MATERNAL SUPPORT IN THE DELIVERY ROOM: DISCUSSION

6 Dec
2009

DELIVERY ROOM

Our study found that among African-American women giving birth at two large hospitals, being unaccompanied by a family member or other support person at the time of delivery was associated with a more than three-fold increase in the odds of having a baby of VLBW. Women who ended up without this aspect of support at the time of delivery tended to be older and to have received less prenatal care than women accompanied by a companion in the delivery room. These women were also more likely to have had four or more pregnancies and reported a higher rate of stressful life events. Over half of the unsupported mothers characterized the pregnancy as unwanted. Absent support at delivery may thus be a useful marker for a cluster of social stressors which exert an adverse effect on pregnancy outcome. Differential exposure of African-American women to psychosocial stress measured in novel ways may prove useful in understanding the disproportionately poor outcomes of black women giving birth in the United States.

African-American infant mortality is now more than twice as high as U.S. white infant mortality, the relative risk having grown from 1.6 to 2.5 over the past half century. The rate of VLBW births among African Americans continues to be 2.8 times higher than whites, a fact of key importance, since two-thirds of the racial disparity in first-year death rates can be attributed to the VLBW gap. The major study by Kempe et al. showed that African-American women experience 2.5 to 3.4 times the prevalence of the main medical causes of VLBW so that no single clinical intervention can be expected to close the racial gap. They concluded that “comprehensive preventive strategies” are called for. In addition, a study by Berg et al. found that “the traditional risk factors were not associated with VLBW delivery in black women, and Wise stated that “the bulk of disparate infant mortality occurs in the mainstream of women who are not teenagers, who receive some prenatal care, and who do not use illicit drugs.” This has led to a growing body of research exploring the role of psychosocial factors in the etiology of VLBW and preterm birth among African Americans. More recently, a biological link between prenatal psychosocial factors and their effects on maternal-placental-fetal neuroendocrine parameters, and, consequently, birth outcomes have been demonstrated. canadian antibiotics

In a classic early study of social support, Nor-beck and Anderson demonstrated a significant relationship between partner support and length of gestation in a group of low-income African-American women. A recent review noted positive associations between social support during pregnancy and birth outcomes in six of eight relevant studies involving a range of populations and social support instruments. Different dimensions of social support have been measured, such as the categories of social embeddedness, perceived social support, and enacted social support employed by Barrera. However, none of these prior investigations used a case-control design focused on VLBW as the outcome measure. We used that approach in the present study to gain more understanding of the impact of social support on this uncommon but potentially very damaging outcome. Our categories of “emotional” and “tangible” support approximate two of Barrera’s categories, but we found no consistent association of our subjects’ questionnaire responses and birthweight. The physical presence of a support person at the time of delivery, however, was very strongly associated with the birth outcome under study.

How might the social support be expected to differ between white and black women in the United States? Data from the 2000 U.S. Census indicate that the percentage of African-American women who are married has decreased from 62% in 1950 to 36% in 2000. Among white women, the percentage married was 66% in 1950 and 57% in 2000. Thus, the rate ratio for being unmarried for African-American women compared with white women increased from 1.1 in 1950 to 1.6 in 2000. Our study findings were consistent, with only 38% married. Availability of a support person in pregnancy and at delivery is clearly not contingent on marriage, but observed racial differentials in marriage rates may be reflective of more general patterns of social behavior. There are a number of reasons to expect African-American families to encounter more obstacles in providing support to mothers. Many obstacles, ranging from employers’ absentee policies to transportation access, are closely related to income, and we know from earlier work that African-American mothers in Chicago are 3.5 times as likely to reside in the poorest neighborhoods. Moreover, black women in their 40s and 50s—the grandmothers—are more likely to have medical problems than white women of the same age— problems that could interfere with their support role for their daughters throughout pregnancy and at delivery. Finally, African Americans are 50-70% more likely to be in the Armed Forces and over 600% more likely to be incarcerated as whites in this country—two stark but very real causes for differential availability of support persons during pregnancy and at delivery. Indeed, fUlly 16% of the women in our study had partners who were incarcerated during the pregnancy, with a somewhat higher proportion among the women who ended up alone in the delivery room (OR 1.5 [0.8-2.8]).

To our knowledge, this is the first study showing such a robust association between social support by a significant other in the delivery room and birth-weight outcomes. Literature exists that documents a reduction of acute labor problems by the presence of a companion in the delivery room, but our finding addresses a different question. The outcome in our study was birthweight below 1,500 g, and all such cases were premature. Length of gestation was not significantly affected by events at the time of delivery, but the presence of a supportive person at that critical time appears to be a marker for longer-range social processes that, in turn, impacted the length of gestation. A variety of questions about social support, religious beliefs, and family structure were poor predictors of VLBW in our study, although some were associated with the presence or absence of a support person at the time of delivery.

One potential problem with using the presence of a support person in the delivery room as a marker for social support is the possibility that exclusion could come about for other reasons, possibly even reasons associated with premature delivery. For example, perhaps the mothers were alone because premature labor was unexpected or because they were transferred to another facility due to preterm labor. Our data did not support this interpretation, since the rate of support persons at delivery was the same for inborn and transported mothers, but such confounding is certainly possible, especially in light of the unexpectedly high OR associated with having a companion in the delivery room. A similar concern would be the possibility that support persons might be barred from the delivery room in critical situations by policies in place in some hospitals. Indeed, in the two hospitals in this study, one was known to have more restrictive visiting policies; therefore, support in the delivery room was less frequent for women giving birth there, compared to the other study site. However, when we analyzed results for women in the two hospitals separately, the odds of VLBW associated with being without a support person in the delivery room was unaffected. Future studies using this outcome measure would be strengthened by collecting more detailed information about support persons, to distinguish women with a family member waiting in the hall from others with no identified support person to notify. Apcalis Oral Jelly

In our study, the African-American women who were 30 or older were more likely to give birth to a VLBW infant, and a disproportionate number of these older women were without a support person at delivery. This finding appears to parallel the worsening birth outcomes among older African-American women described by Geronimus. She noted that the health of African-American women may begin to deteriorate in early adulthood as a physical consequence of cumulative socioeconomic disadvantage, such as ongoing exposure to environmental lead. She suggested the term “weathering” to describe this phenomenon. The association of maternal age over 30 and lack of social support in the delivery room, along with other behavioral and psychosocial risk factors, such as unwantedness of the pregnancy and poor prenatal care, suggests the possibility of a nonphysical dimension to the weathering effect in black women.

Work on unraveling the complex and multilay-ered effects of racial disadvantage in health in this country entered a new phase in the early 1990s with the paradigm shift from the socioeconomic versus genetic dichotomy to a more contextualized approach to social mechanisms. Our study suggests that focus on social mechanisms sometimes means more than just asking for a report of perceptions but may also be strengthened by noting certain objective markers of actual social networks, such as the provision of support at a critical juncture. Attention to the broader social, economic and policy environment as it impacts black and white women in different ways may eventually lead to effective interventions in the ongoing effort to eliminate racial disparities in health. generic cialis in uk

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