Maternal Health Care Racial Disparities: In the U.S. and in Nebraska

Currently, 1 in 6 dollars of the U.S. gross domestic product (17.7%) is spent on medical care. Compared to other developed countries, we are falling behind in health status, and racial/ethnic disparities persist. An African American infant born today is almost twice as likely to be born low birth weight or preterm and nearly three times as likely to be born with very low birth weight than a caucasian infant. This has potential implications for lifelong health disparities as birth outcomes predict a range of outcomes over the life course, including infant mortality, childhood health, educational attainment, and adult chronic disease.

What Does Infant Mortality Mean?

Infant mortality is the death of an infant before his or her first birthday. The infant mortality rate is the number of infant deaths for every 1,000 live births. The infant mortality rate (IMR) is an important marker of the overall health of a society. In 2018, the infant mortality rate in the United States was 5.7 deaths per 1,000 live births (1). It was 5.8 deaths per 1,000 in the state of Nebraska (2). Japan has the lowest infant mortality rate at 2.1 per 1000 live births. 

In 2018, in Douglas County, IMR was 6.8 per 1000 births. The average IMR 2015-2017 in Douglas County was 6.5. However, it was 14.5 per 1000 for African American infants, 6.2 for Hispanic, and 5.0 for Caucasian infants born in Douglas County in the same year (3,4).

How Prematurity Affects Infant Mortality

To date, the number one cause of infant mortality is prematurity (when a baby is born at less than 37 weeks gestation). Prematurity frequently leads to infant mortality (or death) within the first 28 days of a baby's life (which is known as the neonatal period), often as a result of extremely low birth weight. One in 9 infants in the United States is born preterm (Hamilton 2015). To date, many factors, medical and non-medical, can increase someone’s risk of having preterm birth and therefore higher infant mortality rates. These individual factors may include factors such as maternal age, current income, education, health behaviors, neighborhood environment, and others.

In Nebraska, approximately 2,600 babies are born prematurely every year, which in 2018 was 10.4% of all births (a significant climb from 8.7% in 2013). This was higher than the Healthy People 2020 objective of 9.4% of all births  and the March of Dimes 2020 goal of 8.1% of all births. In Douglas County, prematurity rates are 11.7% of all births, the highest in the entire state5. This rate was significantly different based on race, ethnicity, income, and education (4): 

• 14.4% of African American women delivered prematurely compared to 9.6% of  Caucasian women
• 8.3% of births to low income women were premature compared to 7.1% for women with household income over 194% of the Federal poverty level
• 11.8% for women with less than high school education delivered prematurely compared to 9.0% for women with college degree or more. 

What is Being Done to Help the Issue

Awareness of the effect of diversity and social determinants of health on women’s health in general --  and preterm birth in particular -- has been growing in recent years. The COVID-19 pandemic and the politicization of healthcare have only intensified this awareness. Several  initiatives have been developed to address  preterm birth, some nationally and many others locally. To name a few, such as the CDC, March of Dimes, National Healthy Start Association, the American Pediatric Association, the American College of Obstetrics and Gynecology, Society of Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and many others. Some focus on gathering and interpreting data, some focus on education (especially Sudden Infant Death Syndrome/Sudden Unexpected Infant Death (SIDS/SUID)), and many others focus on injury prevention and control.

Here is a sample of the local organizations addressing this issue:

• Baby Blossom Collaborative
• Charles Drew
• Community Health Needs Assessment (CHNA) - this is a collaboration work with CHI Health and other associations in Omaha
• Nebraska Pregnancy Risk Assessment Monitoring System (PRAMS)
• Nebraska Title V

• One World Community Health Center

Another important development in the area of addressing infant mortality rates is  Medicaid expansion, which can now  cover individuals up to 138% of the federal poverty level. This allows women to avoid disruption to healthcare during the postpartum period.  It also allows more women to maintain access to healthcare, therefore improving  maternal and child health outcomes. There is another proposal for expanded Medicaid coverage underway that would extend coverage for women from 60 days post-partum to a full year following the birth of their baby.

Below is a proposed list of initiatives to consider in order to address racial disparities in both maternal care and infant mortality:

• Improve access to critical services:
  Strengthen existing health programs and supporting reproductive health care. 
• Screen and treat women at risk for preterm birth by adopting a screening tool for all pregnant patients (such as cervical length measurement at their 20-week ultrasound.
• Provide access to maternity care in all areas of the community
• Offer women tools to navigate the health care system. Example of tools:
  • Doulas and Midwifery services
  • Group prenatal care such as centering pregnancies
  • Kangaroo maternal care: This includes several interventions, including immediate skin-to-skin care, on-demand breastfeeding, and minimal intervention for the childbearing family and newborn immediately after birth
• Train providers to address racism and build a more diverse health care workforce.
• Improve the quality of care provided to all pregnant women: 
  • Create standardized culturally-sensitive assessments for mothers and infants and provide them in multiple languages. 
  • Adopt new models of care and link provider-reimbursement to quality. 
• Address maternal and infant mental health:
  • Identify barriers to accessing maternal mental health services.
  • Dismantle mental healthcare barriers with a comprehensive approach.
  • Screen for and address infant and early childhood mental health issues. 
• Enhance supports for families before and after birth: 
  • Invest in and expand access to policies and programs that support families’ basic needs. 
  • Invest in community programs that offer one-stop comprehensive services. 
  • Simplify enrollment across public benefit programs. 
  • Invest in home visiting. 
  • Fund community-based education and communications initiatives to support families. 
• Screening all women, especially those who are of an age to become pregnant, for factors related to social determinants of health. 

Although there has been significant progress in recognizing and addressing the social determinants of health as they impact infant mortality rates -- particularly in underserved/African-American populations -- , many challenges remain. Most notably, communities may not always have sufficient service capacity or resources to meet identified needs, or sufficient understanding of how data regarding the social determinants of health can be used to improve access to care where it is most needed. With the increased awareness of inequity in healthcare including recognition of the disparities and the impact of the social determinants of health  across all sectors, the time is right to engage in a serious efforts to explore the social and political determinants of health further. Above all, improving the infant mortality rates in general, and especially in communities experiencing higher health disparities,  requires a willingness to bring together a public health perspective.

References

1. Infant mortality rate: The United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
2. National center for health statistics: Nebraska https://www.cdc.gov/nchs/pressroom/states/nebraska/ne.htm
3. https://www.dchealthdata.com/images/files/MCH_2017.pdf
4. https://www.douglascountyhealth.com/images/FIMR_BBC/Publications_Reports/FIMR_Annual_Report_2018_Printable_8.5_x_11.pdf
5. https://www.marchofdimes.org/peristats/tools/reportcard.aspx?reg=31
6. Hamilton, B.E., Martin, J. A., and Osterman, MJ.K. (2015) Births: Final Data for 2014. Hyattsville, MD: National Center for Health Statistics; http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf. 
7. Hughes, D., and Simpson, L. (1995) The Role of Social Change in Preventing Low Birth Weight. Future Child; 5(1):87-102. doi:10.2307/1602509.
8. Kaufman, J.S., Dole, N., Savitz, D.A., et al. (2003) Modeling community-level effects on preterm birth. Ann Epidemiol. 13(5):377-384. 
9. Kim, D., and Saada, A. (2013). The Social Determinants of Infant Mortality and Birth Outcomes in Western Developed Nations: A Cross-Country Systematic Review. International Journal of Environmental Research and Public Health. 10 (6): 2296–2335 doi: 10.3390/ijerph10062296
10. Kovner, A., and DiAunno, T. (2017) Evidence-Based Management in Healthcare: Principles, Cases, and Perspectives. Second Edition, ISBN-13: 978-1-56793-871-5
11. Margerison-Zilko, C., Cubbin, C., Jun, J., Marchi, K., Fingar, K., and Braveman, P. (2015) Beyond the Cross-Sectional: Neighborhood Poverty Histories and Preterm Birth. Am J of Public Health. 195 (6): 1174-1180.
12. Metcalfe, A., Lail, P., Ghali, W.A., et al. (2011) The association between neighborhoods and adverse birth outcomes: a systematic review and meta-analysis of multi-level studies. Paediatr Perinat Epidemiol. 25 (3):236—245. 
13. McDorman, M., Mathews, T., Mohangoo, A., and Zeitlin, J. (2014) International Comparisons of Infant Mortality and Related Factors: United States and Europe, 2010.; http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf.
14. Pies, C., Barr, M., Strouse, C., and Kotelchuck, M. (2016) Growing a Best Babies Zone: Lessons Learned from the Pilot Phase of a Multi-Sector, Place-Based Initiative to Reduce Infant Mortality. Matern Child Health J; 20:968–973 DOI 10.1007/s10995-016-1969-1.  https://link.springer.com/content/pdf/10.1007/s10995-016-1969-1.pdf
15. Richardson, S., Daniels, C., Gillman, M., et al. (2014) Society: don’t blame the mothers. Nature; 512(7513):131–132.
16. Scott, K., Britton, L., and McLemore, M. (2019) The Ethics of Perinatal Care for Black Women Dismantling the Structural Racism in “Mother Blame” Narratives; J Perinat Neonat Nurs: 33(2), 108–115 DOI: 10.1097/JPN.0000000000000394