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Infant Mortality Rate Disparities in America:A Closer Look at infant loss in the African American Population
Presented by: 1LT Rickenbach, Alecia
Objectives
• Define infant mortality, neonatal mortality, and post neonatal mortality
• Compare international infant mortality rates (IMR) and explore racial disparities in IMR in the US
• Analyze factors that predispose the African American population to increased infant mortality
• Discuss nursing interventions that promote wanted pregnancies, term gestation, infant survival and wellness
Definition of Terms•Infant Mortality
Rate•Fetal Mortality
Rate•Neonatal Mortality
Rate•Post-Neonatal
Mortality Rate•Pre-Term Birth
•Very Pre-Term Birth
•Low Birth Weight•Very Low Birth
Weight
Kim & Saada, 2013
Finland
KuwaitCuba
Japan
Russia
International Infant Morality Rates
Central Intelligence Agency (CIA), 2014
Preterm Birth Rates among OECD Nations
CDC, 2014
Causes of Infant Loss in the U.S.
CDC, 2013CDC, 2015
Causes of Infant DeathsNeonatal Post-Neonatal
• Congenital defects• Complications of preterm
birth• Maternal Health Conditions• Complications of Labor
and Delivery• Lack of Care Access
• Injury• Infection• Complications of surviving
preterm infants• Sudden unexpected infant
death (SUID)▫ASSB▫SIDS▫ Ill-defined deaths
CDC, 2013CDC, 2015
What country’s infant mortality rate is closest to the infant
mortality rate in the African American population?
The Republic of Palau: 11.46/1000Non-Hispanic Blacks in the US: 11.22/1000
CIA, 2014
IMR Disparities Among U.S. Racial Groups
African Americans Non-Hispanic Whites
IMR 11.22/1000 live births IMR 5.07/1000 live births
Preterm Birth Rate 16.6% Preterm Birth Rate 10.2%
CDC, 2013Cole-Lewis, et al., 2014
Infant Mortality Rates by State
MacDorman, Hoyert & Mathews, 2013
Are Genetics to Blame?•African women
immigrants = IMR of American Caucasians
•Second generation black women = IMR of American-born black women
Kramer, Hogue, Dunlop, & Menon, 2011)
What is Happening to non-Hispanic black Women in
America?
Socioeconomic Status•Low SES = IMR
•1/3 of African Americans live below the national poverty line
Bravemen, et. al, 2015Collins, Rankin, Rankin, & David, 2011Kim & Saada, 2013
IMRs in African Americans with increased SES• Retrospective study of 10,400
black and white women ▫ Increased SES = Improved
preterm birth (PTB) rate for white women
▫ Increased SES = no change for PTB rate for black women
• Retrospective study of 11,265 black women and their infants▫ Increased SES = no change in
PTB rate if mother had been a low birth weight infant
Bravemen, et al., 2015Christopher & Simpson, 2014Collins, et al., 2011David & Collins, 2014Kramer, et al., 2011Porter, 2010
PTB Rate in African Americans with increased SES (Theories)
• Experience race specific workplace stressors▫Minority in workplace▫Pressure to overcome
racial biases• More likely to be
supporting family in low SES categories▫Emotional & Financial
StressBravemen, et al., 2015Christopher & Simpson, 2014Collins, et al., 2011David & Collins, 2014Kramer, et al., 2011Porter, 2010
Residential Segregation
Kim & Saada, 2013
The Great Migration
History of Residential Segregation in America•Racially restrictive
covenants concentrated urban poverty▫Utilized until 1960’s
Gotham, 2000McFarland & Smith, 2011
Residential Segregation Remains an Issue Today
•White-majority housing▫More valuable in real
estate markets•Realtor audits
▫Racial discrimination▫Non-minority
applicants favored
Gotham, 2000McFarland & Smith, 2011
Impact of Residential Segregation on Infant Outcomes
• Segregated white populations ▫No impact on infant
outcomes• Segregated black populations
▫Increased IMR and LBW• Segregated Hispanic
populations▫Protective for infant
outcomes▫ “Hispanic Paradox”
McFarland & Smith, 2011Shaw & Pickett, 2013
The Hispanic Paradox• Residential segregation
protective against infant death, despite low SES▫Strong Kin Networks▫Value Mothers & Families▫Traditions of healthy
behaviors• Hispanic density improves
infant outcomes for all races in that area▫#powerofsocialcohesion
Kim & Saada, 2013McFarland & Smith, 2011Shaw & Pickett, 2013
Pregnancy Intention•1/3 of pregnancies in the U.S. are unintended:
▫Slightly mistimed: pregnancy was wanted within two years
▫Grossly mistimed: pregnancy was wanted, but not within 2 years
▫Unwanted
Kost & Lindberg, 2015
Pregnancy Intention•An analysis of surveys results of 4,297 women’s
pregnancy intentions found:▫Unwanted & grossly mistimed pregnancies
Occurred more frequently among African American women
Delayed entrance into prenatal care decreased breastfeeding rates
▫Unwanted pregnancies increased PTB and LBW risk 62% were third order or higher birth order infants
Kost & Lindberg, 2015
Pregnancy Intention•Study involving 282
low SES, majority black women who received inadequate prenatal care▫93% unwanted
pregnancies▫22% admitted had not
used contraceptives
Katz, et al., 2011
Maternity Leave• World Health Organization
Recommends 16 weeks• Benefits
▫Bonding▫ Infant growth▫Maternal recovery▫Longer breastfeeding
duration▫Higher infant
immunization rate▫More well-child visits
Shepherd-Banigan & Bell, 2014Vahratian & Johnson, 2009
Kim & Saada, 2013Shepherd-Banigan, Megan & Bell, 2013Vahratian & Johnson, 2009
Maternity Leave In the United States•Family & Medical
Leave Act of 1993▫12 weeks unpaid
maternity leave if:▫>50 employees▫>1,760 hours worked
in last year•Low SES Mothers more
likely to take less leaveGuendelman, Goodman, Kharrazi, & Lahiff, 2014Shepherd-Banigan, et al., 2013United Census Bureau, 2013
Epigenetics & Allostatic Stress Load
CDC, 2011
Kramer, et al., 2011Martini & Nath, 2009 Smith & Vale, 2006
Hypothalamic-Pituitary-Adrenal (HPA) Axis
Kramer, et al., 2011 Martini & Nath, 2009 Smith & Vale, 2006
Kramer, et al., 2011Martini & Nath, 2009Smith & Vale, 2006
Effects of Glucocorticoids & Catecholamines
Glucocorticoids Catecholamines • Increased glucose &
glycogen synthesis• Increased utilization
of lipids peripherally• Anti-inflammatory
effects• Decreased immune
response
• Increased glycogen breakdown
• Increased blood sugar• Elevated lipid release• Increased heart rate
and contractility• Increased blood
pressureKramer, et al., 2011Martini & Nath, 2009Smith & Vale, 2006
HPA Axis and the Placenta• Normal amount of CRF
▫Adequate placentation• Elevated CRF
▫Release of catecholamines
▫Vasoconstriction Reduced blood to
uterus/placenta Placenta releases even
more catecholamines▫Uterine contractions
Bonis, et al., 2012Smith & Vale, 2006
Preconception Stress Theory #1:Early Life Programming of Chronic Disease
Kramer, et al., 2011Smith & Vale, 2006
Stressful experiences in utero and early
childhood
Hypersensitive HPA axis
Preterm labor
Early Life Programming of Chronic Disease—Supporting Evidence
•Prior preterm birth▫3.8X risk for another
preterm birth•HPA dysfunction in
baby rats with:▫Poor mothering ▫Injected maternal
stress hormones•Dutch Famine
▫Lower birth weights Collins, Rankin, & David, 2011Kramer, et al., 2011
Preconception Stress Theory # 2:The Weathering Hypothesis
Chronic Exposure to Stressors
Wearing of body’s stress response
Permanent Immune & Vascular Dysfunction
Preterm Labor Kramer, et al., 2011Smith & Vale, 2006
The Weathering Hypothesis: U-Curve
Kramer, et al., 2011
Prime Child Bearing AgeBlack Mothers: 20-25
Prime Child Bearing Age White Mothers: 25-35
Preconception Stress Theory # 3:Psychosocial Responses to Stressors
Chronic Stressors
Unhealthy Coping Mechanisms
Preterm Labor
Kramer, et al., 2011
International GDP Expenses
U.S . Healthcare expenses exceed
other OECD Nations, while Social Service
expenditures are far less
Bradley, Elkins, Herrin & Elbel, 2011
National Efforts to Improve Infant Outcomes
Pregnancy Risk Assessment Monitoring System (PRAMS)
• Surveillance program used to identify geographic specific pregnancy & infant care education needs
• Has led to successful interventions: ▫“Tobacco Free Pregnancy
Initiative”▫“Infant Safe Sleep
Campaign”
CDC, 2013
Home Visitation Programs
• Paraprofessionals or Nurses visit homes of high risk families to provide teaching & improve safety▫ Infant care▫ Parenting Skills▫ Home Environment▫ Parent-child interaction▫ Reduce Abuse/Neglect▫ Connect w/ Community
ResourcesAzzi-Lessing, 2013Katz, et al., 2011Kothari, et al., 2014
Home Visitation ProgramsPros Cons
• For Highly Engaged Families:▫ Improved Home
Environments: Increased safety Developmentally
appropriate ▫Better mothering skills▫ Improved perception of
support▫Reduce child abuse &
neglect
• Expensive• Time Intensive• Minimal overall benefits• No improvements in
preterm birth rates or gestational age
• Failure to engage highest risk population
Azzi-Lessing, 2013Katz, et al., 2011Kothari, et al., 2014
Challenges of Home Visitation Programs•Overwhelming life
stressors•Mistrust of federal/state
programs• Inadequate skill level of
paraprofessionals
Azzi-Lessing, 2013
What is Centering Pregnancy?
•Group Prenatal Care▫8 to 12 women
•Ten Sessions during pregnancy▫1 to 1.5 hours each:
30-40 min. Individual Assessment w/ provider
1 hour Group Teaching
Rotundo, 2011
Centering Pregnancy• Empowers women to be
active care participants▫ Take their own vitals▫ Calculate their gestational
age• Teaching Session
▫ Discussion based▫ Encourages knowledge
exchange• Increased Social Capital
▫ Groups remain consistent throughout their pregnancies
Rotundo, 2011
Benefits of Centering Pregnancy
• Increased Patient Satisfaction
• Increased Breastfeeding Rates
• Improved Birth Outcomes
• Increased Educational Time with Providers
Catling, 2015Ickovics, et al., 2011Rotundo, 2011Tanner-Smith, Steinka-Fry, & Lipsey, 2013Thielen, 2012
Supporting Evidence for Centering Pregnancy (CP)
• Retrospective study of 651 CP patient statistically matched with traditional prenatal care▫Did not improve preterm
birth rate ▫Preterm infants were 2.5
weeks older & 300g heavier at delivery
▫Decreased risk of fetal demise
Catling, 2015Tanner-Smith, Steinka-Fry, & Lipsey, 2013
Nursing Implications: Prevention of Unwanted Pregnancies
• Pathways▫ Indifference▫ Inaccurate information to
pregnancy prevention▫ Lack of access to adequate
birth control• Contraceptive Education
▫ access • Pregnancy Spacing
▫ 18 to 23 months between pregnancies recommended Katz, et al., 2011
Kost & Lindberg, 2015Nabukera, et al., 2009Thomas, 2012Wendt, Gibbs, Peters & Hogue, 2012
Nursing Implications: STI Prevention
• Identify at risk patients▫Assess for risky sexual life
style• Importance of STI testing for
partners• Education of adverse effects
on pregnancy and infants▫ Fetal Demise▫ Preterm Birth▫ Low Birth Weight▫ Opthalmia, pneumonia,
mental delays,
Fontenot & George, 2014
Nursing Implications: Nutrition
• 60% of African American women are obese
• Education on pregnancy & infant risk factors associated with obesity▫ Gestational Diabetes▫ Preeclampsia
• Nutrition Counseling▫ Diet composition▫ Appropriate pregnancy
weight gain▫ Caloric consumption per
trimester American Psychological Association, 2014Marshall, Guild, Cheng, Caughey, & Halloran, 2014Lowdermilk, et al., 2015
Nursing Implications: Substance Abuse
• Education on negative effects of substance use
• Greater risk for African Americans who smoke ▫Preeclampsia▫Fetal Demise
• Evaluate for Intention to Quit▫Provider referral to
cessation/rehab programs▫Self-help resources▫ If unwilling to quit, see if
they’ll cut back
Lowdermilk, et al., 2015
Nursing Implications: Social Support
•Assess for adequate social support
•Ask provider if Centering Pregnancy is a good option
Rotundo, 2011Tanner-Smith, et al., 2014Thielen, 2012
Nursing Implications: Depression Screening
• Low SES women with low social support = risk
• Ensure 100% of patients are screened
• Screening Tools▫ Edinburgh Postnatal
Depression Scale▫ Two question screening tool
• Times to Screen▫ Every Prenatal Appointment▫ Prior to discharge from
hospital▫ 4 weeks post partum Bansil, et al., 2010
Lefkovics, Baji, Rigo, 2014Lowdermilk, et al., 2015
Nursing Implications: Promotion of Breastfeeding•Educate women on the
benefits of breastfeeding▫Decreased SIDS risk▫Decreased Infection
risk▫Improved bonding
•African American women have lowest breastfeeding rates
Ahluwalia, Morrow, D’Angelo & Li, 2012Chen & Roger, 2004
Summary• Defined relevant terms related to fetal and infant
mortality• Compared international infant mortality rates and
maternity leave policies to the United States• Racial infant mortality disparity in the United States was
explored• Reviewed effectiveness of some interventions to reduce
infant mortality & reduce the racial disparities in America• The role of nurses in improving outcomes for women and
infants, especially in vulnerable socioeconomic populations
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QUESTIONS?