What Will it Take to Improve Birth Outcomes in African American Infants?
By Darline Turner, BS, MHS, PA-C
Owner and Founder of Mamas on Bedrest & Beyond
My daughter was born at 36 weeks and 6 days, just 3 hours and 57 minutes shy of 37 weeks, the mark of a full term infant. She was tiny, 18 inches long and a mere 5 lbs 3oz. My daughter was a preterm, low birth weight African American baby, another data point in the statistics which show that African American infants are twice as likely to be born premature (before 37 weeks gestation) and low birth weight (less than 5 lbs 5 oz).
How could this be? I am a physician assistant with a Masters Degree. My husband, an engineer, MIT trained in Physics and Mathematics. We had premium health insurance and I literally saw my obstetrician within days of my home pregnancy test showing two blue stripes. I never missed a prenatal visit and if anything, I had more than the recommended visits because I had a history of uterine fibroids for which I had undergone surgical removal prior to this pregnancy, had had a previous miscarriage and was 36 years old. Was I at risk for an adverse outcome? Most certainly, but according to the literature, my reproductive history is not the only reason.
Researchers have been studying the disparities in birth outcomes in African American women and infants and have found that neither socioeconomic status nor access to prenatal care are able to explain the persistent gap that exists in birth outcomes. Neonatologists Richard David, MD (Neonatologist, Stroger Hospital of Cook County, Chicago) and James Collins, MD (Neonatologist, Children’s Memorial Hospital, Chicago) have been studying the disparities in birth outcomes and were shocked to find that in African American women, prenatal care, education and socioeconomic status were not driving forces when it comes to birth outcomes. They found, like others who have studied this phenomenon and as it’s been reported by the US Centers for Disease Control and Prevention, that the gap between African Americans and whites has remained constant by these indicators and they found in their research, that the gap in maternal mortality between African Americans and Whites actually widened as African American women gain more education. African American Women with advanced degrees, who had great prenatal care, didn’t smoke, drink or do any recreational drugs had birth outcomes that were on par with White women who had not even finished high school! Dr. David summarized their findings,
“There’s something about growing up as a black female in the United States that’s not good for your childbearing health. I don’t know how else to summarize it.”
The neonatologists’ work was the focus of a segment called “When the Bough Breaks” one part of the four part documentary “Unnatural Causes” produced by California Newsreel in 2008 which asks the question, “Is inequality making us sick?” The neonatologists and others cited in the documentary noted that while high socioeconomic status and higher education are supposed to be predicative of better birth outcomes, this is not the case for African American women. Infant mortality in white American women with a college degree or higher is about 4 deaths per one thousand births. In African American women with the same level of education, infant mortality is about 10 per one thousand births, almost three times higher. The researchers also noted that African American mothers with college degrees have worse outcomes than white mothers without a high school education. Michael Lu, MD, MPH, Obstetrician, David Geffen School of Medicine, UCLA said it this way,
“Think about this. We’re talking about African-American doctors, lawyers, and business executives. And they still have a higher infant mortality rate than non-Hispanic white women who never went to high school in the first place.”
In an attempt to explain this phenomenon, researchers questioned if there is some sort of genetic predisposition to preterm labor, prematurity and low birth weight in African Americans, but again, the data did not bear this out. They compared newborns born to African American Women, African Immigrants to the U.S., and U.S. born white women. Dr. David recounts,
“It turns out that the Africans and the whites were about the same. The African Americans, on the other hand, had babies that weight almost eight or nine ounces less than the other two groups.”
The researchers also found that when African women immigrate to the US, it takes only one generation before their daughters are at risk of having premature babies at a significantly higher rate and with poorer birth outcomes. As Dr. Collins summarized,
“This to us really suggests that something is driving this that’s related to the social milieu that African American women live in throughout their entire lives.”
According to Drs David and Collins racism is a key factor that can no longer be ignored. Their data suggests that chronic stress associated with being African American increases the risk of having a premature, low birth weight infant more than two fold.
This is the premise of “Closing The Black-White Gap In Birth Outcomes: A Life-Course Approach” a research publication by Dr. Michael Lu. Lu and his colleagues at UCLA have developed a 12 point plan to reduce Black-White disparities in birth outcomes using a life course approach. The first four points address health care across the life span,
- Increases to inter-conception (between births) care
- Pre-conception care
- Prenatal care
- Access to quality healthcare throughout the life course.
The second four points focus on strengthening the family and community ties that may influence health,
- Strengthen father involvement
- Improve family support services
- Create reproductive social capital (features of social organization that facilitate coordination and cooperation to promote reproductive health within a community)
- Build stronger communities.
The last four points seek to remove the social and economic disparities,
- Close the education gap
- Reduce poverty
- Support working mothers
- Undo racism.
As one can see, as it pertains to African Americans, health is not just a function of increased access to care and/or improved education and social status. How one lives day to day and the support system one has on a day to day basis seems to be as influential on health as income and access to health care. From what researchers have been able to ascertain, the breakdowns within African American communities:
- a) families no longer living in close proximity
- b) dispersions of and migrations out of black communities
- c) the lack of infrastructure and resources in black communities
is having a significant impact on African American health, and in this case, the health and survival of African American infants and African Americans in general.
Lu and his colleagues propose that if this 12 point plan is carried out, we may be able to reduce the gap that exists in birth outcomes for African American women compared to white women and lower maternal and infant mortality in African American women and infants.
Dr. Lu concludes in his publication,
“For too long we have looked for a quick fix to close the gap. Elimination of racial disparities in birth outcomes is attainable if we make the life course, perhaps intergenerational, social investments it will take. The 12 points are a beginning. The health of our nation tomorrow depends on the choices we make today.”
If we hope to end racial disparities in health care, we as a nation are going to have to tackle racism head on. The United States has long wanted to forget the role and impact that slavery, segregation and racism have had on our culture and society at large, and on African Americans in particular. But as we look at the maternal and infant mortality rates, leading heath indicators, we are confronted with the facts. Lifelong unequal treatment of African Americans is proving deadly for them (us) and damaging our society as a whole. If we hope to ever close the disparity gap in African American birth outcomes, this nation is going to have to put an end to racism.
State Specific Maternal Mortality Among Black and White Women—United States, 1987-1996. The US Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, June 18, 1999; 48(23); 492-496.
Differences in Maternal Mortality Among Black and White Women—United States, 1990
The US Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, January 13, 1995; 44(01); 6-7.13-14.
“Racial and Ethnic Disparities in Maternal Mortality in the United States” Kyriakos S. Markides, PhD, University of Texas Medical Branch, Galveston, Texas. Presented at the Howard Taylor International Symposium “Maternal Mortality”, Washington, D.C., Annual Clinical Meeting of the American Association of Obstetrics and Gynecology, May 3, 2011.
“Unnatural Causes…is inequality making us sick?” A four-hour series airing on PBS and a national public impact campaign. Produced by California Newsreel with Vital Pictures. Presented by the National Minority Consortia. Public Engagement Campaign in Association with the Joint Center for Political and Economic Studies Health Policy Institute. 2008
Michael C. Lu, MD, MPH, Milton Kotelchuck, PhD, MPH, Vijaya Hogan, DrPh, Loretta Jones, MA, Kynna Wright, PhD, MPH, Neal Halfon, MD, MPH. Closing the Black-White Gap in Birth Outcomes: A Life Course Approach. Ethnicity & Disease, 2012; 20 (Suppl 2): s2-62-s2-76.