Chapter I Introduction

Infant mortality often is used as an international indicator of the health and well-being of a nation. It provides a quick measure of the quality of food and water, housing and clothing, health care, and education available in a population (Reidpath and Allotey 2003). The United States, despite being the largest, most technologically advanced economy in the world, ranks 37th of 191 countries in infant mortality (Appendix A, Table A.1) (World Health Organization 2004). Although the rate of infant mortality in the United States declined by 74 percent over the four decades between 1960 and 2000, to 6.9 infant deaths per 1,000 live births (Figure I.1), the degree of decline has slowed in the past decade (Centers for Disease Control and Prevention 2004b). In the 1990s, the rate of infant mortality decreased by 22 percent, compared to 27 percent and 37 percent in the 1980s and 1970s, respectively (Figure I.1). Much of the decrease in the 1970s and 1980s was due to technological advances in high-risk obstetrics and neonatal intensive care (Wise 2003). More recently, technological strides in neonatal health have slowed, making it more challenging to create the large rates of decline seen previously in the United States. [D]

Although it is more difficult to achieve the magnitude of decreases in infant mortality today that occurred in previous decades, the United States’ world ranking in infant mortality suggests that there is still progress to be made. Experts in neonatal health attribute this ranking to the prevalence of poor birth outcomes among certain racial and ethnic groups in the United States, particularly Black, American Indian/Alaska Native, and Puerto Rican populations. The rate of infant mortality is notably higher among these three racial/ethnic groups than the national average (Figure I.2). For example, in 2002, infants born to Black women were twice as likely to die in their first year than infants overall in the United States. In that same year, American Indian/Alaska Natives and Puerto Ricans had infant mortality rates 15 percent above the national average. Hawaiians also had a rate above the national average. However, as shown in Table II.2, the rate for Hawaiians fluctuates below and above the national average from year to year, likely due to small sample size.

In response to these racial/ethnic disparities, the U.S. Department of Health and Human Services has set a goal to reduce infant mortality to less than 4.5 infant deaths per 1,000 births among all racial/ethnic groups in its Healthy People 2010 objectives (U.S. Department of Health and Human Services 2000a). Although infant mortality rates for people in the United States of Cuban and Chinese ancestry are already below the Healthy People 2010 goal, those who are Black, Puerto Rican, Hawaiian, and American Indian/Alaska Native have a rate of 8.2 infant deaths per 1,000 births or higher (Figure I.2). This relationship holds at the State level as well. For all States in 2001, Blacks and American Indian/Alaska Natives consistently have higher infant mortality rates than Whites, while Asian/Pacific Islanders consistently have lower rates (Appendix A, Table A.2).

[D]

High rates of infant mortality tend to be concentrated in the South and North Central regions of the United States (Figure I.3). Those States with higher overall rates of infant mortality also tend to have larger racial/ethnic disparities in infant mortality. For example, when States are divided into thirds by infant mortality rate, States in the lowest tertile (less than 6.5 infant deaths per 1,000 live births) had an average difference in rate between Whites and Blacks of 6.3 infant deaths per 1,000 live births. In comparison, States with rates greater than 7.4 infant deaths per1,000 live births (highest tertile) had an average difference in rate between Whites and Blacks of 8.4 infant deaths per 1,000 live births (Appendix A, TablesA.2 and A.3).

The Institute of Medicine’s (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, offers some insight into the causes of the racial/ethnic disparities in infant mortality (Institute of Medicine 2003). In this report, the IOM attributed the racial/ethnic disparities in health care and, consequently, health to lower health care quality and access for minorities. The IOM reviewed more than 100 studies assessing the health care quality for various minority groups. It consistently found evidence that minorities are less likely than Whites to receive needed services and are more likely to receive less desirable services. The research also showed that disparities are present even when controlling for clinical factors. Although minorities are disproportionately represented among the uninsured and those of lower socioeconomic status, the IOM noted that these factors are not the cause of poorer quality of health care among minorities. Even when minorities have the same health insurance as nonminorities, and similar access to care, minorities still tend to receive a lower quality of care and have poorer outcomes than Whites (Institute of Medicine 2003). When education is used as a proxy for socioeconomic level, Blacks, American Indian/Alaska Natives, and Puerto Ricans continue to have the highest rates of infant mortality compared to other races/ethnicities,regardless of socioeconomic level (Table I.1).The IOM proposes that the sources of racial/ethnic disparities in health are “complex, rooted in historic and contemporary inequities, and involve many participants at several levels, including health systems, health professionals, and patients” (Institute of Medicine 2003). Many factors other than socioeconomic and clinical ones contribute to the problem. These factors include minority behavior and attitudes, cultural and language barriers within health systems, and patients’ and providers’ lack of knowledge. As a result, the IOM promotes a comprehensive, multilevel approach to eliminating disparities that targets patients, providers, and health care systems. This approach includes (1) raising awareness of the problem among the public and health care professionals; (2) employing health systems interventions to equalize and promote high-quality care for all patients; (3) implementing legal, policy, and regulatory improvements to increase minority access to care and reduce cultural barriers to care; and (4) increasing the education of patients and providers.

[D]

Healthy Start is a federally-sponsored, community-based program that works on many levels to eliminate racial/ethnic disparities in infant mortality. The program recognizes the complex nature of racial/ethnic disparities in health and the need to address other factors besides socioeconomic and clinical ones. The goal of Healthy Start is to improve perinatal system access and knowledge by providing culturally competent services, including outreach, health education, and case management, and by enhancing the local perinatal health system. The activities of the Healthy Start program are designed to encourage pregnant and interconceptional women, providers, and other community stakeholders to address the risk factors associated with poor perinatal health outcomes. Healthy Start relies on community involvement to lead to better access to care and knowledge of perinatal risks for high-risk women, which should in turn bring about improved birth outcomes and ultimately eliminate racial/ethnic disparities in infant mortality. In this paper, an evidence base for Healthy Start and other perinatal health initiatives is provided by describing in detail the racial/ethnic disparities in birth outcomes and the risk factors that may be the underlying causes of differences in birth outcomes. To gather this information, a literature review of infant mortality trends and risk factors among various racial/ethnic groups was conducted. The National Vital Statistics Reports was used, and Pubmed, Ovid, and the Internet were searched using key words related to racial/ethnic disparities in infant mortality, causes of infant mortality, and its associated risk factors. Data were amassed from many sources, including vital statistics, peer-reviewed journal articles, and press releases and reports from organizations such as the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the IOM. Because data cited in this paper are from different sources, categorizations of race and ethnicity on the tables and figures vary. While some sources categorized race and ethnicity separately (for example, White and Black, Hispanic and non-Hispanic), others grouped race and ethnicity together (for example, White non-Hispanic, Black non-Hispanic, and Hispanic). Unless explicitly stated as non-Hispanic, White and Black include both Hispanics and non-Hispanics. When possible, race and ethnicity are presented separately. For consistency, African Americans are referred to as Black, and Caucasians are referred to as White. For comparison and consistency, year 2002 data are presented whenever possible, because, in most cases, 2002 is the most recent year for which data are available. In a few cases, however, data are shown for years before 2002 and are aggregated over several years. Appendix A contains tables with detailed data used to create the figures in the paper. Appendix B provides a glossary defining terms used in the paper that relate to birth outcomes.