among the most segregated in the country, according to 2010 census data.
In an effort to understand the geography of prematurity, researchers at UCLA and the University of California, Irvine analyzed 81, 000 births from 1996 in California. They found that women of all races who live up to a mile and a half from busy roads or freeways, and therefore had greater exposure to harmful car exhaust, had more than double the risk of having their babies before 30 weeks’ gestation. Nationwide, African-Americans are much likelier to live near freeways and other congested roads.
A second study showed blacks living near freeways had nearly triple the risk of miscarriage and stillbirth. While African-Americans may not be more susceptible to toxic environments, they are more often exposed to them.
The grind of living in poverty also may worsen the odds for some African-American women. Poor women, for instance, tend to have worse health and poorer birth outcomes than affluent women, even when they don’t actually engage in riskier behavior.
Everyone has a threshold for how much stress she can handle on a daily basis.
“If you have a lot of stress in your life, your husband beats you, your boss at work is pushing you too hard, and then you have a sudden death in your family, all this builds up,” said Calvin Hobel, an obstetrician/gynecologist at Cedars-Sinai Medical Center in Los Angeles who has studied the effect of stress on birth outcomes. “People who have chronic stress, throughout the day, your heart rate goes up but it doesn’t come down.”
Before she started high school, Zapata’s parents owned their small house in a Milwaukee neighborhood near N. 90th St. and W. Good Hope Road, and seemed rooted in the middle class. Then they divorced.
Zapata, her younger brother and their mother moved into an apartment near Northridge Mall. A year after the divorce, they went on food stamps and BadgerCare, Wisconsin’s public health insurance program. But they were not so poor that they ever had to worry about their next meal.
Today, Zapata is a medical student who receives BadgerCare for health coverage. Her husband is a security guard. While Zapata should earn a good living someday, finances are, for now, a struggle.
Even if she were wealthy, however, and had been so all her life, Zapata would still face a higher risk of a preterm birth than a white woman with a lower income.
Racism – both personal and institutional – may be one reason that affluent, high-achieving African-American women are at higher risk for preterm delivery than similar white women, several researchers say.
At Northwestern University, Collins has found that women who say they’ve experienced more discrimination or racism are more likely to give birth to low birthweight or premature babies. Other work has shown that racism heightens the risks of prematurity if women also are experiencing symptoms of depression during pregnancy.
Many think what’s needed nationally is a comprehensive reassessment of how medical care is delivered, as well as a transformation of our communities. Prenatal care, some say, needs to be re-imagined. Instead of an obstetrician being at the center of the pregnancy universe, the focus would shift to one-stop, comprehensive health care homes or community centers.
Milwaukee is starting to make changes. Since 2007, the Milwaukee Health Department has partnered with a national organization called Nurse Family Partnership. As part of the program, at-risk women in the most blighted neighborhoods are visited by a nurse weekly during pregnancy and every other week for two years after the baby is born. The nurse offers suggestions for healthy lifestyle changes.
The partnership focuses on helping the mother get a better handle on her life as a whole, by setting goals for staying in school, finding safer housing, coping with stress and applying for a job, said nurse Mary Jo Gerlach.
Employed in a handful of cities over the last three decades, the program can improve birth weight of babies but has limitations. It relies on referrals, costs the city about $8,000 to $10,000 per family, and only reaches the poorest women – a total of about 134 as of May.
In Milwaukee, infant mortality rates dropped 14% from 2009 to 2010, though it is too early to say whether this was the beginning of a trend or merely a statistical blip.
Zapata may never know why her baby girl was born too early. This much she knows: Aameira, now 7 months old, healthy and remarkably jolly, has survived. For more than three months, Aameira stayed in the hospital. Slowly, she grew. She gained weight. Finally, Zapata learned she would be able to bring her child home to her husband and their son.
The baby would still need oxygen. Aameira would be tethered for a while to an apnea monitor that would trigger an alarm if her heartbeat or breathing fell below certain levels. Aameira’s day-to-day care would be in the hands of her parents, a notion they found a little scary. They did not know what, if any, deficits she suffered from her premature birth.
They may not know until she is 2 years old.