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Shame on Us: Intolerable Inequality in U.S. Infant Mortality

Even as it leads the planet in medical and scientific accomplishments, the United States also has some downright shameful disparities in its health care, and one of the worst is in the area of infant mortality.
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In Boston, a construction worker, ravaged by burns, successfully underwent a total face transplant. In San Antonio, surgeons have injected a glue-like substance that hardens and prevented the bursting of a woman's brain aneurysm. And in my own institution, researchers have shown that stem cells from a patient's own heart can help regenerate tissue and repair damage caused by a heart attack.

Every day the headlines are filled with breath-taking reports about the advances in American medicine. But even as it leads the planet in medical and scientific accomplishments, the United States also has some downright shameful disparities in its health care, and one of the worst is in the area of infant mortality.

Every year about 30,000 babies in our nation, a disproportionate number of them African Americans, die before reaching their first birthday.

U.S.: Laggards of industrial world

Last year, the infant mortality rate in the United States was an estimated 6.06 deaths per 1,000 live births, just ahead of Croatia, but lagging behind all of industrialized Europe and Asia.

For African Americans, the rate is worse. In 2007, the most recent year that a comparison is available, there were 13.3 deaths per 1,000 live births for African Americans, compared to 5.6 for whites.

Here, in California, public health officials have campaigned to address infant mortality, an apparently successful and commendable effort that has sent our rates to new lows with 4.9 deaths per 1,000 live births. Still, African Americans are plagued by a rate double that, according to 2009 statistics.

African Americans nationwide also have a stillbirth rate double that of whites. What's more, these unacceptable disparities have persisted for a half century.

Research shows that women's and infants' health are hugely affected by socioeconomic factors, such as family income, education, a lack of access to adequate care and the environmental, physical and mental conditions impacting both parents. Women who are obese or smoke, for example, are more likely to experience issues that lead to delivery complications and an unhealthy baby.

Still, these factors don't entirely explain the persistent racial divide, as even African American women with graduate degrees are more likely to lose a child in its first year than are white women who did not finish high school.

Puzzling the racial divide

To solve that part of the puzzle, researchers are scrutinizing environmental concerns such as air quality, chronic stress, genetics and even racism.

Among African Americans, as well as the general population, preterm births (less than 37 weeks) and low birth-weight (less than five pounds, six ounces) are leading causes of infant mortality. The prevalence of preterm births in the United States is the chief reason we rank so poorly compared to other wealthy countries. In Sweden, for instance, 6.3 percent of births were premature, compared with 12.4 percent in the United States in 2005, the latest year for which international rankings are available.

In the past three years, overall preterm births have declined in the United States. However, the number of preterm births for African Americans babies has not. It remains substantially higher at 17.47 per 1,000 births.

The causes of preterm birth and low birth-weight are vast and varied and some remain a mystery. The complexity and interactions between them has made it a challenge to sort out what accounts for the racial disparity. But one factor that we know plays a role is access to prenatal care. African-American women are 2.3 times less likely than white mothers to have seen a healthcare professional before their third trimester, or to have received prenatal care at all.

The hurdles to prenatal care for some African-American women may include their higher uninsured rates, their working and living in areas with reduced access to medical facilities and their lesser income and education. Some African-American women also have expressed fear about mistreatment in the health care system.

To close the racial gap, quality health care needs to be accessible to all and provide an approach that begins before conception and follows the woman through her prenatal and post-delivery times -- and beyond. Even the number of births and the length of intervals between pregnancies can affect outcomes for babies and moms, so access to high quality, knowledgeable care is very important.

Infant mortality related to congenital anomalies is 38% higher in African Americans. Though the cause of most birth defects is unknown, preventive measures (such as folic acid intake, access and use of prenatal ultrasonography and chromosomal analysis) can help in some cases to increase the chances that a woman delivers a healthy baby.

Care also must continue after delivery, including screening for post-partum depression and education about breastfeeding. In California, research recently showed that at 22 hospitals more than 75% of mothers were supplementing their infants with formula at the time of discharge. Many of these hospitals serve the poorest families.

The benefits of breastfeeding have been well documented for years, [see my earlier post on this] yet nationwide, 65% of all black infants were breast fed versus, 79% of white infants, according to a 2005-2006 study.

Once babies go home, follow-up care must be part of the plan. SIDS, the unexplained sudden death of infants, has declined by more than 50% since 1990 among the general population. But rates for African-American infants remain 1.9 times higher than for whites.

Though the cause of SIDS is unknown, several factors have been identified to decrease its risks. These include: putting infants to sleep on their backs, getting them a firm mattress, removing from their cribs the clutter of stuffed toys and loose bedding and keeping the room temperature right and not overheating them with excessive blankets or clothes. Preterm and low birth weight babies and those, whose mothers smoked during pregnancy, are also at higher risk.

New research also suggests that the brains of infants who die of SIDS produce low levels of serotonin, a brain chemical that conveys messages between cells and plays a vital role in regulating breathing, heart rate and sleep. Researchers theorize that this newly discovered serotonin abnormality might reduce infants' capacity to respond to breathing challenges, such as low oxygen levels or high levels of carbon dioxide. These high levels may result from re-breathing exhaled carbon dioxide that accumulates in bedding while sleeping face down.

Maryland and South Carolina have driven down infant mortality rates at least 10% from 2008 to 2009 by relentlessly preaching the basics of safe sleep and having nurses visit new mothers at home.

What can be done

To close the racial gap, programs must address all aspects of women's lives, especially those unique to African-American women. In 2008, the Association of Maternal and Child Health Programs, CityMatCH and the National Healthy Start Association (NHSA), created the Partnership to Eliminate Disparities in Infant Mortality to explore the effects of racism and other disparities on infant mortality.

Recent research suggests, for example, that African Americans who live in segregated neighborhoods, face racism, lack paternal support and live near freeways and congested roads breathing unhealthy air are likelier to have their babies prematurely, putting them at risk.

In a recent article, my colleague Calvin J. Hobel, MD, an expert on the effects of stress on preterm birth, explains that chronic stress, precipitated by such factors as poverty, living in a dangerous neighborhood or racism, may trigger the release of a hormone called corticotrophin-releasing hormone. CRH, produced by the brain and the placenta, is closely tied to labor. It prompts the body to release chemicals called prostaglandins, which help trigger uterine contractions.

Researchers hope to learn more about these and other factors, including genetics, child rearing and exposure to chemicals, through the National Children's Study, an ambitious undertaking in which researchers are examining the lives of more than 100,000 children from before birth to age 21. The Southern California coordinating center is at UCLA in collaboration with Cedars-Sinai, The Charles R. Drew University of Medicine and Science, the University of Southern California, the Los Angeles Department of Public Health, the Research Triangle Institute, the Rand Corporation and several Ventura County organizations.

To be sure, some programs already are targeted to assist African-American mothers, such as Los Angeles' Black Infant Health Program. It offers steps-in 10 sessions prenatally and 10 postpartum-designed to empower and support women with crucial information and skills.

In Milwaukee, the Health Department and the Nurse Family Partnership have joined forces so nurses visit at-risk women in the poorest neighborhoods weekly during pregnancy and every other week for two years after the baby is born. The healthcare pros offer suggestions for healthy lifestyle changes, finding safer housing and coping with stress.

To slash infant mortality, of course, we in the U.S. also must tackle teen pregnancy prevention programs, family planning, full coverage of prenatal care and child health. We also need to step up our efforts to get pregnant women to stop smoking and abusing drugs.

Since the sixties, the United States has become a beacon for the world in seeking to eliminate inequality in its society. Now we need to ensure that the inequities surrounding infant mortality get fixed so we can be proud of not only our headline-grabbing, world-class, scientific and medical advances but also the health of each and every American newborn.