Black and Hispanic Women With Multiple Sclerosis Are More Likely to Have Complicated Pregnancies
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Black and Hispanic women with multiple sclerosis are more likely to have advanced disease and complications during pregnancy and childbirth than white women with MS, according to a study published January 23 in the journal Neurology.
“We found that Black and Hispanic women with MS entered pregnancy with lower socioeconomic opportunity — things like education, employment, insurance, and even the Childhood Opportunity Index, which is a measure of the quality of resources and conditions that matter for children to develop in a healthy way in the neighborhoods where they live,” says the senior author of the study, Riley Bove, MD, a neurologist and researcher at the University of California in San Francisco.
“This article highlights racial disparities in Black and Hispanic/Latinx women with MS who unfortunately have higher disability rates at the time of conception, and during their pregnancy find additional challenges to maintain both the fetal and their own health,” says Luis Manrique-Trujillo, MD, a multiple sclerosis fellow at Georgetown University in Washington, DC, who was not involved in the research.
Black and Hispanic Women Face Health Disparities in Pregnancy Care and in MS Outcomes
In the general population, Black and Hispanic women are already known to face higher barriers to adequate pregnancy care than white women, says Dr. Bove. Black women are three times more likely to die of a pregnancy-related cause than white women, per the Centers for Disease Control and Prevention (CDC), for example, and the rates of short and long-term health complications related to pregnancy are rising faster for Hispanic women than any other racial or ethnic group, per BlueCross BlueShield.
Researchers also already know that, pregnancy aside, Black and Hispanic women with MS have worse neurological outcomes than white women. Research shows they’re more likely to be younger at the onset of MS, and have a higher risk of early and total disability, and lower overall survival.
But how those issues intersect hasn’t been well-researched. Most of the studies on MS pregnancy outcomes have focused on white women, and consideration of factors such as education and income are generally lacking, noted the authors.
“We decided to ask whether Black and Hispanic women with MS experience differences in opportunity, pregnancy care, and MS outcomes than their white counterparts,” says Bove.
Black Women With MS Are More Likely to Deliver Via Emergency C-Section
Researchers searched medical records at nine MS centers throughout the United States and found nearly 300 women whose pregnancies resulted in live births. Nearly all the women — 95 percent — had relapsing-remitting MS (RRMS), the most common type of MS, in which symptom flare-ups alternate with periods of recovery.
Approximately half the patients were white, about 30 percent were Black, and 20 percent were Hispanic. Black and Hispanic women were ages 31 and 30, respectively, at the time of conception — younger than the white women, who were an average of 34 years old.
At the time of conception, Black and Hispanic women were more likely to live in under-resourced neighborhoods, to be unemployed, and less likely to have private health insurance.
In addition to the differences in opportunities, investigators also found some differences in the use of prenatal ultrasound and the type of delivery. “Black women were more likely to deliver via emergency cesarean sections, and Hispanic women were more likely to deliver via natural vaginal delivery,” says Bove.
Both Black and Hispanic women were more likely to give birth to infants with lower birth weights than children born to white women.
Breastfeeding Can Protect Against MS Relapse
All three groups had similar rates of breastfeeding, but white mothers breastfed for six months — about six weeks longer than the 4.5-month average for Black and Hispanic women. “This is important, since breastfeeding is considered protective against MS relapses in the postpartum period,” says Bove, and research shows.
MS Care Was Similar Among All 3 Groups of Women
Minority women also had higher levels of inflammation both before and after pregnancy, an indication that they were more susceptible to myelin loss and injury to the underlying axon part of the nerve cell, which suggests disease progression, noted the authors.
“What we didn’t see is that MS care — for example, whether effective MS medications were used and when women stopped these before pregnancy or resumed them after delivery — was substantially different between the groups of women,” says Bove. It’s unclear why disparities weren’t observed in care. The authors speculated that drug companies’ financial assistance programs for low-income patients may enable women with fewer resources to access more effective therapies.
“But there was no data on other factors that may influence outcome, such as racism among clinicians, severity of accompanying medical conditions, and access to experts, like lactation consultants,” says Bove.
It’s important to note that when using data derived from medical records, the categories for race and ethnicity are limited and flawed, says Bove. “Categories like ‘Black,’ ‘Hispanic,’ or ‘white’ do not encompass the diversity of geography, opportunity, culture, genetic ancestry, and other factors important to the health of the individuals they describe. They also don’t reflect the individuals who self-identify as belonging to many different groups,” she says.
How Lack of Resources Contributes to Health Disparities in MS
“Living with a chronic disease like MS represents a real burden to young adults,” says Bove. The condition requires regular lab and MRI monitoring, seeing various specialists such as physical therapists, talk therapists, and urologists regularly, while still balancing work and family obligations. Adding pregnancy care on top of that can be challenging for women with MS, especially if they have less money and a higher burden of daily symptoms, she says.
“Even if they are well-aware of all the requirements for prenatal and postnatal care, patients who depend on hourly work have poorer paid childbearing leave policies,” Bove points out. Responsibilities at home, lack of transportation, and a lack of resources to be able to continue to breastfeed or pump may also contribute to the inequities observed here, she says.
Dr. Manrique-Trujillo has witnessed how these disparities can impact the lives of women with MS. “I have already seen two young Black women who were employed before their MS onset and became homeless afterwards. They both have been struggling during their application for disability benefits due to invisible symptoms mainly affecting their ability to work,” he says.
Far from being an isolated example, these scenarios are more common in vulnerable and underserved groups who often experience diagnostic delays and are not started on disease-modifying therapies early enough, he says.
Long-Held Biases Impact the Care That Women of Color Receive
A major factor that couldn’t be adequately evaluated in the study are the implicit and explicit biases in the medical profession that lead women of color — regardless of their education or income — to receive worse care during pregnancy and postpartum, says Bove. “This poorer care includes pain control, recognition of medical complications, or referral to lactation experts,” she says.
Black women with MS face additional burdens because of the historical challenges the Black community has endured in the medical field. As a group, they’ve been neglected, says Manrique-Trujillo.
“Until the early 2010s we used to believe that MS was a disease that usually afflicted white patients. Nonetheless, increasing evidence since 2013 has shown similar incidence and prevalence in Black and white patients,” he says.
This misconception reinforced an implicit bias that has persisted in clinical practice throughout the world, says Manrique-Trujillo. “Breaking this thought pattern might take more than a generation, but it is something we are trying to improve,” he says.
Black Patients Are More Likely to Experience Delays in MS Diagnosis
“A prospective study in our MS center found that Black patients are statistically more likely than non-Hispanic white patients to experience diagnostic delays of six months or more,” says Manrique-Trujillo. That matters because starting disease-modifying therapy as soon as possible is crucial to slow down disease progression and prevent relapses, he says.
“Increasing awareness as providers, understanding that these patients have higher rates of disability and mortality, can help us to think about secondary prevention with different tools than we use for other, privileged individuals,” says Manrique-Trujillo.
Bove says the medical community needs to step up to ensure that care for the individual patient is comprehensive and coordinated.
Training of professionals can help, as the findings also reflect a national problem where individuals of color continue to face structural inequality and, many times, overtly racist medical care during pregnancy and the postpartum period, she says.
Women With MS Need to Be Involved in Their Care and Advocate for Themselves and Their Children
Unfortunately, a large amount of the burden falls on patients to continue to educate themselves about the comprehensive care they will need during their pregnancy, and to partner with their care team to meet these goals, says Bove.
“As a stop-gap measure, we are developing a comprehensive checklist that we aim to disseminate to women contemplating pregnancy so that they can plan their MS and pregnancy-related care,” she says.
The best way for the patients to advocate for themselves is to become involved in their care and stay informed, says Manrique-Trujillo. Pregnant women also need to advocate for their unborn children through different associations and hospital resources to help them in different stages from preconception through motherhood, he says.
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