Maternal Nutrition: Racial Disparities and the Links to Birth Outcome Disparities

Topic Proposal

I am proposing the addition of a course topic centered on maternal health to the syllabus. Maternal health is a significant variable during pregnancy affecting both the mother and fetus from the antenatal period through the duration of their lives. Prenatal care interventions during pregnancy aim to improve women’s nutrition for their own sake and the sake of the fetus. However, like many other reproductive technologies, these treatments are not utilized universally and there are distinct patterns of disparities across racial and social categories. The syllabus already addresses many issues regarding both the beginning and end of pregnancy, but is more limited in its inclusion of technologies that impact the intervening months of gestation. Therefore, I suggest a topic focusing on the aspects of reproduction that are especially important during the middle of pregnancy.

I propose that this topic be added to Module 3: Technologies of Pregnancy and Childbirth. This module discusses the bookends of pregnancy, beginning with conception (contraception, abortion, initial fetal imaging) and ending with parturition (birth experiences, obstetric racism). A discussion of prenatal nutrition would give a more comprehensive examination of how a mother’s health during the intermediate months of her pregnancy is impacted by biological and social forces. This insight would facilitate discussion on how these forces impact different women in different ways and contribute to reproductive disparities.

Background on Maternal Health and Nutrition

Maternal health is a term that encompasses many aspects of a woman’s condition. Broadly, health is defined as a state of physical, mental, and social well-being and not just the absence of disease (WHO). Specific to pregnancy, maternal health is influenced by increased energy and nutrient demands by the fetus, maternal stress, pre-existing conditions, gestational conditions, health behaviors, and more (Odhiambo et al., 2020). It is important to note that a woman’s well being is influenced not only by her physiology but by her social environment.

There is a large volume of research that emphasizes the importance of nutrition in maintaining the health of a woman and the proper development of her fetus in pregnancy. Thus, I suggest this course topic be centered around nutrition during pregnancy and the disparities across different groups of women. Nutrition affects a woman’s body and the developing body inside of her for better or worse; a balanced diet supports her pregnancy and an inadequate diet can have irreversible consequences. Both maternal undernutrition and maternal obesity alter fetal growth and increase the likelihood of developing diseases later in life (Odhiambo et al., 2020). Interventions regarding maternal nutrition include education on the importance of a well-balanced diet, advice from physicians on eating well during pregnancy, and taking a prenatal vitamin (Singh et al., 2020).

Maternal Nutrition During Pregnancy will be split into two days of assigned reading and discussion. The first day will focus on prenatal nutritional habits and prenatal vitamin use among different groups of women and how this contributes to disparities in maternal and fetal outcomes. The second section will examine attempts to improve the implementation of a healthy diet and vitamin use during pregnancy, targeting specifically minority populations in an attempt to ameliorate these disparities. The discussion should aim to identify common themes between this material and the previous course readings.

Day 1: Prenatal nutrition, supplement use, and racial disparities

Goal of the First Section

This section presents research on maternal nutritional habits and vitamin use in different populations and examines how disparities across socioeconomic and racial groups contribute to disparities in pregnancy outcomes. It begins with an overview of the impact of nutrition during pregnancy, discusses how nutrition varies by race, identifies how vitamin supplementation varies, and ends by connecting the disparities in nutrition to disparities in low birth weight and prematurity.

Selected Readings

A Review of Maternal Nutrition during Pregnancy and Impact on the Offspring through Development: Evidence from Animal Models of Over-and Undernutrition (Odhiambo et al., 2020)

This article provides an overview of how maternal undernutrition and maternal obesity both contribute to adverse outcomes immediately after birth and many years later in the child’s adult life. Undernutrition has long been a concern during pregnancy, but with the rise in obesity around the world, overnutrition is a rapidly developing issue (Odhiambo et al., 2020). A fetus’ prenatal environment alters the course of its development and prepares it for the environment that it will face once born. This is accomplished by metabolic imprinting, likely through epigenetic mechanisms, and endures into adulthood (Odhiambo et al., 2020). Classic research on epigenetics revealed that folic acid supplementation was linked to reduced obesity in Agouti mice, mediated by DNA methylation (Odhiambo et al., 2020). Research demonstrates that undernutrition and obesity alter fetal growth and development in similar ways, increasing the predisposition to many diseases. In an animal model, nutrient-restricted fetuses and fetuses of obese mice both had decreased growth rates in utero, leading to smaller pups at birth (Odhiambo et al., 2020).

The crux of this article is the evidence that poor maternal nutrition can contribute to the development of disease upon birth and when the fetus reaches adulthood. Although the underlying mechanisms are not entirely clear, it is evident that there is an association between maternal nutrition habits and diseases such as metabolic syndrome, type II diabetes mellitus, hypertension, and cardiovascular disease (Odhiambo et al., 2020). These diseases are increasing in prevalence, difficult to treat, and contributing to more deaths each year. Additionally, it is demonstrated that these diseases affect minority racial groups and those of low socioeconomic status disproportionately. These conclusions prime the discussion of how differences in prenatal care among minority groups may contribute to disparities seen outside of the prenatal period.

The goal of this reading is to demonstrate that nutritional conditions in early life have an enduring effect on the long term health of a child. The mechanisms of epigenetic change are still being elucidated, but it is clear that there is a link between nutrition and many common diseases that affect adult populations today. This article should emphasize the importance of the prenatal period and demonstrate the importance of ensuring proper development. This research should facilitate discussion about how many diseases that are most prevalent in minority populations may be traceable to disparities in prenatal nutrition.

Nutrient and Food Group Intakes of Low-Income Pregnant Women by Race/Ethnicity (Hill et al., 2019)

This article addresses how women of different racial groups differ in their nutritional habits during pregnancy. First, it discusses the link between maternal dietary patterns and adiposity in childhood. According to the CDC, greater than half of all women exceed the recommended weight gain during pregnancy (Hill et al., 2019). Women who have a lower income or less education are more likely to be over the gestational weight gain limit. Alarmingly, 48% of African American women and 43% of Hispanic women gained more weight than was recommended in this study (Hill et al., 2019). The majority of the caloric intake of pregnant minority women comes from fat and their intake of carbohydrates and sodium was higher than recommended. These dietary patterns increase the risk for metabolic diseases and likely contribute to the higher rates of hypertension, gestational diabetes, C section, and preterm delivery in African American women (Hill et al., 2019). The article also discusses the implications of these nutrition differences for the fetus in terms of the intergenerational cycle of maternal-childhood obesity. Maternal obesity is undoubtedly linked to childhood obesity and the influence of the prenatal environment may be a stronger predictor (Hill et al., 2019).

At the same time, the authors noted that 43% of their total sample were considered food insecure during their pregnancy, with increased risk associated with minority status (Hill et al., 2019). Low-income and minority women are at high risk for not meeting additional nutrient vitamin and mineral requirements during pregnancy (Hill et al., 2019). In fact, the intake of the majority of the nutrients described in this study differed significantly by race and socioeconomic status, with minority women always more likely to be deficient (Hill et al., 2019). Inadequate nutritional intake is associated with improper neurodevelopment, preterm delivery, and decreased infant growth, all of which disproportionately affect the children of minority women (Davis, 2019).

This article builds on the previous reading by providing specific information about how maternal nutrition differs across women of different racial groups. These nutritional disparities potentially contribute to disparities in pregnancy outcomes, prenatal, and beyond. This article should facilitate discussion on how racial disparities in maternal nutrition affect the health in the life of the mother and child well past the pregnancy.

Racial Disparities in Preterm Birth: An Overview of the Potential Role of Nutrient Deficiencies (Dunlop et al., 2011)

This article explores the relationship between nutrient deficiencies and preterm birth. As discussed in the previous course material, minority women are at higher risk for several adverse birth outcomes including fetal mortality, low birth weight, and maternal mortality (Davis, 2019). The mortality rate of black infants is 2.3 times higher than white infants and up to 80% of this disparity is due to differences in preterm birth (Dunlop et al., 2011). This disparity exists across income and education levels. Black mothers are two times more likely to give birth prematurely and three times more likely to die in childbirth compared to their white counterparts (Davis, 2019).

This study investigated the relationship between several nutrients and the likelihood of preterm birth by reviewing a large body of previous literature. Among several nutrients investigated, iron and folate stood out among the rest. Iron deficiency anemia is associated with preterm birth and infant mortality. The risk of iron deficiency for African American expectant mothers is twice that of their white counterparts (Dunlop et al., 2011). Thus, the risk of iron deficiency is likely a mediator for the relationship between race and preterm birth, although additional controlled research is needed to further support this. Low levels of folate are also associated with an increased risk of preterm birth and fewer African American women intake the recommended amount of folate during pregnancy (Dunlop et al., 2011).

This article begins to draw connections between nutrient deficiencies in minority women and the birth outcome disparities that are well supported by research. While there are many potential causes of preterm birth disparities, such as birth induction and Cesarean section, nutrient deficiencies may be another influential factor contributing to racial disparities (Davis, 2019). Dana-Ain Davis and Karen Scott discuss the impact and experience of structural and institutional racism on preterm birth (Davis & Scott, 2020). It is important to consider how the experience of racism may contribute to nutritional disparities in minority pregnant women. This research should facilitate discussion on the reasons why minority populations have inadequate nutrient intake and how this contributes to the reproductive disparities we have previously discussed.

Plasma 25-hydroxyvitamin D During Pregnancy and Small-for-gestational-age in Black and White Infants (Burris et al., 2012)

This research examines another nutrient, vitamin D, and its contribution to patterns of low birth weight infants. Much research has supported the higher incidence of prematurity and low birth weight in minority populations (Davis, 2019). African American women are 2-3 times more likely to have small gestational age infants (Burris et al., 2012). Low birth weight can lead to further complications for both the mother and baby (Davis, 2019). This study draws a connection between vitamin D deficiency and premature births specifically in black women and their babies.

This prospective cohort study specifically investigated the relationship between vitamin D status and differences in the growth of the fetus. Vitamin D status was associated with specific demographic features; women who were white, older, married, highly educated, had a higher income and had a healthy body mass index were more likely to have adequate levels of vitamin D in both 2nd-trimester maternal blood and infant umbilical cord blood at delivery (Burris et al., 2012). Vitamin D is an essential component for the proper physiology of any body, but the nutrient is especially important during pregnancy. Inadequate vitamin D is associated with adverse pregnancy outcomes. For instance, in this study, lower maternal vitamin D levels were correlated with an increased likelihood of having a small-for-gestational-age infant in both black and white populations (Burris et al., 2012). This demonstrates that vitamin D is a determinant of low birth weight because other variables were controlled for. This study also supported previous research that demonstrated that black infants had higher odds of being small for their age compared to their white counterparts (Burris et al., 2012).

Vitamin D is an interesting nutrient to investigate racial disparities because of how it is obtained by the body. Vitamin D is consumed in the diet and produced by the skin through a reaction that requires exposure to UV light. However, darker pigmented skin synthesizes vitamin D less efficiently than lighter skin (Burris et al., 2012). This could contribute to a greater need for vitamin D intake through the diet in women with darker skin, and could explain why African American women are commonly vitamin D deficient.

This article elaborates on previous research that demonstrates that black women are more likely to have small newborns (Davis, 2019). It considers perhaps that vitamin D intake disparities are contributing to the greater prevalence of premature birth among African American women that has been identified by numerous studies (Davis & Scott, 2020). The authors do point out that a deficiency in one vitamin likely only accounts for part of the disparity. As Davis discusses, other factors must also be considered in explaining disparities in premature birth and low birth weight such as the experience of racism and inadequate care by doctors (Davis, 2019).

Periconceptional Multivitamin Use and Infant Birth Weight Disparities (Catov et al., 2011)

This study investigated the use of multivitamins in pregnancy and the risk of preterm birth and small-for-gestational-age infants. Multivitamins are almost universally recommended by doctors to ensure proper fetal growth and development. Despite being a seemingly simple intervention, many women do not take them as prescribed. This research identified a connection between prenatal vitamin use and decreased risk of adverse pregnancy outcomes.

This study found that certain groups of women were more likely to take a prenatal vitamin than others. Women who were older during their pregnancy and of higher socioeconomic status were more likely to use some sort of multivitamin supplementation during pregnancy (Catov et al., 2011). The women who took a multivitamin were less likely to have a preterm birth and less likely to have a small-for-gestational-age infant (Catov et al., 2011). This article also points out that multivitamin use is correlated with other healthy lifestyle factors, therefore, it is impossible to clearly determine if vitamin use causes decreased pregnancy complications (Catov et al., 2011). There is a need for a randomized controlled trial to more clearly elucidate the connections. Nonetheless, this connection is significant and should be taken seriously. This article also points out that women who have a preterm birth or growth-restricted infant in one pregnancy are increasingly likely to have complications in subsequent pregnancies (Catov et al., 2011). This calls to mind the importance of considering the effects of inadequate maternal nutrition beyond the timeline of one pregnancy.

Additionally, women who were overweight did not benefit from multivitamin use compared to women who had a healthy body mass index. Overweight women who took prenatal vitamins did not have a decreased risk of preterm birth or a lower chance of having a small-for-gestational-age infant (Catov et al., 2011). Women who are overweight may have a greater nutritional requirement and thus higher levels of vitamins are required for them or they may be metabolically dysregulated and their bodies are not making use of the vitamins they are intaking (Catov et al., 2011). This is an interesting connection because minority women may be more likely to be overweight which could contribute to premature birth via the route of leading to vitamin deficiencies (Rapp, 2001). This article demonstrates that prenatal vitamin use does correlate with a decreased risk of birth complications such as premature birth and low birth weight. This supports the idea that taking a multivitamin is advantageous during pregnancy. This article should facilitate discussion on how prenatal vitamins could be used to improve adverse birth outcomes, specifically in minority populations.

Fewer Than Half US Women Take Recommended Vitamins Prior to Pregnancy (March of Dimes, 2017)

This research was conducted by March of Dimes, an organization that helps support mothers and their babies. The organization’s mission is to build a “legacy to level the playing field for all moms and babies, no matter their age, socioeconomic background or demographics” (March of Dimes, 2017). They accomplish this by advocating for adequate healthcare and encouraging research. The organization has a special focus on prematurity and birth defects.

March of Dimes reports that 70% of the 3,000 infants born with neural tube defects in the United States could be prevented if all women took vitamins with folic acid (March of Dimes, 2017). However, many women are unaware that folic acid supplementation is necessary. Minority women are less likely to use multivitamins that contain folic acid during their periconceptional period compared to their white counterparts (March of Dimes, 2017). The underutilization of prenatal vitamins has a measurable effect on adverse pregnancy outcomes.

While 97% of women reported that they took vitamins at some point in their lives, very few took prenatal vitamins in the critical period before and after conception (March of Dimes, 2017). The racial disparities in this regard were stark; 34% of white women took a vitamin before conception, 27% of Hispanic women did and only 10% of African American women did (March of Dimes, 2017). This demonstrates that racial minority women are less likely to use a prenatal vitamin compared to their white counterparts. Up to 50% of women in the study reported that the cost of prenatal care had an impact on whether they sought care 92% of women who did take vitamins reported that they did so based on the recommendation from a healthcare provider (March of Dimes, 2017). This connection is important because it means that women who are unable to afford prenatal care may not get a recommendation for vitamins from a doctor and thus never take these vital supplements. The racial disparities in socioeconomic status contribute to disparities in who has access to care and may explain why minority women are less likely to take a prenatal vitamin.

This research draws the connection between the previous reading which discusses prenatal vitamin use and reduction in adverse pregnancy outcomes and the lower rates of vitamin use among minority women. This study demonstrates that adverse prenatal outcomes that are linked to vitamin deficiencies may be caused by disparities in the use of prenatal vitamins across racial groups. This supports the theme of stratified reproduction that is pervasive throughout this course. This research connects back to the concept that the reproduction of some women is supported while the reproduction of others is inherently suppressed by the stratification of many social factors (Ross, 2001)

Questions for Discussion

How do the diseases that are linked to poor nutrition (Insulin resistance, T2DM, obesity, dyslipidemia, hypertension, and CVD) differ across racial and socioeconomic lines? Do you think it is likely that differences in prenatal nutrition could contribute to the elevated incidence of these diseases in some groups? How does this research change how you think obesity and the associated diseases should be targeted for intervention?

Why do you think that minority women are less likely to have sufficient levels of the necessary nutrients during pregnancy? Why do you think they are less likely to take a prenatal vitamin? (Relate to the experience of obstetric racism, healthcare stereotype threat, mistrust of the medical community)

What other factors besides nutrient deficiencies may contribute to racial disparities in premature and low birth weight infants? (Recall many of the social factors that Davis discusses such as the experience of racism)

Day 2: Interventions to improve nutrition during pregnancy

Goal of the Second Section

This day of discussion transitions into possible interventions for the disparities in prenatal nutrition and vitamin use across different racial groups. The main goal of this section is to facilitate discussion of how nutrition can be targeted as a way to ameliorate racial disparities in birth outcomes. The readings begin with a study that focuses on improving the nutritional intake of pregnant women to improve their birth outcomes. It then transitions into efforts to increase nutrient intake in specific populations of minority women.

Selected Readings

Maternal Nutrition Intervention Focus on the Adjustment of Salt and Sugar Intake Can Improve Pregnancy Outcomes (Seo et al., 2020)

This research first uses previous literature to outline the negative effects of poor nutritional habits on both the neonate and the mother. For instance, excessive sodium intake due to increased snacking during pregnancy can lead to increased risk for cardiovascular diseases, cerebrovascular disease, kidney disease, and more (Seo et al., 2020). At the same time, increased consumption of excessively sweetened beverages during pregnancy can lead to a reduction in the birth weight of the infant (Seo et al., 2020). These are just a few of the links between inadequate nutrition and adverse pregnancy outcomes reviewed by this article.

This article also provides evidence of how lifestyle changes of diet during pregnancy can improve the outcomes of pregnancy for both the mother and the fetus. There is a large body of research that connects nutrition education programs and individual counseling with improvements in diet habits (Seo et al., 2020). These diet habits can be translated to reductions in disease. The researchers implemented a nutrition intervention in pregnant women. The control group received no advising while the intervention group received education and counseling focused on lowering sugar and salt intake (Seo et al., 2020). While mean gestation age at delivery did not differ between the groups, mean birth weight was significantly higher in the group that received the intervention (Seo et al., 2020). Additionally, maternal blood pressure was lower in the control group compared to the group without education and counseling (Seo et al., 2020). This demonstrates that the intervention was successful in improving not only the dietary patterns of the women but the health outcomes for both mother and baby.

This research shows that educational interventions are effective at improving maternal nutrition and birth outcomes. These interventions should be implemented to target minority groups that are known to intake a higher amount of sugar and salt in order to increase the birth weight of these populations (Hill et al., 2019). This reading should demonstrate that educating and counseling on nutritional habits should be part of an intervention program to improve maternal nutrition during pregnancy. It should facilitate discussion on how a program like this could be more widely implemented to improve maternal nutrition of the pregnant population.

Promoting Folic Acid to Spanish-Speaking Hispanic Women: Evaluating Existing Campaigns to Guide New Development (Quinn et al., 2006)

This next study investigated the use of a social marketing campaign to promote the use of folic acid in a population of Hispanic women. Social marketing is the application of traditional marketing principles towards the promotion of health behavior change. This strategy involves reducing barriers to making a health behavior change while highlighting the benefits without threats (Quinn et al., 2006). This type of intervention assists people in altering their environment to make it easier to change their behavior for the better.

Deficiency in folic acid during the periconceptional period is strongly linked to the development of neural tube defects. Despite the recommendations for universal folic acid use, neural tube defects are still prevalent. This is because these defects can occur before a woman knows she is pregnant and therefore before she is taking a multivitamin containing folic acid (Quinn et al., 2006). Surveys by March of Dimes show that Hispanic women are less likely to have heard about or take folic acid and are thus 40-50% more likely to have a child with a neural tube defect (Quinn et al., 2006). A radio and television intervention by March of Dimes encouraging Hispanic women to take folic acid supplements was unsuccessful in decreasing neural tube defects in this population (Quinn et al., 2006). In the early 2000s, the University of South Florida Birth Defects Surveillance program began a marketing campaign to target Hispanic women and promote the use of folic acid. They had discovered that folic acid was misunderstood by many Hispanic women and many were unaware of the causes of many birth defects and thus sought to increase awareness of its benefits (Quinn et al., 2006). They implemented a culturally sensitive approach to promote folic acid use in these women. They used fotonovelas, radio, and TV to convey the importance of taking folic acid to promote healthy development and prevent neural tube defects.

While the results of this study have not been made available yet, this research demonstrates an ideal way of increasing awareness to improve maternal nutrition. There is a need for targeting specific health behavior interventions to specific populations to best accomplish change. The same intervention will not work for all groups of women and it is most important to target populations in which women are most likely to be affected. Therefore, women who are most at risk for being nutrient deficient during pregnancy (minority women and women of low socioeconomic status) should be specifically targeted by these intervention programs.

Public Health Interventions to Improve Maternal Nutrition During Pregnancy a Nationally

Representative Study of Iron and Folic Acid Consumption and Food Supplements in India (Singh et al., 2020)

This article discusses two public health interventions by the Indian federal government to improve maternal nutrition during pregnancy and will inform our discussion of how we can improve maternal nutrition. The first intervention was the provision of iron and folic acid tablets to pregnant women and the second was the distribution of supplemental food to the same population. However, these programs were largely underutilized. Only 30% of those eligible received the vitamin tablets and only 52% of those eligible received supplemental food (Singh et al., 2020). This demonstrates that just because resources are available does not mean that they will be fully utilized by those who could benefit from them.

The study identified several factors associated with an increased likelihood of using supplemental food and the vitamin supplements. Older women who had higher levels of education were more likely to take advantage of the resources provided by the program (Singh et al., 2020). The disadvantaged classes were much less likely to use the nutrient supplements and food provisions, which was hypothesized to be due to the lack of awareness of the benefits (Singh et al., 2020). This points to the importance of ensuring that the resources are not only available to a population, but they are aware of the benefits of using them. Additionally, those who sought prenatal care earlier in their pregnancy were more likely to use both resources (Singh et al., 2020). Finally, of the strongest indicators of the use of supplemental food and the nutrient tablets was contact with a health provider. Having contact with a health provider, especially under a government health institution setting, increased the likelihood of using these services by nearly five times (Singh et al., 2020). This significant relationship demonstrates the importance of health professionals in encouraging women to use these services.

This research provides important details on how to target specific populations for use of nutritional services and vitamin supplements. There is a need to educate women on the value of improving their nutrition status for their sake and the sake of their fetus. It also demonstrated that early contact with a health provider who recommends nutrition monitoring and vitamin use will increase the likelihood of compliance. Therefore, it is important for doctors to recommend to all pregnant women that they monitor their diet and take a prenatal vitamin. This should facilitate the discussion of how to ensure that all women have access to a culturally competent healthcare provider who will encourage them to adopt healthy behaviors and utilize the resources available to them during pregnancy.

Vitamin D May be a Link to Black-White Disparities in Adverse Birth Outcomes (Bodnar & Simhan, 2011)

This article discusses vitamin D status and its role in adverse birth outcomes. A previous reading from the first day of discussion demonstrated that African American women and their children are more likely to have deficient vitamin D. This study investigates this issue further by connecting vitamin D status to low birth weight and exploring the possibility of improving outcomes with vitamin D supplementation.

The researchers found that African Americans tend to drink less milk, an important source of added vitamin D, than their white counterparts (Bodnar & Simhan, 2011). Interestingly, they showed that consuming the recommended vitamin D levels does not prevent insufficiency in these populations (Bodnar & Simhan, 2011). This demonstrates that there may be a need for a higher intake of vitamin D in African American populations compared to white populations. A possible explanation for this may be due to the fact that higher amounts of melanin limit the amount of vitamin D that can be synthesized by the body (Burris et al., 2012). This combined with the fact that African Americans generally have lower oral intake of vitamin D from their diet indicates that supplementation may be necessary to give women the amount of vitamin D that their bodies need during pregnancy. This review concludes that vitamin D supplementation in these populations may have a tremendous impact but the causal relationship still needs to be investigated by controlled trials (Bodnar & Simhan, 2011).

This reading provides further evidence that vitamin supplementation may ameliorate birth disparities seen among different racial groups. It also emphasizes the fact that more research is needed to examine this relationship. Different women may need different amounts of vitamins to cope with the demands of their changing bodies and the growing fetus.

Questions for discussion

How might access to food contribute to increased salt and fat intake in minority women compared to white women and women of higher socioeconomic status? How can we improve access to improve nutrition? Is just improving access enough to improve nutrition?

How can we ensure that resources for prenatal care are not just available but utilized by women? How do you think distrust of physicians contributes to disparities in the use of prenatal healthcare? How can we dismantle mistrust in the medical community that has resulted from the complicated history of the mistreatment of minority populations?

Can you think of any other interventions that would also help ameliorate disparities in birth outcomes via prenatal nutrition? What other factors besides prenatal nutrition do you think play a role in maternal health and fetal development during this critical period?

Possible Guest Speakers

The first guest speaker I envision would enhance our discussion would be Janet Catov PhD., who authored the article from the first day of discussion entitled Periconceptional Multivitamin Use and Infant Birth Weight Disparities. This research showed that only women with a healthy body mass index benefited from multivitamin use in terms of decreased risk of preterm birth and small-for-gestational-age infants. It would be interesting to know if she has further investigated the link between obesity and the need for higher amounts of vitamins during pregnancy. Could minority populations that are more obese benefit from increased levels of vitamin supplementation to decrease the negative outcomes of deficiency? Some of her more recent research focuses on the link between preterm birth and later development of maternal cardiovascular disease which demonstrates that maternal health in pregnancy has long term effects on the health of the mother in addition to the fetus.

The second speaker I would recommend is Gwendolyn Quinn Ph.D., one of the authors of the assigned reading Promoting Pre-Conceptional Use of Folic Acid to Hispanic Women: A Social Marketing Approach. As previously mentioned, this research focused on an intervention to increase folic acid consumption targeting specifically Hispanic women who could likely become pregnant. Rates of neural tube defects caused by insufficient folic acid are greatest in this population, thus making it an ideal target. They implemented messages about what folic acid is and the importance of preventing birth defects in Spanish fotonovela and radio programs (Quinn et al., 2006). It would be interesting to hear about the program from her perspective and learn about its results. There is not much information currently available about the outcome of the intervention and it would be interesting to hear about the patterns she has seen thus far as a result of her interventions. Did the targeted approach to improving folic acid supplementation in this population actually improve the rate of neural tube defects?

Concluding Remarks

It is clear that maternal health is a complex yet important factor during pregnancy that affects mother and fetus over the long term. Maternal nutritional status is influenced by many factors, from physiological processes to social forces. The disparities in prematurity and small-for-gestational-age that infants in minority populations are likely caused in part by nutritional disparities. It is important to elucidate these disparities and determine their causes so that they may be targeted. It is evident that education about and access to nutritious foods and vitamin supplements is a key component. These birth disparities are not caused by the personal failure of minority women, but the combination of forces that have long regarded their reproduction as less important than that of other women (Rapp, 2001).

There are steps that can be taken to ameliorate these disparities but they need to be further investigated. The best program to improve maternal nutrition would involve a variety of methods, from education on nutritional habits and their importance, provision of food resources to those who need them, and access to prenatal care and vitamin supplementation at appropriate times. Certainly, more research will be vital to the process of implementing positive changes in maternal nutrition. However, improving maternal nutrition will not completely mitigate the disparities in prematurity and low birth weight. Premature birth outcomes are related to economic factors, inadequate care, and the experience of racism (Davis, 2019). There needs to be a more general effort to promote reproductive justice for all women, to ensure that they have the right to control their reproductive lives and raise their children in the way they see best (Ross, 2006).

References

Bhanbhro, S., Kamal, T., Diyo, R. W., Lipoeto, N. I., & Soltani, H. (2020). Factors affecting maternal nutrition and health: A qualitative study in a matrilineal community in Indonesia. PLOS ONE, 15(6), 1-16. doi:https://doi.org/10.1371/journal. pone.0234545

Bodnar, L. M., & Simhan, H. N. (2011). Vitamin D may be a link to black-white disparities in adverse birth outcomes. Obstetrics Gynecological Survey, 65(4), 273-284. doi:10.1097/OGX.0b013e3181dbc55b

Burris, H. H., Rifas-Shiman, S. L., Carmargo, C. A., Jr., Litonjua, A. A., Huh, S. Y., Richardson, J. W., & Gillman, M. W. (2012). Plasma 25-hydroxyvitamin D during pregnancy and small-for-gestational-age in black and white infants. Annual Epidemiology, 22(8), 581-586. doi:10.1016/j.annepidem.2012.04.015.

Catov, J. M., Bodnar, L. M., Olsen, J., Nohr, E. A., & Olsen, S. (2011). Periconceptional multivitamin use and infant birth weight disparities. American Journal of Clinical Nutrition, 94, 906-912.

Davis, D. (2019). Reproductive injustice: Racism, pregnancy, and premature birth. New York, New York: New York University Press.

Davis, D., & Scott, K. (2020). Translating obstetric racism into a patient-reported experience measure – Department of humanities and social sciences. Retrieved December 11, 2020, from https://humsci.ucsf.edu/lecture-videos/translating-obstetric-racism-into-a-patient-reported-experience-measure/

Dunlop, A. L., Kramer, M. R., H, C. J., Hogue, Menon, R., Rama & Krishan, U. (2011). Racial disparities in preterm birth: An overview of the potential role of nutrient deficiencies. Obstetrics and Gynecology, 90, 1332-1341. doi:10.1111/j.1600-0412.2011.01274.x

Hill, A. M., Nunnery, D. L., Ammerman, A., & Dharod, J. M. (2019). Nutrient and food group intakes of low-income pregnant women by race/ethnicity. Journal of Health Disparities Research and Practice, 12(1).

March of Dimes. (2017). Fewer than half of US women take recommended vitamins prior to pregnancy, according to March of Dimes New Prenatal Health and Nutrition Survey. Retrieved December 03, 2020, from https://www.marchofdimes.org/news/fewer-than-half-of-u-s-women-take-recommended-vitamins-prior-to-pregnancy-according-to-march-of-dimes-new-prenatal-health-nutrition-survey.aspx

Odhiambo, J. F., Pankey, C. L., Ghnenis, A. B., & Ford, S. P. (2020). A review of maternal Nutrition during Pregnancy and Impact on the offspring through development: Evidence from animal models of over-and undernutrition. Environmental Research and Public Health, 17(6926), 1-10. doi:doi:10.3390/ijerph17186926

Quinn, G. P., Hauser, K., Bell-Ellison, B. A., Rodriguez, N. Y., & Frias, J. L. (2006). Promoting pre-conceptional use of folic acid to Hispanic women: A social marketing approach. Maternal and Child Health, 10(5), 403-412. doi:1092-7875/06/0900-0403/0

Rapp, R. (2001). Gender, Body, Biomedicine: How some feminist concerns dragged reproduction to the center of social theory. Medical Anthropology Quarterly, 15(4), 466-477. doi:10.1525/maq.2001.15.4.466

Ross, L. (2006). Understanding reproductive justice. Feminist Theory Reader, 14-19. doi:10.4324/9781003001201-11

Seo, Y., Jeong, Y. S., Koo, K., Yang, J. I., & Park, Y. K. (2020). Maternal nutrition intervention focused on the adjustment of salt and sugar intake can improve pregnancy outcomes. Food Science and Nutrition, 9, 3900-3911. doi:10.1002/fsn3.1699

Singh, P. K., Dubey, R., Singh, L., Kumar, C., Rai, R. K., & Singh, S. (2020). Public health interventions to improve maternal nutrition during pregnancy: A nationally representative study of iron and folic acid consumption and food supplements in India. Public Health Nutrition, 23(15), 2671-2686. doi:doi:10.1017/S1368980020001007