A study published in the journal Neurology on January 23 reveals that Black and Hispanic women diagnosed with multiple sclerosis (MS) are predisposed to experiencing advanced disease progression and complications during pregnancy and childbirth compared to white women.
Senior author of the study, Riley Bove, MD, a neurologist and researcher at the University of California in San Francisco, said, “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.”
A multiple sclerosis fellow at MedStar Georgetown University Hospital in Washington, DC, who was not involved in the research. Luis Manrique-Trujillo, MD, said, “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.”
Health Disparities Faced by Black and Hispanic Women in Pregnancy Care and MS Outcomes
Dr. Bove underscores existing racial disparities in pregnancy care, citing higher obstacles faced by Black and Hispanic women in accessing adequate prenatal services compared to white women. Statistics from the Centers for Disease Control and Prevention (CDC) highlight stark differences, with Black women being three times more likely than white women to succumb to pregnancy-related complications.
Moreover, the incidence of short and long-term health complications related to pregnancy is escalating at a faster rate among Hispanic women than any other racial or ethnic group, according to BlueCross BlueShielddata.
In addition to pregnancy-related challenges, prior research indicates that Black and Hispanic women diagnosed with MS confront more severe neurological outcomes than their white counterparts. Studiesdemonstrate that they tend to experience earlier onset of MS, heightened risk of early and total disability, and diminished overall survival rates.
However, the intricate interplay between these issues remains largely unexplored. The majority of studies examining MS pregnancy outcomes have predominantly focused on white women, neglecting to account for socioeconomic factors such as education and income, as emphasized by the study 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 Dr. Bove.
Black Women With MS More Likely to Have Emergency C-Sections
This gap highlights the need for comprehensive research to clarify the complex interactions between race, MS, and pregnancy outcomes, thereby informing more equitable and effective healthcare practices for all women affected by this debilitating autoimmune condition.
A comprehensive examination of medical records from nine multiple sclerosis (MS) centers across the United States identified nearly 300 women whose pregnancies culminated in live births. Among these women, the overwhelming majority – 95 percent – had been diagnosed with relapsing-remitting MS (RRMS), the most prevalent form of the condition characterized by alternating periods of symptom exacerbation and remission.
Demographic analysis revealed that approximately half of the patients were of white ethnicity, while about 30 percent were Black, and 20 percent were Hispanic. Notably, Black and Hispanic women were, on average, younger at the time of conception compared to their white counterparts, with Black women averaging 31 years old and Hispanic women averaging 30 years old, whereas white women had an average age of 34.
Further scrutiny of socioeconomic factors uncovered disparities between racial groups at the time of conception. Black and Hispanic women were disproportionately represented in under-resourced neighborhood, exhibited higher rates of unemployment, and were less likely to possess private health insurance compared to white women.
Furthermore, apart from variations in opportunities, researchers also observed discrepancies in the utilization of prenatal ultrasound and delivery methods.
“Black women were more likely to deliver via emergency cesarean sections, and Hispanic women were more likely to deliver via natural vaginal delivery,” says Dr. Bove.
Moreover, both Black and Hispanic women were more inclined to deliver infants with lower birth weights compared to infants born to white women.
Breastfeeding Protects Against Relapse of MS
The research also showed that all three groups showed similar rates of breastfeeding. However, white mothers breastfed for six months – around 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.
All 3 Groups of Women Had Similar MS Care
The authors noted that minority women exhibited elevated levels of inflammation both preceding and following pregnancy. This observation suggests a heightened susceptibility to myelin loss and injury to the underlying axon portion of nerve cells, indication potential disease progression.
“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 Dr. Bove.
The reasons for the absence of disparities in care remain uncertain. The authors hypothesized that financial aid programs from pharmaceutical companies aimed at low-income patients might facilitate access to more effective therapies for women with limited resources.
“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.
In addition, Dr. Bove explains that it’s important to note that when using data derived from medical records, the categories for race and ethnicity are limited and flawed.
“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 Does Lack of Resources Contribute to Health Disparities in MS?
“Living with a chronic disease like MS represents a real burden to young adults,” says Dr. Bove.
Managing the condition entails undergoing routine lab tests and MRI scans, as well as scheduling frequent appointments with a range of specialists, including physical therapists, talk therapists, and urologists. All this while juggling work and family responsibilities. Incorporating pregnancy care into this already demanding regimen can prove challenging for women with MS, particularly those with limited financial resources and a heavier burden of daily symptoms.
“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,” Dr. Bove points out. She also adds that all the responsibilities at home, a lack of transportation, and a lack of resources to be able to continue to breastfeed or pump could also contribute to the inequities observed here.
As per Dr. Manrique-Trujillo, he 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.
According to him, these scenarios are not isolated incidents but rather prevalent among vulnerable and undeserved groups who frequently encounter delays in diagnosis and lack early initiation of disease-modifying therapies.
The Persistent Influence of Biases on Healthcare for Women of Color
Dr. Bove highlights a crucial factor that the study couldn’t adequately assess: the presence of implicit and explicit biases within the medical profession. These biases contribute to women of color, irrespective of their education or income, receiving inferior care during pregnancy and postpartum periods.
“This poorer care includes pain control, recognition of medical complications, or referral to lactation experts,” she says.
Furthermore, Dr. Manrique-Trujillo points out the Black women with MS face additional challenges due to historical disparities within the Black community’s interactions with the medical field. He emphasizes that this group has been historically neglected.
“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.
Dr. Manrique-Trujillo explains that this misconception reinforced an implicit bias that has persisted in clinical practice throughout the world. “Breaking this thought pattern might take more than a generation, but it is something we are trying to improve,” he says.
Black Patients Face Higher Rates of Delayed 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 Dr. Manrique-Trujillo.
Dr. Bove emphasizes the need for the medical community to take proactive steps to ensure that patient care is comprehensive and well-coordinated. She suggests that professional training can play a crucial role in addressing the systemic inequalities faced by individuals of color, which often result in racially biased medical care during pregnancy and postpartum periods.
Women with MS Need to Take Active Roles in Their Care and Advocating for Themselves and Their Children
Regrettably, Dr. Bove notes that a significant portion of the burden falls on patients themselves to educate and advocate for their comprehensive care needs during pregnancy. She stresses the importance of patients actively engaging with their care team to achieve these goals.
“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.
Dr. Manrique-Trujillo emphasizes that patients must advocate for themselves to be actively participating in their care and staying informed.
Additionally, he stresses the importance of pregnant women advocating for their unborn children through various associations and hospital resources, providing support form preconception through motherhood.
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