Pediatric Health Inequities: The Case of Infant Mortality

M. Norman Oliver, M.D., M.A.Associate Professor,

Departments of Family Medicine, Public Health Sciences, and Anthropology;

Director, UVa Center on Health Disparities

Wise P. The Anatomy of a Disparity in Infant Mortality. Annu Rev. Public Health 2003;24:341-62.

Oberg CN and Rinaldi M. Pediatric Health Disparities. Curr Probl Adolesc Health Care 2006;36;251-68

Infant Mortality Rates by Maternal Race and EthnicityUnited States, 1995 and 2003

* Deaths of infants aged <1 year per 1,000 live births. † Includes persons of Hispanic and non-Hispanic origin. § Difference not significant at p<0.05 (z test). ¶ Persons of Hispanic origin might be of any race. Infant mortality rates decreased significantly (p<0.05, z test) in the United States from 1995 to 2003. The rate for non-Hispanic black mothers was

significantly higher than for all other groups for both years; the rate for American Indian/Alaska Native mothers was significantly higher than for non-Hispanic whites, Hispanics, and Asians/Pacific Islanders for both years.

SOURCE: Mathews TJ, MacDorman MF. Infant mortality statistics from the 2003 period linked birth/infant death data set. Natl Vital Stat Rep 2006;54(15).

Wise P. The Anatomy of a Disparity in Infant Mortality. Annu Rev. Public Health 2003;24:341-62

Birth weight: How do we intervene?

• Birth-weight specific mortality – improve high-risk obstetrical and neonatal intensive care

• Birth weight distribution requires prenatal and preconceptual interventions

• Our strategy must be to improve the health of the woman before she becomes pregnant or the fetus’ health during pregnancy or both

Prenatal care

• Widely perceived that improving access to prenatal care will improve birth outcomes

• Selection bias: Women receiving prenatal care are likely to be at lower risk for preterm birth for other reasons.

• Some evidence that prenatal care has little impact on preterm birth (Goldenberg RL, Rouse DJ. Prevention of premature birth. N Engl J Med 1998;339: 313-20).

• Other important reasons to provide it.

Intervention targets to reduce risk of birth of VLBW infants

• Huge literature re: factors that increase risk of premature or VLBW infants-- Low income, poor housing, maternal age & parity, maternal smoking, cocaine use, STDs

• These factors tend to explain only a small proportion of the inequities in preterm or VLBW infants

• Psychosocial well-being of women of child-bearing age

• Genetics

Being a Black Woman in America is a #@$%&!!

• Vast social science literature on role of racial discrimination and gender oppression on the psychological well-being of Black women.

• A little over a decade ago, Geronimus showed that these social inequities were associated with inequities in birth outcomes. (Geronimus A. Black/white differences in the relationship of maternal age to birthweight: A population-based test of the weathering hypothesis. Soc Sci Med 1996;42:589-97.)

Being a Black Woman in America is a #@$%&!!

• Higher maternal education is associated with reduced prematurity rates.

• However, highly educated Black women have nearly twice the infant mortality rate of their white counterparts.

• Geronimus demonstrated that the inequities in the birth of LBW and VLBW increased with increased maternal age.

• The embodied effects of racial discrimination, therefore, seem to be cumulative.

Life-Course Perspective

Lu MC, Halfon N. Racial and Ethnic Disparities in Birth Outcomes: A Life-Course Perspective. MCH Jour. 2003; 7:13-30.

Thanks to assistants

• Kristen Wells, MPH

• Kevin Vilsaint, MD

For more information on infant mortality

• CDC Office of Minority Health and Health Disparities: http://www.cdc.gov/omhd/AMH/factsheets/infant.htm

• CDC’s SIDS Web page: http://www.cdc.gov/sids/

• National Center for Health Statistics Infant Health Page: http://www.cdc.gov/nchs/

• US Department of Health and Human Services Office of Minority Health: http://www.omhrc.gov/

• National Institute of Child Health and Human Development: http://www.nichd.nih.gov/

• National Women’s Health Information Center: http://www.4woman.gov/

• Back to Sleep Campaign: http://www.nichd.nih.gov/sids/sids.cfm

Pediatric Health Inequities: The Case of Infant Mortality

M. Norman Oliver, M.D., M.A.Associate Professor,

Departments of Family Medicine, Public Health Sciences, and Anthropology;

Director, UVa Center on Health Disparities