I thought everyone in England drank tea and grew beautiful gardens

Monique from Episode 7 of Call the MidwifeIt was a treat to get to see Episode 7 on Mother’s Day and I enjoyed this episode with my own mother.  Cynthia witnessed Mr. John Lacey consistently belittle his wife Annie.   Jenny saw a different kind of abuse when she cared for a black mother-to-be, Mrs. Monique Hyde, who was subjected to racial prejudice from neighbors. As a modern-day certified nurse midwife (CNM), this episode made me reflect on the impact of racial disparity on perinatal outcomes.

When there is a difference in health outcomes between population groups there is a disparity.  The term “disparity” can include such things as race or ethnicity but it also includes gender, sexual identity, age, disability, religion, socioeconomic status, and geographic location, as these can contribute to one’s ability to achieve good health.  A health disparity is a particular health difference that is closely linked to things that have historically been linked with discrimination or exclusion.

Infant death rates by racial group.

SOURCE: National Vital Statistics System—Mortality and Natality (NVSS-M, NVSS-N), CDC/NCHS.

The U.S. population is just under 309 million people (U.S. Census).  Approximately 33 percent, or more than 100 million persons, identified themselves as belonging to a racial or ethnic minority population.  The most recent data from the Centers for Disease Control (CDC) reports the infant mortality rate in 2010 was 6.14 infant deaths per 1,000 live births.  The mortality rate for black infants was 2.2 times the rate for white infants.  A significant portion of this racial gap in infant mortality is attributable to preterm birth (a birth prior to 37 weeks gestation).  Among black infants there is a near twofold increase in low birth weight and a near threefold increase in very low birth weight (CDC, National Vital Statistics System, 2012). This graphic shows we can visually see this startling gap in a graph displaying infant deaths among different racial groups between the years 1997- 2007.

Healthy People 2020 is a framework with a 10-year snapshot of national health objectives.   The framework is a group effort between the U.S. Department of Health and Human Services, other federal agencies, public stakeholders, and their advisory committee.  One of the overarching goals of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups.

Lu & Halfon (2003) explore racial and ethnic disparities in birth outcomes in their research and make recommendations for researchers, clinicians, and policy makers. They discuss two risk factors with promising explanations for racial-ethnic disparities in birth outcomes.  The two risk factors involve stress and infection.  Stressful life events or perceived stress and anxiety during pregnancy are associated with preterm birth and low birth weight infants.  Maternal stress is thought to begin a biological cascade leading to the onset of preterm labor, and prolonged stress responses are thought to impact or alter the immune function so that an individual may be more vulnerable or susceptible to infection.  The authors write of two mechanisms that are thought to impact birth outcomes based on disparities: early programming and a cumulative pathway model.

In early programming it is thought that both exposures and experiences during sensitive critical developmental periods in early life may impact and influence health and disease later in life.  It is also proposed that this influence can impact one’s future reproductive potential.  In the cumulative pathway model, it is theorized chronic and repeated stress over the entire life course can cause a decline in reproductive health.  Chronic diseases are thought to be caused from this cumulative wear and tear.  This repeated over-activity or hyperactivity of the stress response (repeated activation of the hypothalamus pituitary adrenal (HPA) axis) is like a car engine idling too high for too long.  After a while this takes a toll on the body and this can lead to health problems that are associated with chronic stress.

The authors suggest that the models should not be considered separately and that strategies that combine and address both of these mechanisms are needed to assist with eliminating racial-ethnic disparities.  They discuss the need to close the gap from one generation to the other, targeted interventions during critical sensitive developmental periods (throughout the entire life cycle), and health promotion risk reduction strategies across the entire lifespan.

Much of my work clinically works on trying to help women learn techniques to counter this stress response.  There are varied techniques to elicit the relaxation response.  People can learn varied techniques such as deep breathing exercises, guided imagery, meditation, and yoga.

Some things this show reinforced for me as a clinician and that I will emphasize with the women I serve and with my graduate students:  

  • A culturally sensitive health care provider can influence or impact health outcomes.
  • Consider the entire life course of women to impact change and decrease health disparities (family planning, pre-conceptual care, pregnancy, and primary care of women).
  • All women need access to quality health care throughout their life span
  • The social context of health behaviors must be addressed for optimal health (availability of healthy food in all neighborhoods, opportunities for physical activity, chronic social stressors).

Here are some interesting links and resources that we have explored in our University of Michigan Nurse Midwifery courses.


U.S. Census Bureau, Fact Finder


Murphy SL, Xu JQ, Kochanek KD. Deaths: Preliminary data for 2010. National vital statistics reports; vol 60 no 4. Hyattsville, MD: National Center for Health Statistics. 2012.

U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy people2020.  Washington, DC: U.S. Government Printing Office

Maternal, Infant, Child Health: Healthy People 2020 Goals and Objectives concerning Pregnancy: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26

Healthy People: Information regarding disparities: http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx

Lu, M. C. & Halfon, N. (2003).  Racial and ethnic disparities in birth outcomes: A life-course perspective.  Maternal and Child Health Journal, 7(1), 13-30.

Harvard Health Publications: Understanding the stress response. http://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2011/March/understanding-the-stress-response

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