America's health centers: reducing racial and ethnic disparities in perinatal care and birth outcomes

Health Services Research, Dec, 2004 by Leiyu Shi, Gregory D. Stevens, John T. Wulu, Jr., Robert M. Politzer, Jiahong Xu

In the United States, substantial racial/ethnic disparities exist in birth outcomes. As of 2002, the infant mortality rate for blacks (13.5 per 1,000 live births) was more than 2.5 times that of whites (5.7 per 1,000), Hispanics (5.4 per 1,000), and Asians (4.7 per 1,000) (Arias et al. 2003). Black infants were about twice as likely to be delivered low birth weight (LBW) (13.3%) as whites (6.9%) and Hispanics (6.5%); and black infants (17.5%) were more likely to be delivered preterm than either Hispanics (11.6%) or whites (11.0%). Both LBW and preterm birth have been associated with increased risks of infant mortality, and developmental disabilities such as mental retardation and cerebral palsy (Avchen, Scott, and Mason 200l; Copper et al. 1993; Escobar, Littenberg, and Petitti 1991; Hack, Klein, and Taylor 1995; Holzman et al. 2001; Horbar et al. 2002; Thompson et al. 2003).

Substantial racial/ethnic disparities also persist in the receipt of prenatal care that has been associated with better birth outcomes (Alexander and Korenbrot 1995; Goldenberg and Rouse 1998; Ickovics et al. 2003; Kogan et al. 1994; McCormick and Siegel 2001). In 2002, blacks (75%) and Hispanics (77%) were less likely than whites (89%) and Asian/Pacific Islanders (85%) to receive prenatal care in the first trimester (Martin et al. 2003). Similarly, receipt of adequate prenatal care (defined by the Revised-Graduated Index of Prenatal Care Utilization) was reported by 57% of whites and 51% of blacks (Alexander, Kogan, and Nabukera 2002). Despite these differences, other studies have challenged the effectiveness of prenatal care in reducing disparities in birth outcomes due to the strength of other, more difficult to address, factors such as social class and hereditary risks (Alexander and Kotelchuck 2001; Barfield et al. 1996; Fiscella 1995; Hughes and Simpson 1995; Goldenberg et al. 1996; Lu and Halfon 2003; Lu et al. 2003; Murray and Bernfield 1988).

Birth outcomes--and infant mortality in particular--are considered barometers for the public's health. Despite great national wealth, the U.S. continues to rank poorly relative to other industrialized nations on basic health indicators, and with wide inequities by race/ethnicity and socioeconomic stares (SES). The U.S. currently ranks 25th among Organization for Economic Cooperation and Development (OECD) countries in national infant mortality rates (Health at a Glance 2003). Such a poor ranking in the U.S. is incongruous with its national healthcare expenditures, which are the highest among developed countries (i.e., totaling more than 14% of the U.S. Gross Domestic Product) (Health at a Glance 2003). Fundamental improvement of the nation's health and international ranking on health indicators cannot be accomplished without reducing or eliminating disparities in the health of racial/ethnic minorities.

Since their inception in the 1960s, America's community health centers (CHCs) have served as a primary care safety net for underserved populations in both inner-city and rural areas (Freeman, Kiecolt, and Allen 1982; Gardner 1993; Lefkowitz and Todd 1999; Regan et al. 2003). The central mission of CHCs is to increase access to community-based primary care services and improve the health status of vulnerable populations. To receive funding, CHCs must meet federal requirements for community need and potential impact, health services, management, and finance and governance. CHCs are operated by the Bureau of Primary Health Care (BPHC), which is part of the Health Resources and Services Administration in the Department of Health and Human Services.

CHCs provide comprehensive, coordinated, and integrated health care including primary and preventive health services. They also provide enabling services such as case management, transportation, health education, translation, and child care within a single institutional setting for persons residing in their service areas. These services facilitate primary care access for vulnerable populations--predominantly racial/ethnic minorities, low-income families, and uninsured or Medicaid-enrolled individuals (Forrest and Whelan 2000). In 2001, nationally, 748 CHCs delivered care at about 3,300 sites to over 10 million of the nation's estimated 50 million underserved persons (Bureau of Primary Health Care 2003).

Recognizing the importance of primary care and the potential of CHCs to improve national levels of health, the Bush administration has embarked on an initiative to serve an additional 6.1 million underserved persons by providing 1,200 communities with new access points and significantly expanding existing facilities. By targeting the most at-risk groups, there is the potential to produce large improvements in national health that may be reflected in improved national rankings on health status indicators.

Health centers have been previously credited with improving access to and quality of care for vulnerable populations (Dievler and Giovannini 1998; Frick and Regan 2001; Politzer et al. 2001; Shiet al. 2001). Given continuing racial/ethnic differences in birth outcomes and prenatal care utilization, the purpose of this study is to examine whether CHCs contribute to reducing these disparities. This study examines birth outcomes (i.e., birth weight) and receipt of perinatal services (i.e., prenatal, postpartum, and newborn care) across racial/ethnic groups receiving care in CHCs. Where possible, disparity rates are compared to nationally reported population rates. This study also identifies factors associated with perinatal care and achieving positive birth outcomes, such that these can be promoted by policy' makers and CHC administrators to enhance outcomes for the nation's most vulnerable populations.