Forthcoming Changes in Healthcare Financing and Delivery Offer Opportunities for Reducing Racial Disparities in Risks to Reproductive Health

In the United States, there are well-documented racial disparities in rates of maternal mortality, pregnancy complications, preterm and low birthweight delivery, and stillbirth for non-Hispanic blacks compared to non-Hispanic whites. ^{1 –3} These black-white racial disparities in reproductive outcomes persist across socioeconomic strata and despite improvements in the quality and reach of prenatal and postnatal care of women and infants. ^4,5 The underlying reasons for racial disparities in reproductive health outcomes are not completely elucidated or understood, but there is accumulating evidence for the role of women's preconception health in subsequent reproductive health outcomes ^6,7 and racial differences in women's preconception health status as an important driver of racial disparities in reproductive health outcomes. ^{8 –11}

In this issue of the Journal of Women's Health, Denny et al. ¹² used data from the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the prevalence of five selected preconception risk factors for adverse pregnancy outcomes—at-risk drinking, smoking, obesity, diabetes, and frequent mental distress—among U.S. women of reproductive age. The authors further examined differences in these risk factors by race and ethnicity. The study demonstrated that compared to non-Hispanic white women, non-Hispanic black women had a lower prevalence of at-risk drinking and smoking and a higher prevalence of obesity, diabetes, and frequent mental distress. After adjusting for demographic and psychosocial characteristics (including age, education, employment, marital status, and social and emotional support), black women had a significantly lower prevalence of two or more of the studied preconception risk factors than did white women. These findings are consistent with other studies that have found a lower prevalence of modifiable behavioral risks, such as at-risk drinking and smoking, among black compared with white women yet a higher prevalence of chronic conditions. ^{13 –15}

When considered together with data that document the persistence of disparities in reproductive health outcomes despite increased access to and use of prenatal care, these studies underscore that differential exposure to readily quantified and easily modified behavioral risk factors cannot fully explain the black-white disparities in reproductive health outcomes. ^{15 –18} Although further research is needed to understand the origins and most effective and expeditious means of addressing racial disparities in health in the United States, a life-course perspective in maternal-child health has been proposed as a broad strategy for addressing racial disparities in reproductive health, given what is known currently. ^{19 –21} The life-course perspective conceptualizes birth outcomes as the result of the entire life course of the woman before pregnancy and offers contextual and longitudinal strategies for improving reproductive health outcomes through improving access to and quality and continuity of healthcare for African American women, to include preconception and preventive healthcare; strengthening African American families and communities; and addressing social and economic inequalities. While the challenge of fully implementing and realizing a life-course perspective in maternal-child health remains, forthcoming changes in healthcare delivery—including improved access to affordable healthcare coverage through the Affordable Care Act, expanded efforts to implement the Patient-Centered Medical Home (PCMH) in clinical practice, and growing enthusiasm for public health and primary care partnerships—offer promise for achieving some goals of the life-course perspective in the not-so-distant future.

The Patient Protection and Affordable Care Act promises to expand coverage to an estimated 30 million lower-income Americans in 2014 and advances a prevention theme that will improve access to preventive care relevant to preconception and reproductive health promotion in a number of ways. ²² First, the Act would provide individuals with improved access to clinical preventive services by reducing cost as a barrier. For example, directives for the new health plans include coverage with no cost sharing of tobacco use counseling and evidence-based tobacco cessation interventions as well as obesity screening and counseling for adults and children. ^22,23 In addition, health plan coverage guidelines for women's preventive services, developed by the Institute of Medicine (IOM), support that women receive at least one well-woman preventive care visit annually, to include preconception care, and education and counseling about the full range of Food and Drug Administration (FDA)-approved contraceptive methods. ²⁴ Second, healthcare reform has the potential to cover large numbers of young persons of reproductive age, particularly those 19–29 years of age, who at present represent one of the largest segments of the uninsured. Critical provisions in the new law, such as the ability to enroll in a parent's health plan up to age 26, significant expansion in eligibility for Medicaid, and the creation of state or regional health insurance exchanges for people with low and moderate incomes, will specifically expand the pool of young persons with healthcare coverage. ²⁵ Third, the Act offers Community Transformation Grants to improve nutrition, increase physical activity, and promote smoking cessation, social and emotional wellness, and strategies to reduce healthcare disparities. ^22,23

The PCMH is a model for healthcare delivery endorsed by the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association. The model is based on a physician-led multidisciplinary team approach providing comprehensive, continuous, personalized primary care to patients, with the goal of optimizing health outcomes. There are seven essential principles that guide the PCMH approach: (1) each patient has a personal physician, (2) the physician leads a team of providers, (3) the team takes a whole-person approach to healthcare provision, being responsible for all aspects of healthcare throughout all stages of life, (4) care is coordinated and integrated across all aspects of the healthcare system and community, (5) quality, safety, and attainment of evidence-based patient-centered outcomes are emphasized, (6) patients enjoy greater access to care, and (7) the system employs a reimbursement structure that recognizes the value of enhanced coordination, access, and outcomes. ^26,27

Recognizing the shared principle of longitudinal care, Files et al. ²⁸ suggested that the PCMH be used as a model for the delivery of comprehensive reproductive healthcare, including preconception and interconception care. The potential benefits of incorporating preconception health care into the PCMH approach are numerous. Such an approach could bring together reproductive health, preventive, and primary care services within the same healthcare provider or team, within the same practice, or connected by a shared electronic medical record, in contrast to the siloed approach of traditional women's healthcare. The continuity of care affords the opportunity for reproductive life planning with individuals, which is viewed as an important means of bringing the life-course perspective to reproductive health care ¹⁹ and vital to avoiding unintended pregnancies. ^29,30 Women with pregnancy complications, such as gestation diabetes and hypertensive disorders of pregnancy, who are at increased risk of later diabetes and cardiovascular disease, ^31,32 could potentially benefit from the PCMH emphasis on continuity of preconception, prenatal, and postpregnancy care. Risk factors for adverse pregnancy outcomes could be addressed at visits for chronic disease management, not segregated to specific reproductive health visits. Quality improvements might employ care team reminders for vaccination or folic acid supplementation or patient reminders for contraception refills. Safety could be enhanced through alerts about teratogenic medications prescribed by other linked providers.

In addition, there are several aspects of the PCMH approach that render it amenable to addressing disparities. First, it is designed with the goal of providing high-quality care and employs feedback and improvements toward this aim. Second, it is patient centered and culturally appropriate. High-quality care and patient education and empowerment are key elements to reducing health disparities. Third, care is organized around a multidisciplinary team approach that treats the whole patient to include, ideally, behavioral modification, provision of mental health services, and linkage with social support services. Finally, women with complex medical issues, who disproportionately belong to racial and ethnic minority groups, might be expected to gain the most from the structured, coordinated care.

Recently, the IOM called for greater cooperation and coordination between public health and primary care in order to achieve improved population health. ³³ Incorporating elements of the PCMH approach into public health could further this goal. Local public health entities are ideally suited to coordinate care. Many provide an array of services, including family planning; screening and treatment for sexually transmitted infections (STIs); nutrition support through the Women, Infants and Children (WIC) program; and various social support services. Linkage of these disparate services and incorporation of preconception health promotion and care elements, including reproductive planning, screening, counseling, and referral to needed services, would be a step toward streamlining access to appropriate healthcare for underserved populations, who disproportionately belong to racial and ethnic minority groups.

There is not an easy answer to closing the long-standing black-white disparities in reproductive health and reproductive health outcomes. However, embracing forthcoming changes in healthcare that advance attainment of the life-course perspective, including reform of healthcare financing with an emphasis on preventive healthcare, the PCMH approach, and integration of public health and primary care, offers promise for more comprehensively addressing the reproductive health needs of the population across the life span. However, the success of these approaches in reducing racial disparities in reproductive health outcomes will require that policies and services be purposefully constructed to include reproductive planning and preconception health elements and consider the prevailing context: that more than half of reproductive-aged women have at least one recognized modifiable risk factor for an adverse pregnancy outcome. ¹² Approximately half of all pregnancies are at increased risk for an adverse outcome, as they are unintended, ^{34 –36} requiring that strategies be targeted to all women of reproductive age according to their changing needs across the life course.