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Infant Mortality Health Care Disparities in Infant Mortality Numerous empirical studies have demonstrated a significant discrepancy in survival rates of newborns of different race. It has been shown that black infants are two times more likely to die within the first month of life than their white counterparts. Identification of these disparaged findings has prompted analysis of health care offered from a demographic perspective, considering racial treatment and socioeconomic conditions.

The Center for Disease Control (CDC) has examined race-specific mortality information on newborns, and reported a series of noted and persistent trends coinciding with the data differences. It is necessary to address this inconsistency in survival rates between the black and white races to identify potential changes in health care delivery systems and eliminate racial factors in infant mortality. The U.S. government has identified six classes of racial and ethnic minority discrepancies in health care access, experience, and outcomes.

In addition to infant mortality issues, the areas also include cancer screening and management, cardiovascular disease, diabetes, HIV infection and AIDS, and immunizations. In 1998 the presidential goal was established committing governmental resources to eliminating these health care differences and improving the overall health of all Americans. This involved contributions by the Health and Human Services (HHS) department. The strategies for administering these goals were written up in the Healthy People 2010, a revision of Healthy People 2000, specifically addressing the greater degree of illness and death experienced by minorities.

Through this agenda, targeted disparities were identified, reliable national data was accumulated, near-term goals outlined, and Department leadership and resources put forth to accomplishing improvements in the health care provided to affected groups. The HHS has an outline of their plan to combat health care discrepancies (HHS, 2000). Their goals are directed at providing leadership through research, and expanding and improving programs aimed at the delivery of health care services, poverty reduction, safe and healthy environments, and trauma and disease prevention.

The committee providing these tasks is headed by the Assistant Secretary for Planning and Evaluation of the Department and the Surgeon General. They partnership with state and local governments, and national and regional minority health organizations, to gain better access to affected communities. The charge of the HHS involves the directed review of disparity reduction goals and currently developed applicable programs.

They also determine consultation programs for the minority communities, as well as the health services groups, and review scientific data, demographics, and health care services for their potential areas of improvement in order to satisfy the goal of eliminating racial and ethnic factors in the outlined six groups. Specifically considering the research aspect of the HHS minority outreach programs, the Department has required changes to be made to local and national data collection formats.

For instance, they have adopted a policy requiring all HHS-sponsored data reporting programs to itemize racial and ethnic categories. The goal of this addition to the data reports allows the HHS to better monitor the distribution of federal funds for the guarantee that monies, services, and health care access are being equally applied in a nondiscriminatory manner. Also, improved interactions, interventions, and partnerships can be provided to minority communities to stimulate research involvement for disparaged groups, and determine and implement better strategies for health care access and delivery.

The persistence of infant mortality rate disparities among black and white babies, as addressed by Healthy People 2010, also involves the intervention by the CDC. The CDC has analyzed data from birth and death certificates obtained from the National Center for Health Statistics (Iyasu et al., 2002). Through this examination certain trends in infant mortality rates related to low birth weight (LBW) at less than 2500 grams and very low birth weight (VLBW) at less than 1500 grams were identified for the years 1980 to 2000.

A subcategory of data analysis included birth weight-specific mortality rates (BWSMRs), calculated from data collected for 1983 to 1991 and 1995 to 1999. Race-specific data for these three categories used the mother's race. Statistics showed that 3,612,258 live births occurred in 1980 (almost 3 million born to white women and over 560,000 to black women), with an average of 12.6 deaths per 1,000 live births. These statistics significantly improved for all races, with infant mortality decreasing 45.2% in the year 2000, with 6.9 deaths in 1,000 live births, and 4,064,948 total births reported (3.2 million to white women and almost 620,00 to black women).

Although the decline in infant mortality was noted, the decrease was greater for babies born to white mothers than to black mothers, with the white decline determined to be 47.7%, and 36.9% for blacks. During the time span analyzed, the ratio of black-white infant deaths actually increased 25% for a constant ratio of 2.4 for the years 1990 to 1998. This compelling information regarding the preponderance of black infant deaths to white is the basis of the health issue review in the Healthy People 2010, and of importance to racial health care disparities.

A prime determinant in the identification of causes of infant mortality discrepancies is birth weight, which involves several racial and ethnic factors. In the CDC's investigation of statistical data, it was found that the gap in low to very low birth weight risk increased significantly between black and white babies, with smaller declines in BWSMR over the two decades noted for blacks than whites. Thus, birth weight-specific influence on mortality rates among infants persisted as a persuading effector (Iyasu et al., 2002).

In recent years, improvements in medical technology, the introduction of neonatology, and the regionalization of perinatal care have accounted for increases in infant survival when birth weight is a factor. While this has overall benefited the odds of all races of infants surviving the conditions and causes related to low birth weight, the etiology of the disparities must still be accounted for.

It should be first noted that some increases in low to very low birth weight infants has resulted from changes in obstetrical practices, such as assisted reproductive technology, induction of labor, and preterm delivery, which is most significantly reported in whites which have shown increases from 1986 to 1996, as compared to a decrease of 10% in blacks. Also, twin births increased at twice the rate for whites than blacks, lending to affected low birth weight ratios (Iyasu et al., 2002). In review of this information, mortality discrepancies are still presented.

This infers evidence of race-related factors involved in the distortion of mortality rates. Identified factors that may be potentially involved in the mortality rate for black infants includes demographic risk factors such as maternal age, income, education, lack of social support, use of drugs, alcohol, or tobacco during pregnancy, pregnancy spacing, maternal medical conditions (i.e. bacterial vaginosis, HIV), maternal health experiences that might be exclusive to black women, access to quality medical care (obstetric and neonatal), and medical expense coverage.

However, in a joint study done by the New Jersey Department of Health and Senior Services and the Northern New Jersey Maternal/Child Health Consortium, when these race-related variables are not relevant, black infants continue to demonstrate mortality rates at twice those of white babies under one year of age (Marshall et al., n.d.). Upon noting this discrepancy, a Blue Ribbon Panel was devised to further investigate this problem. It was determined that several other factors may play a role in black infant mortality rates, primarily of social consideration.

One area found to impact these rates was the community's lack of awareness of the black infant mortality health concern, and the effect of social racism on adding psycho-social stress to the mother. Also, a significant lack of quality pre- and postnatal services exists for black families, especially those mothers and infants at risk (Marshall et al., n.d.).

Thus, the influence of demographic risk factors as well as the attitudes and influences of social racism have seemingly affected infant mortality rates, accounting for the described discrepancies, which see higher rates of black infant deaths than white. The socio-economic condition of all women, white and black, has also been demonstrated to affect infant mortality. In the assessment by Malkin et al.

(2000) of newborn deaths related to early discharge (less than thirty hours after birth), it was found that the death rate for infants less than 28 days old showed an odds ratio of 3.65 for early discharges as compared with those sent home after thirty hours. It was specifically cited that early discharge infants were also more likely to suffer from heart conditions and infections in the first year of life.

With the average postpartum stay for vaginal deliveries in the hospital at two days in 1993, and down to one day in 1995, the rise of early discharges is relevant to the consideration of infant mortality rate effectors. The concern, then, are what factors are affecting early discharge, and what groups does it apply to.

The primary cause of the reduction in postpartum hospital stay is the influence of managed health care, with Medicaid making it more difficult to keep mothers and babies in for the longer periods of time deemed medically beneficial in reducing risk of infant illness and death. It was concluded in the study that, "newborns discharged early had significantly lower socioeconomic status than newborns with longer stays" (Malkin et al., 2000).

This demonstrates the apparent group involved in the shorter hospital stays, of which, proportionately, more blacks belong to than whites, and the hindrance of medical insurance and Medicare in providing optimal postpartum care to mother and child, resulting in increased mortality rates. The statistical findings and related data analysis of several prominent groups has determined that racial and socioeconomic factors consistent with race do influence the higher infant mortality rates in black babies as compared to white babies.

The problem is identified, as are related effectors, such as low birth weight, health care delivery and access, and managed health care budgets. It is necessary to take that information and develop key solutions to apply to circumventing the problem.

While governmental task forces have struggled to review this health care issue and implement theoretical measures to narrow the gap in the infant survival ratio of blacks to whites, new plans for action must be developed to pursue other means for saving these black infants who could benefit with greater survivability if they were white. II.

Development of Plan For Action Given the persistence of the discrepant black-to-white ratio of infant mortality rates among black and white babies, further legislative action must be taken to narrow this gap as it appears to be based on race. The Healthy People 2010 addresses the issue on several fronts, but the deficiency in access to quality medical care, as a result of managed health care coverage resisting expenditures required by those in a lower socio-economic bracket, has negatively impacted the minorities who demonstrate a need for improved health care.

With managed health care limiting postpartum stays to levels far below the recommendations for optimal postnatal care, the infant mortality risk is influenced, as seen in studies demonstrating the adverse effects of shortened hospitalization lengths. Thus, a plan for action aimed at improving access to pre- and postnatal health care and increasing the length of hospital stays following delivery should narrow the gap between black and white babies suffering from illness, infections, and potentially death. Survivability for infants should not be based on race or socioeconomics.

A major component in the Plan of Action is the determination of goals to which the strategy for implementation can be applied. This first involves outlining the issue from a statistical perspective. Also, areas of improvement should be targeted to develop successful strategies. Identification of available resources as well as key groups and individuals to lobby to would additionally be necessary in the advocating portion of the Plan so as to focus on manners relevant to the proposed legislators.

As produced from data analysis, black infant mortality rates are statistically higher than those for white infants, even upon consideration of extenuating circumstances. The persistence of these ratios over the last decade implies evidence of racial factors involved in infant risk of death, disease, and trauma. Thus, statistically determined in the goals of the Plan of Action, the established ratio of 2.4 black-to-white infant deaths is the basis of the issue, to which the Plan will address methods to lower this documented figure.

Numerous recommendations can be made to benefit discussions of and changes to health care delivery for the black population based on this report. The Blue Ribbon Panel Report by Marshall et al. (2000), which discussed the Task Force investigation of successful Black Infant Mortality reduction programs. The Task Force surveyed a field of sources, which included medical schools, health agencies, state health departments, national foundations, public health schools, and Healthy Start projects.

Through this survey they were able to discover 79 Black Infant Mortality (BIM) programs in the United States, primarily referred by medical schools Departments of Pediatrics and Chairs of Departments of Obstetrics and Gynecology. These sources of information are relevant because they demonstrate groups keenly aware of the situation and that are proponents for implemented change in the health delivery system.

Also, resources provided by the HHS Department, the CDC, the American Academy of Pediatrics, and other private and government groups can provide further statistical data and analysis, as well as sources of legislators to which to lobby. The findings by several groups of governmental and private investigations in the issue have brought forth a variety of potential effectors. Understanding these effectors enables one to then produce recommendations.

For instance, the finding that little awareness exists of the BIM problem, at the community level, could prompt attention to developing a public awareness campaign and delivering it to a wider prospect of individuals, including men, so that they can understand their role in BIM. Formal education programs on BIM can be offered to medical training facilities, and exposing the problem at health care forums can be conducted.

Community outreach to improve public transportation for women to reach prenatal and pediatric services could be arranged with seminars offered to teach expectant and new mothers about pregnancy and childcare. Most important is the encouraging of the black community, once made better aware of the situation, to lobby legislators and other groups who have the capabilities to impact BIM to reform health care policies and induce change. Other factors identified to influence BIM are social-racial based.

With black babies accounting for the majority born premature and with very low birth weight (while only making up 17% of the infant population), racial effectors need to be combated. Recommendations in this area could include achieving increased diversity of health care providers who would be sensitive to the needs of black women and babies. Also, advocating improved lifestyle behaviors (i.e. nutrition, exercise, coping with stress) for this group can better prepare them for positive pregnancy outcomes. Improving accessibility to quality health care is essential to affecting the ratio discrepancy.

This would require special consideration for high risk women and infants, the implementation of outreach support groups, and ease of administering medical attention, possibly through "one stop shopping" of medical services at one location. Those mothers who demonstrate increased apprehension over seeking out these medical services could be better supported through groups like the Healthy Mothers / Healthy Babies Coalition. Thus, support and access are essential to providing optimal medical care to both mother and child to reduce infant mortality rates, especially among black babies.

The Plan of Action summary can encompass all of the proposed recommendations, but the more specific the goal and the written Testimonial Statement, the more successful the outcome. While many of the suggestions can benefit the issue of BIM, the focus of this Plan will be the need for improved health care access, both physically and financially. This calls for the Plan to be aimed at relevant groups involved in health care delivery, and Medicare / Medicaid which often manages patient health care and thus limits postpartum hospital stays.

With the issue statistically outlined and legislator action determined, the Plan summarily involves the following: Produce a Testimonial Statement to be provided to determined legislators, discussing the issue and goals of health care policy reform; Identify key legislators to whom the Statement would be relevant; and, Establish communication with the determined legislators. This Plan of Action is designed to address the BIM problem and recommend corrections to current policies and practices to benefit the survival of black infants.

The issue of BIM must become a national priority, given its social establishment as a race-related phenomenon. The development of a Plan of Action directly involves the lobbying of those groups affiliated with health care benefits. Thus, action at the legislative level must be spurred, even if through grass-roots organizations and plans. III. Communication With Legislators As legislative action is necessary to carry out change in the health care system to benefit disenfranchised women of race, specific considerations of a direct legislative request should be devised.

The Plan of Action outlined above will only be fruitful if applied to the ideal legislators, and presented in such a way as to stimulate action on their part. The analysis of legislator petitioning follows, with a summary testimonial statement aimed at lowering infant mortality rates across the board, emphasizing racial awareness of the issue and the need for the significant and primary improvement of the black infant mortality rate. Choosing legislators to communicate with over this issue requires analysis of previously reported task force work.

One group for extracting legislative sources can be taken from those identified to support the Departments of Pediatrics and Obstetrics and Gynecology. The American Academy of Pediatrics (AAP) holds a professional membership of 55,000 pediatricians, and is involved in advocating the betterment of health care practices for infants through young adults. The AAP recently appointed Molly A. Hicks, MPA, to the position of Assistant Director in the Federal Affairs Office, giving her the responsibility for the legislative lobbying on issues relevant to children's health care.

Testimonial statements directed to her office would be reasonable since her purpose is to review such issues.