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LETTER |
Virginia A. Rauh is with the Heilbrunn Center for Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY. Howard F. Andrews is with the Sergievsky Center, Mailman School of Public Health, Columbia University, and the New York State Psychiatric Institute, New York, NY. Robin S. Garfinkel is with the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY.
Correspondence: Requests for reprints should be sent to Virginia A. Rauh, ScD, Heilbrunn Center for Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B-2,New York, NY 10032 (e-mail: var1{at}columbia.edu).
Racial/ethnic differences in the distribution of births across the childbearing years are indeed dramatic and likely reflect powerful economic and sociocultural influences on the timing of births—influences determining who is selected into the pool of women giving birth at older ages. We know that fewer births occur among African American women than among White women after 30 years of age.1,2 We also know that postponement of first birth may be intentional or unintentional, and in the latter case postponement may be due to a medically complicated history.
Since intentional postponement is associated with higher income and African Americans have lower average incomes than Whites, we might expect a smaller proportion of first births to older African American women to result from intentional postponement. By default, a higher proportion would result from medical problems. That the effect of maternal age on birthweight is slightly attenuated among second births to African Americans is consistent with this reasoning, since the pool of women having a second birth is reduced by the number of women who experienced the most serious medical problems in relation to first birth.
However, multivariate analyses show that the effect of maternal aging on African American births is independent of parity, which would argue against a selection hypothesis, and is exacerbated for the poorest women. As suggested by Geronimus, poverty and the stresses that accompany poverty may work to erode overall health among African American women, with serious consequences for birthweight regardless of birth order.3 The appropriateness of the term "weathering" to name this process is debatable, and the underlying mechanisms deserve further study, but some combination of increased exposure and heightened susceptibility over time is operating. Recent work points to the role of chronic stressors in preterm birth,4,5 possibly mediated by infection,6,7 and both conditions are more prevalent among African American and low-income women.8,9
With respect to childbearing in the United States, social selection is anything but "natural" in the Darwinian sense. Rather, selection forces are socially produced—a consequence of limited choices, diminished resources, and structural constraints. The focus on maternal age–related patterns of risk merely highlights the cumulative nature of the problem. The challenge for public health is to identify the fundamental sources of risk, explore mechanisms that translate social risk into biological adversity, and design policies and interventions to ameliorate this risk among African American women of all ages.10
References
1. Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Report of final natality statistics, 1996. Month Vital Stat Rep. 1998;46(suppl 11).
2. Summary of Vital Statistics, 1997. New York: City of New York, Office of Vital Statistics and Epidemiology, New York Department of Health; 1998.
3. Geronimus AT. The weathering hypothesis and the health of African American women and infants: evidence and speculations. Ethn Dis. 1992;2:207–221.[Medline]
4. Cullhane JF, Rauh VA, McCullum KF, Hogan VK, Agnew K, Wadhwa P. Maternal stress is associated with bacterial vaginosis in human pregnancy. Maternal Child Health J.2001;5(2):127–134.
5. Wadhwa PD, Culhane JF, Rauh VA, et al. Stress, infection and preterm birth: a biobehavioral perspective. Pediatr Perinat Epidemiol.2001;15(suppl 2):17–29.
6.
Kurki T, Sivonen A, Renkonen OV, Savia E, Ylikorkala O. Bacterial vaginosis in early pregnancy and pregnancy outcome. Obstet Gynecol.1992;80:173–177.
7.
Martius J, Krohn M, Hillier SL, Stamm WE, Holmes KK, Eschenbach DA. Relationships of vaginal lactobacillus species, cervical chlamydia trachomatis, and bacterial vaginosis to preterm birth. Obstet Gynecol.1988;71:89–95.
8. Meis PJ, Goldenberg RL, Mercer BM, et al. Preterm Prediction Study: is socioeconomic status a risk factor for bacterial vaginosis in black or in white women? Am J Perinatol.2000;17:41–45.[Medline]
9.
Goldenberg RL, Iams JD, Mercer BM, et al. The Preterm Prediction Study: the value of new vs standard risk factors in predicting early and all spontaneous preterm births. Am J Public Health.1998;88:233–238.
10.
Geronimus AT. To mitigate, resist, or undo: addressing structural influences on the health of urban populations. Am J Public Health. 2000;90:867–872.
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