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  • Asthma in Pregnancy: DISCUSSION

socioeconomic status

This study confirms previous reports of rates of asthma during pregnancy in the range of 0.4% to 1.3% (Table 2). It also demonstrates that rates of asthma during pregnancy are racially disparate, with African Americans and Hispanics at greater risk than whites. Furthermore, women with Medicaid and Medicaid Healthstart are at greater risk for asthma during pregnancy than are women with indemnity insurance. In a multivariable model, insurance status appears to explain much of the racial disparity in asthma during pregnancy. As mentioned earlier, insurance status provides a surrogate measure of socioeconomic status and access to medical care. This finding is consistent with the model of

Williams et al., in which the racial impact on health outcomes is mediated through factors, such as socioeconomic status and access to medical care.
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In a sequential multivariable model in which insurance type was placed in the model before maternal education, education had no effect on the racial difference in risk. When maternal education was placed in the model before adjustment for insurance type, education again had minimal impact on the overall odds ratio. This demonstrates that insurance type is the more important confounder of the relationship between race and asthma during pregnancy. Type of insurance may affect the quality of care a patient receives. This may be due to less prestige associated with Medicaid as well as a less favorable rate of reimbursement to providers. In this study, insurance status may provide a surrogate measure of both conceptual components of socioeconomic status, prestige and access to material goods. While Medicaid insurance coverage presumably increases access to care for those who otherwise would not have access, it does not ensure the provision of high-quality care. Viewing insurance status in this way, in addition to our finding that trimester of prenatal care was not a significant predictor of asthma in pregnancy, it is unlikely that the pregnant woman’s behavior was responsible for her poor outcome. This finding is consistent with prior evidence that other factors besides those related to individual behavior impact socioeconomic differentials in outcomes.

Liberatos et al. have pointed out many of the limitations of education as a measure of socioeconomic status. There has been an increase in the homogeneity of years of education in the general population, which limits its explanatory value. Also, number of years of education alone provides less information than type of education completed and type of degree earned. More years of education does not necessarily lead to higher income or a more prestigious occupation—traditional indicators of higher socioeconomic status.

According to Ross and Mirowsky, the few studies that have examined the relationship between insurance status and health outcomes show that public insurance is associated with poorer health outcomes. Use of public insurance may be a better predictor of an individual’s level of economic disadvantage, relative to typical measures of socioeconomic status, such as years of education. Insurance status, as a measure of socioeconomic status, has the potential to explain many racial/ethnic disparities in health outcomes.
Self-pay for healthcare often indicates lower socioeconomic status, along with Medicaid insurance coverage. Our finding that overall, self-pay did not predict higher rates of asthma in pregnancy, but that within the self-pay category African Americans were more likely than whites to have asthma in pregnancy and Hispanics were not, may reflect heterogeneity of socioeconomic status within the self-pay category. Another explanation is that harsh conditions—in this case, lack of insurance coverage may affect African Americans more severely than other groups. This is due to the multiple vulnerability to which African Americans are often subject, due to the many social roles they inhabit that place them at higher risk.

Furthermore, insurance status may represent access to care, such that those with indemnity insurance may have greater access to preventive care for their asthma, and those without insurance or with Medicaid may be less likely to have access to such high-quality preventive care. This would explain a greater severity of symptoms in those who are self-pay or who are Medicaid recipients, as their would be more clinically apparent and therefore their asthma diagnosis would be coded with a higher frequency than those with more controlled, less-symptomatic asthma. Thus, these individuals are more likely to be counted as a case in this study.

Our finding that African Americans and Hispanics were more likely than whites to have had asthma during pregnancy when they initiated their prenatal care in the first or second trimester but not when they had no prenatal care or when they initiated prenatal care in the third trimester, may be a result of differential bias in receiving a diagnosis for existing asthma between those with and without timely initiation of prenatal care. We were able to minimize this bias by stratifying the analyses by each level of prenatal care initiation/utilization.
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Some of the similarities and differences between the HealthStart recipients and other Medicaid recipients in this study are worth noting. The Medicaid-eligible pregnant women in HealthStart have received case coordination of medical services with other social and health support services. It is notable that prenatal care initiation/utilization was much better for the Health-Start than for the Medicaid and the self-pay insurance categories. However, the diagnostic rates at the time of delivery for asthma in pregnancy were not notably dif­ferent for HealthStart and Medicaid clients. These findings underline the fact that early initiation of prenatal care services is not a major determinant of asthma diagnosis during pregnancy in these data. Again, quality of care may be the larger issue.

Several limitations of our study must be kept in mind. As noted in Demissie et al., administrative databases are prone to some degree of coding errors. However, we validated our data set by comparing the rates of various infant and maternal outcomes to published results. For example, in our population, the rate of preterm births was 11.9%, of small-for-gestational age was 11.9%, of very-small-for gestational age was 2.9%, of large-for-gestation-al age was 12.5%, of cesarean delivery was 24.7%, and of placenta previa was 0.6%. These figures are in agreement with those reported in the literature.
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Because the analyses reported here depend on the patient data recorded at the time of obstetrical delivery, it is possible that only mothers with severe or active asthma would have been identified as such, and mothers with less-severe asthma may have been omitted from this classification. As such, our measure of asthma may reflect more clinically apparent, severe asthma, which is more likely to be noted and coded in the administrative database. It is possible that milder or more controlled asthma might not be coded as frequently as more severe asthma. In our analyses by calendar year, the finding that the rate of maternal asthma during pregnancy almost doubled from 1989 (0.3%) to 1993 (0.6%) might have been related to diagnostic fashion. However, this may reflect the increase in morbidity and hospitalizations due to asthma that has been observed in the last two decades in both children and adults. Furthermore, the prevalence of asthma among these parturient women (0.55%) is consistent with estimates of 0.4-1.3% obtained by others for asthma in pregnancy.

In conclusion, the results of the present study provide evidence suggesting that social disadvantage explains much of the racial disparity in the risk of asthma during pregnancy. These results have important public health and policy implications. Because uncontrolled asthma during pregnancy has been linked with adverse infant and maternal outcomes and because asthma is a highly manageable disease, efforts to monitor the quality of treatment for disadvantaged pregnant women should be advocated. Such programs may improve infant and maternal outcomes during pregnancy and delivery, and as a result may pay for themselves. buy cialis soft tabs

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