I spoke with Joan Bloch, PhD, CRNP, about her work on the causes of disparities in preterm birth. Although premature births are declining in America, African-American women are still far more likely than white women to have a baby born too early.
In a recent research project, presented at the American Public Health Association meeting, her team studied bus routes in the low-income areas of Philadelphia, PA where preterm birth is highest. They found that women likely spend upwards of 19 hours and $69 just for bus fare in the course of a healthy pregnancy—or, for a high risk pregnancy, 27 hours and $98.
On calculating bus travel for this project:
I have 30 years experience in caring for low income populations of women that take the bus to prenatal care, and I also work with people in my clinic and other clinics. So we had a panel of experts and a spatial analyst who rode around the city and we looked at different neighborhoods. We identified what would be a typical case, but maybe not such a dramatic case, right? Because we could go into a neighborhood where the houses are all boarded up and create a scenario where somebody has poor health behaviors and whatnot.
So we drove around and identified an apartment house, you know, young people often live in apartments. We identified an apartment house on a main street where there’s a bus stop right in front of it. And we said, [this hypothetical woman who lives here] gets pregnant, what would her travel through the bus system be like for prenatal care? And we just mapped it out.
On how to fix the situation:
I don’t know if we can make healthier places for everyone. That would be wonderful but that would take a long time. Maybe in 10 years we can make a bad neighborhood better, but in the meantime babies are being born every day, so what can we do to make it easier for those mothes to take care of their babies?
It would be great if we can have maternal/child centers, and mothers would come there, take care of their kids, and they can be cared for. [Agencies] could come together and make it one stop shopping. If the WIC program has their own building, maybe the prenatal care and infant care can be there too.
On why mothers travel just days after birth:
In efforts to decrease infant mortality, in this country we decreased the length of stay for mothers after childbirth in the hospital. Women who have a healthy normal delivery go home within 48 hours. But babies can go south quickly, so pediatricians, with good intentions, require that mothers bring their babies back to their pediatricians within two days after discharge.
So what that means is we’re sending mothers home right after this huge physological experience of childbirth and then they’re told they have to bring their baby back within 2 days. And the pediatricians in our city, at least at St. Christopher’s hospital, say that just about 100% of mothers do that.
I was talking to the medical students and they were saying “Ohh! Maybe that explains why we often see mothers with brand new babies on bus corners waiting for the bus. We thought they were totally negligent bringing out these newborn babies and taking them on the bus.”
And to think, what society has so little respect for the childbirth process we would expect a mother to leave her house just days after giving birth, and travel with her baby in tow? I think globally, from my experience and those of nurses around the world, we agree that mothers will do anything to make sure their babies are healthy. In most countries around the world they actually send nurses home to the mother’s house within that first week.
On changes in prenatal care over the years:
in the 1990s there were prenatal care adequacy indices that calculated the amount of prenatal care women got, to see if that was related to their outcomes, and that was actually based on 11 visits during the pregnancy. In our analysis, standards of practice have changed, increasing the number of visits. [Today, a woman] would have to make 25 different visits to get just regular prenatal care.
From 2000 to now, there’s been a plethora of health disparities research. But the reality is that even though we see so much in the literature, at the ground level, the teams I worked with 30, 20 years ago, we had much more resources.
We had a lot more time to spend with women. As a nurse practitioner, it’s not like I was scheduled like a mini doc every 15 minutes to see another patient. I could provide more well women’s health care.
In the past there was more ability to really work with a woman and her family and her support systems (or lack of support systems) and to run around in the neighborhood to get her what she needs. I think nowadays that has sort of been parceled out to funded safety net programs, so back then maybe we didn’t have them, but now there’s no real communication between all these different programs.
On how she got into her field:
I became a nurse in 1978, never knew a nurse in my life, but I was inspired, actually I was obsessed with racism as an adolescent. Like, why people could kill other people and harm other people just because they belong to a certain group. I had the opportunity to listen to Viktor Frankl and his words just resonated with me: Do something that’s going to be purposeful. Find meaning in your life, right? I looked through an occupational forecasting book and I saw nurses help people and I love math and science.
In nursing school when I saw birth it was like a miracle. Birth is a miracle. And I thought wow, I could help women and couples have healthiest birthing experience and babies.
When I went into the PhD program [after 20 years of nursing and teaching], I wanted to understand how the outcomes of health care services are evaluated, and particularly prenatal care. I grew up in nursing at a time there were a lot of changes. Childbirth classes, birthing rooms, I guess it was a product of the feminist women’s health movement. I wanted to know how this was evaluated on a public health level, and that led me into perinatal epidemiology.
On race and poverty:
I came into this work by just taking care of women & trying to promote each individual woman’s optimal health, and it wasn’t a race thing. In my dissertation work [on brain injury in newborns] I saw that if the mothers didn’t come to prenatal care, there was no relationship if the mother was white. But if the mother was black and she didn’t have prenatal care, those babies born to black mothers were two times more likely to have brain injury by 4 hours after birth.
But to tell you the truth once I did these maps, and saw the relationship with poverty and violence in the neighborhood & the racial segregation, it sort of shocked me, because it was so glaringly obvious, that it was more about living in bad neighborhoods. I think at the end of the day it really is about being poor. We need to take care of poor folks with a different approach than perhaps folks that have more resources. We need to take care of individual people and look at the context of their lives and help them be as healthy as they can be, and be sure they can take care of their children the best they can.