In the Fall 2009 issue of Minority Nurse, we published "Preventing Premature Birth Disparities," an article written by Monique Blair, BSN, and Carol Eliadi, EdD, JD, APRN. The article examined the growing crisis of high preterm birth rates in women of color and noted that "unfortunately, there is [little] information available in the literature to explain why premature birth is so disproportionately prevalent in minority women compared to their white counterparts."
In response, we received this letter from Ihsaan Alim, MSN, RN, MPA, who is currently a doctoral candidate in the School of Public Health at New York Medical College in Valhalla, N.Y.
"I applaud the article on preventing premature birth disparities," he writes. "What I found most interesting and troubling is the question of why there is less than adequate information in the literature to explain high premature birth rates and other health disparities in minority women. I agree with the authors that more research into this complex and important issue is urgently needed. The consequences of premature birth are enormous: increased risk of infant death, slow cognitive development, hyperactivity, respiratory problems, obesity and heart disease. Perhaps paying greater attention to this singular health care problem will benefit a host of other minority health issues.
"Literature that I have reviewed does not always point to a direct cause-and-effect principle for premature births. Social and economic inequalities faced by racial and ethnic minorities are complex and cannot be fully captured by the simple means of a socioeconomic position, such as class or education.1, 2 As Ms. Blair and Dr. Eliadi point out, factors such as inadequate prenatal care, smoking, drinking, using illegal substances, domestic violence and short time between pregnancies can all increase a woman's risk for preterm birth. Therefore, instead of a 'linear' cause and effect, I support the idea of a matrix of risk factors that contribute to disproportionate premature birth rates for minority women.
"As a nurse or other clinician, it is important to understand the intersecting factors that contribute to positive or negative health outcomes," Alim continues. "Perhaps at the forefront of these issues is the availability of health care. According to the U.S. Census Bureau, roughly 47 million Americans do not have health insurance. Furthermore, in 2008 the Journal of Health Affairs reported that an additional 25 million Americans are underinsured. Having no or inadequate health insurance means little or no access to medical care, including preventive, diagnostic and treatment services for major health concerns.
"Other factors, such as education, family income, quality of employment and exposure to environmental hazards, all impact health. Where a patient lives is important. Neighborhood conditions, such as air and water quality and the availability of adequate housing, police/fire protection, transportation, stores, parks and libraries are also contributing factors. Employment conditions that affect health include exposure to toxic substances, heavy workloads and stress. And, of course, patients' personal behaviors are determinants of the overall health outcome. Do your patients smoke, do they maintain a healthy diet, do they exercise, use alcohol or illegal drugs, do they have safe sexual practices? These are key questions for any health assessment.
"Our patients are more than just their own particular health issues or diagnoses," Alim concludes. "We must recognize that our patients are totals and multiples of their community, family, lifestyle and socioeconomic backgrounds. Any one of these factors alone could be the tipping point to poor health outcomes, and the more they intersect, the more complex the picture becomes. It is important to incorporate this model into all levels of nursing—from academia and research to inpatient care and community health—so that we can better understand the causes of minority health disparities and develop better solutions."
Kaufman, J.S., Cooper, R.S. and McGee, D.L. (1997). "Socioeconomic Status and Health in Blacks and Whites: The Problem of Residual Confounding and the Resiliency of Race." Epidemiology, Vol. 8, No. 6, pp. 621-628.
Nazroo, J.Y. and Williams, D.R. (2006). "The Social Determination of Ethnic/Racial Inequalities in Health." Social Determinants of Health, Second Edition, M. Marmot and R.G. Wilkinson (Eds.), Oxford University Press, Chapter 12, pp. 238-265.