The Impact Of Chronic Stress On Health Inequities & Maternal Age

Older maternal age contributes to inequities

In the US, the mean maternal age for someone's first birth has been steadily climbing for nearly all racial and ethnic groups.

That shift to older maternal age has exacerbated health inequities between Black and White infants, according to findings published in a 2023 Health Affairs article. Even after taking into account socioeconomic indicators, that age shift increased the relative odds that Black women gave birth to very-low-birthweight babies by 19% compared to 10% for White women. Newborns with very-low birthweight are at a heightened risk for certain health issues.

That recent finding adds to growing literature examining inequities in maternal and infant health and other related outcomes. The need for more research, data, and policy action is pressing. Despite increased health policy attention on identifying and addressing these inequities—and the social determinants of health (SDoH) that influence them—the US still faces persistent barriers to improving access, care, and outcomes.

Exploring the maternal age & health inequity connection

The upward shift in maternal age is a result of a decline in births to teenagers coupled with a rise in women delaying their first birth, explains a report from the Centers for Disease Control and Prevention.

The Health Affairs paper used US data from 1989-2019 and simulated the effect of this shift to older ages at first birth on health inequities between Black and White infants. Authors theorized that the shift largely accounted for the rise in very-low birth weight infants as well as the increase in racial inequities over those years. Those changes could be serious enough to dampen the reductions in infant mortality the country has experienced during the same period, researchers wrote.

Exploring impact of "chronic, high-effort coping"

From access to quality affordable healthcare to higher prevalence of chronic health conditions, there are myriad factors influencing maternal and infant health inequities in the US.

The researchers of that recently-published study suggested that “weathering theory" could also play a role in the racial gap between older Black and White mothers. This refers to the idea that the health of US Black women may be negatively affected as a result of structural racism. Over time, the stress, hardships, and “chronic high-effort coping" could accelerate cellular damage and aging.

That builds on prior research that has connected more rapid biological aging to SDoH, reflecting a growing area of scientific interest. In July 2023, for example, a separate paper published in PLOS One looked at how neighborhood social environment and air pollution exposure contribute to Black/White aging disparities.

Weathering theory gains traction

Earlier this year, the New York Times published an article featuring the lead author of the Health Affairs paper: Arline T. Geronimus, a University of Michigan professor who created the “weathering" framework. She's published more than 130 papers and a book looking at the impact of experiencing high levels of chronic stress on poor health among historically marginalized populations.

That's because an activated sympathetic nervous system can wear away at the body's internal systems. High blood pressure can lead to hypertension while increased cortisol can lead to insulin resistance. Other research has pointed to the long-term changes in the brain caused by chronic stress.

Chronic health conditions play a role in health inequities

A host of other factors can contribute to these maternal and infant health inequities. When looking at the intersection of race and age, it's also important to consider the impact of chronic health conditions, such as heart disease, hypertension, and diabetes. Black individuals in the US experience higher incident rates and poor health outcomes for many chronic health conditions, factors that can also contribute to maternal and infant health gaps.

For example, Black individuals in the US have higher rates of diabetes, a condition that can negatively impact maternal and infant health outcomes. Since the risk of developing that condition increases with age, older Black mothers also face a higher burden of the associated infant and maternal health outcomes.

During the pandemic, maternal mortality rate soared

Those recent findings contribute to a growing body of work focusing on the country's dire maternal mortality figures and the racial and ethnic inequities that contribute. The US has the highest maternal mortality rate among developed countries, notes The Commonwealth Fund.

The pandemic only worsened those figures. In 2021, the US recorded 1,205 deaths from maternal causes, up from 861 in 2020, or a 40% increase, according to the CDC. In 2019, there were 754 deaths. The increases occurred in all racial and ethnic groups, with the largest increase in American Indian/Alaska Native groups, explains a 2023 article published in the BMJ.

Why did maternal death rates increase?

A report from the Government Accountability Office noted that COVID-19 was a contributing factor in a quarter of all maternal deaths in 2020 and 2021 combined. Among the disparities the office highlighted:

• The maternal death rate for Black or African-American women was 44.0 per 100,000 live births in 2019, then increased to 55.3 in 2020, and 68.9 in 2021. 
• The maternal death rate for Hispanic or Latina women was lower at 12.6 in 2019 but increased significantly during the pandemic to 18.2 in 2020 and 27.5 in 2021.
• Comparatively, the maternal death rate for White women was 17.9, 19.1, and 26.1, respectively.

SDoH contribute to maternal mortality

The pandemic exacerbated the impact of SDoH, such as people's ability to access childcare and transportation, which limits their ability to attend medical appointments, as well as the health impact of where people live and work. At the same time, the pandemic underscored the impact racism has on maternal health, the report said, citing the physiological changes caused by chronic stress. These increase the risk of maternal death as well as severe illness from COVID-19.

There are some early signs that maternal morality has decreased to early 2020 levels as the pandemic's disruptions and severity are easing. Provisional maternal death counts ending in March 2023 display figures that are closer in line with early 2020 numbers, according to CDC data.

New analysis highlights state-level trends

Historically, the country's maternal mortality figures have focused on the country as a whole. In July, researchers published a groundbreaking analysis that looked at how state-specific figures can illuminate previously unmeasured inequities, according to findings described in a JAMA article.

When looking at maternal mortality rates in specific states, researchers were able to discover previously unmeasured inequities among specific populations. For example, while the South had high maternal mortality across all race and ethnicity groups, Black individuals had the highest maternal mortality rates in some states in the Northeast. Those surprising findings underscore the value in looking at a state-specific level.

"Often, states in the South are called out as having the worst maternal mortality rates in the nation, whereas California and Massachusetts have the best. But that doesn't tell the whole story," co-author Dr. Allison Bryant Mantha said in a release on the findings published in Science Daily. "It's essential to look at the disparities between populations that exist even in the 'best' states."

Tracking a troublesome trend in maternal mortality

More broadly, the research revealed maternal mortality rates that had more than doubled over a 2-decade period in some states, a troublesome trend that is occurring despite increased federal attention on these inequities.

“Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis," the authors wrote.

Focusing on health before, during, and after birth

That study didn't evaluate the potential causes of death, explained Dr. Greg Roth, a cardiologist and associate professor of medicine at the University of Washington, in a Michigan Advance article. From his own experiences, though, he pointed to social determinants of health. That's why it's so important to focus on women's health before, during the time of delivery and after pregnancy, he explained.

Implementing health policy steps

Meanwhile, the authors of the Health Affairs article explore the impact of weathering suggested policy implications, such as:

• Including universal tertiary care access or specialized care in a hospital setting
• Increasing the supply and distribution of maternity care providers
• Addressing the holistic needs of mothers throughout pregnancy and postpartum
• Expanding family support policies

“Conceptually, we recommend centering the realities of pregnancy and parenting from the perspective of the populations at highest risk—centering on the margins—and taking into account their implications for maternal weathering (accelerated deterioration due to disparate impacts of structural racism)," the authors wrote.

Steps to improve health inequities in pregnancy

Throughout the country, organizations such as the March of Dimes are working to address health inequities that can impact maternal and infant health outcomes. In this briefing, that group described steps that can begin to address some of these inequities and promote healthy pregnancies and babies, such as:

• Advocacy: Looking at state and local government programs that help pregnant people and their families get access to healthcare.
• Research and Data Collection: Better understanding the causes of preterm births, pregnancy-related death, and infant death can help identify treatments and steps that could lower risk and save lives. Increased national data can pinpoint where these are happening and who is most impacted, which could lead to more focused interventions.
• Prenatal education: The March of Dimes is working to launch additional Group education programs throughout the country. 
• Access to care: They're also focusing on expanding access to infant and maternity care in places that lack access, called maternity care deserts.

RTI can tailor interventions

As increased research and policy attention turns to reducing maternal mortality and improving outcomes for all groups, RTI can help you understand the latest research and put the most relevant findings to use. We can help identify SDoH and tailor strategies to promote improved equity and health outcomes. Learn more about our health equity consulting solutions today.