This paper examines persistent racial disparities in infant mortality rates in the United States, focusing on the documented finding that Black infants die at approximately 2.4 times the rate of white infants. Drawing on CDC data spanning 1980 to 2000, the paper analyzes contributing factors including low birth weight, managed care restrictions on postpartum hospital stays, socioeconomic conditions, and social racism. It also reviews federal initiatives such as Healthy People 2010 and the HHS minority outreach framework. The paper concludes by proposing a concrete Plan of Action that includes community awareness campaigns, improved health care access, and direct legislative lobbying, including a model testimonial statement addressed to the U.S. Senate Committee on Health, Education, Labor, and Pensions.
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Numerous empirical studies have demonstrated a significant discrepancy in the survival rates of newborns of different races. It has been shown that Black infants are approximately two times more likely to die within the first month of life than their white counterparts. Identification of these disparate findings has prompted analysis of health care from a demographic perspective, considering racial treatment and socioeconomic conditions. The Centers for Disease Control and Prevention (CDC) has examined race-specific mortality data on newborns and reported a series of persistent trends consistent with these differences. It is necessary to address this inconsistency in survival rates between Black and white infants 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, these areas include cancer screening and management, cardiovascular disease, diabetes, HIV infection and AIDS, and immunizations. In 1998, a presidential goal was established committing governmental resources to eliminating these health care differences and improving the overall health of all Americans. This effort involved the Department of Health and Human Services (HHS). The strategies for achieving these goals were outlined in 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 were outlined, and departmental leadership and resources were committed to improving health care for affected groups.
The HHS has outlined a plan to combat health care discrepancies (HHS, 2000). Their goals are directed at providing leadership through research and expanding and improving programs aimed at health care service delivery, poverty reduction, safe and healthy environments, and trauma and disease prevention. The committee overseeing these tasks is headed by the Assistant Secretary for Planning and Evaluation and the Surgeon General. They partner 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 a directed review of disparity-reduction goals and currently applicable programs. The department also determines consultation programs for minority communities and health services groups, and reviews scientific data, demographics, and health care services for potential areas of improvement in order to satisfy the goal of eliminating racial and ethnic factors in the six outlined health disparity areas.
With respect to the research component of HHS minority outreach programs, the Department has required changes to local and national data collection formats. For instance, HHS has adopted a policy requiring all HHS-sponsored data reporting programs to itemize racial and ethnic categories. This addition to data reports allows the HHS to better monitor the distribution of federal funds and ensure that monies, services, and health care access are being applied equally and without discrimination. Improved interactions, interventions, and partnerships can also be provided to minority communities to stimulate research involvement, and to determine and implement better strategies for health care access and delivery.
The persistence of infant mortality rate disparities between Black and white babies, as addressed by Healthy People 2010, also involves intervention by the CDC. The CDC 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), defined as less than 2,500 grams, and very low birth weight (VLBW), defined as less than 1,500 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 — nearly 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 improved significantly for all races, with infant mortality decreasing 45.2% by the year 2000, reaching 6.9 deaths per 1,000 live births, with 4,064,948 total births reported (3.2 million to white women and nearly 620,000 to Black women). Although an overall decline in infant mortality was noted, the decrease was greater for babies born to white mothers (47.7%) than for those born to Black mothers (36.9%). During the time span analyzed, the ratio of Black-to-white infant deaths actually increased by 25%, remaining at a persistent ratio of 2.4 from 1990 to 1998. This compelling information regarding the disproportion of Black infant deaths relative to white is the basis of the health issue review in Healthy People 2010 and is central to the discussion of racial health care disparities.
A prime determinant in identifying causes of infant mortality discrepancies is birth weight, which is influenced by several racial and ethnic factors. In the CDC's investigation, the gap in low-to-very-low birth weight risk increased significantly between Black and white babies, with smaller declines in BWSMRs over the two decades noted for Black infants than white infants. Thus, birth weight-specific influence on infant mortality rates persisted as a significant factor (Iyasu et al., 2002).
In recent years, improvements in medical technology, the introduction of neonatology, and the regionalization of perinatal care have increased infant survival when birth weight is a factor. While this has broadly benefited infants of all races, the etiology of the disparities must still be examined. It should be noted that some increases in low-to-very-low birth weight infants have resulted from changes in obstetrical practices, such as assisted reproductive technology, induction of labor, and preterm delivery. These practices are most significantly reported in white women, who showed increases from 1986 to 1996, compared to a 10% decrease in Black women. Twin births also increased at twice the rate for whites compared to Black women, affecting low birth weight ratios (Iyasu et al., 2002). Even accounting for this information, mortality discrepancies persist, suggesting evidence of race-related factors influencing mortality rates.
Identified factors potentially involved in the mortality rate for Black infants include 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 (such as bacterial vaginosis and HIV), maternal health experiences that may be unique to Black women, access to quality medical care (both obstetric and neonatal), and medical expense coverage. However, in a joint study conducted by the Northern New Jersey Maternal/Child Health Consortium, even when these race-related variables are controlled for, 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 convened to investigate further. It was determined that several additional factors — primarily social in nature — may contribute to Black infant mortality rates. One area found to impact these rates was the community's lack of awareness of the Black infant mortality problem, as well as the effect of social racism in adding psychosocial stress to mothers. Additionally, a significant lack of quality pre- and postnatal services exists for Black families, especially for mothers and infants at elevated risk (Marshall et al., n.d.). The influence of demographic risk factors alongside the attitudes and effects of social racism thus appears to account for the described discrepancy in Black and white infant mortality rates.
The socioeconomic status of all women, white and Black, has also been shown to affect infant mortality. In the assessment by Malkin et al. (2000) of newborn deaths related to early discharge — defined as less than thirty hours after birth — the death rate for infants under 28 days of age showed an odds ratio of 3.65 for early discharges compared with those discharged after thirty hours. It was specifically noted 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 declining from two days in 1993 to one day in 1995, the rise in early discharges is directly relevant to infant mortality rate considerations.
The primary driver of the reduction in postpartum hospital stays is the influence of managed health care, with Medicaid making it more difficult to keep mothers and babies hospitalized for the longer periods deemed medically beneficial. The study concluded that "newborns discharged early had significantly lower socioeconomic status than newborns with longer stays" (Malkin et al., 2000). This demonstrates that shorter hospital stays disproportionately affect lower-income patients — a group that, proportionately, includes more Black families than white — and that the constraints of managed care are limiting optimal postpartum care for mother and child, contributing to increased mortality rates.
The statistical findings and related data analysis of several prominent organizations have established that racial and socioeconomic factors do influence the higher infant mortality rates among Black babies compared to white babies. The problem has been identified, as have its related contributors: low birth weight, health care access and delivery, and managed care budgets. It is necessary to take this information and develop key solutions to address the problem. While governmental task forces have worked to review this health care issue and implement measures to narrow the gap in the Black-to-white infant survival ratio, new plans for action must be developed to pursue other means for saving Black infants who could benefit from greater survivability.
Given the persistence of the discrepant Black-to-white ratio in infant mortality, further legislative action must be taken to narrow this gap, as it appears to be rooted in race. Healthy People 2010 addresses the issue on several fronts, but the deficiency in access to quality medical care — resulting from managed health care coverage resisting expenditures required by those in lower socioeconomic brackets — has negatively impacted minorities who demonstrate the greatest need for improved health care.
With managed health care limiting postpartum stays to levels far below the recommendations for optimal postnatal care, infant mortality risk is increased, as demonstrated by studies showing the adverse effects of shortened hospitalization. A plan of 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 preventable death. Survivability for infants should not be determined by race or socioeconomic status.
A major component of the Plan of Action is establishing goals to which an implementation strategy can be applied. This first requires outlining the issue from a statistical perspective, identifying target areas for improvement, and determining available resources, key groups, and individuals to lobby — focusing on matters most relevant to prospective legislators.
"Social racism and Medicaid cuts worsen Black infant outcomes"
"Outreach, access improvements, and legislative lobbying proposed"
"Model Senate testimony requests postpartum policy reform"
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