SlideShare a Scribd company logo
1 of 24
Download to read offline
1
Infant Mortality Rate Disparities in America:
A Closer Look at infant loss in the African American Population
I. INTRODUCTION: (Slide 1 Title)
Good Afternoon, my name is LT Rickenbach. Today we will be exploring infant
mortality rates in America. Infant mortality is a commonly cited indicator of the health of a
society as a whole (Kim and Saada, 2011). Although infant mortality rates (IMR) in the United
States have improved dramatically since 1960, they continue to lag behind other developed
countries (Center for Disease Control and Prevention [CDC] Grand Rounds, 2013). In 2010,
IMRs were compared among developed nations involved in the Organization for Economic Co-
Operation and Development (OECD) in which the US ranked 26th of the 29 nations. The overall
US infant mortality rate may be high, but some sub-populations within the country are even
worse off. Despite improvements in recent years, in the United States, African American infants
die at rate of 11 per 1000 live births. This is more than twice the rate of infant deaths among non-
hispanic whites with a rate of 5 per 1000 live births (CDC, 2013).
There are a myriad of factors that contribute to infant mortality, as well as a broad
spectrum of research that has found links between certain factors and infant mortality among the
African American population. Despite the large body of literature on the topic, the exact cause of
the large disparity in infant deaths between racial groups remains unknown and resistant to
efforts of reduction. Due to the vastness of this topic, this presentation will focus on the
socioeconomic status (SES), interaction of environmental factors and genetics, and women’s
health legislation as it applies to maternity leave and how these factors may impact infant
outcomes in the African American population in the United States.
II. (Slide 2) LIST OF OBJECTIVES
Objective 1: Define infant mortality, fetal mortality, neonatal mortality and post neonatal
mortality.
Objective 2: Discuss how the IMR in the United States compares internationally and racial
disparities in regards to IMR within the US
Objective 3: Analyze factors that predispose the African American Population to Infant Mortality
Objective 4: Discuss interventions aimed at reducing infant mortality
Objective 5: Discuss nursing interventions that promote wanted pregnancies, term gestation,
infant survival and wellness
III. (Slide 3) DEFINITION OF TERMS
A. Before we get started, I would like to take a moment to review some terms that will be
used throughout this presentation.
1. Infant Mortality Rate (IMR): The number of infant deaths per 1,000 live births
(Kim & Saada, 2013)
2. Fetal Mortality Rate (FMR): Spontaneous intrauterine deaths occurring at >/= 20
weeks of gestation (Kim & Saada, 2013)
2
3. Neonatal Mortality Rate (NMR): Infant deaths occurring at </= 28 days of life
(Kim & Saada, 2013)
4. Post-Neonatal Mortality Rate (PNMR): Infant deaths after 28 days of life, but
within the first year of life (Kim & Saada, 2013)
5. Pre-Term Birth (PTB): <37 weeks gestation (Kim & Saada, 2013)
6. Very Pre-Term Birth (VPTB): <32 weeks (Kim & Saada, 2013)
7. Low Birth Weight (LBW): Less than 2,500g (Kim & Saada, 2013)
8. Very Low Birth Weight (VLBW): less than 1,500g (Kim & Saada, 2013)
B. All of these categories are associated with poor infant outcomes. Consistently around the
globe, the biggest predictor of infant outcomes is gestational age. The majority of infant
mortalities are related to preterm or very preterm birth (Kim & Saada, 2013). In addition,
low birth weight infants are twenty times more likely to die than infants weighing more
than 2,500g (Kim & Saada, 2013). Given this correlation, throughout the presentation
many of the variables that will be discussed will relate to pre-term birth or low birth
weight infants since they are so closely linked to infant morbidity and mortality.
III. EXPLANATION
A. (Slide 4) We will now discuss how the IMR in the United States compares
internationally and as well as within racial subgroups in the United States
1. International Comparison of IMR
a. First off, out of the 224 nations worldwide, where do you think
the United States ranks in terms of infant mortality rate?
i. Answer—as of 2014, 56th with an infant mortality rate of 6.17/1000
live births (CIA, 2014)
b. Raise your hand if you think the United States has better infant
mortalities rates than the following countries:
i. Finland—if you didn’t raise your hand, you’re correct.
With a rate of 3.36, Finland has the 14th lowest IMR in the
world reported by the Central Intelligence Agency (CIA) in
2014.
ii. Cuba—Again, if you have your hand down you win. Cuba
is ranked 42nd with a rate of 4.70. (CIA, 2014)
iii. Kuwait—You guessed right if you raised your hand.
Kuwait is ranked 66th with a rate of 7.51 (CIA, 2014)
iv. Russia—is 65th with a rate of 7.08 (CIA, 2014)
v. Japan—Sweden is 2ndwith a rate of 2.13/1000 live births
(CIA, 2014)
c. (Slide 5)According to a 2014 National Vital Statistics Report that
compared IMR among developed nations, the United States had the
highest percentage of preterm births, 9.8%, of the 19 countries compared
(CDC, 2014). Preterm births account for approximately 19% of annual
infant mortalities in the United States (CDC, 2014).
2. (Slide 6) We will not take a closer look at the breakdown of when infant
deaths occur in the United States
a. Fetal death, or demise beyond 20 weeks of gestation, accounts for nearly
half of all reproductive loss in the United States. The other half of
3
reproductive loss consists of infants who are born alive but later die
(CDC, 2015).
b. (Slide 7) Of these infants, 2/3 of their deaths occur during the neonatal
period (the first 28 days of life), and 1/3 occur in the post-natal period
(after 28 days but before 1 year of life) (CDC, 2015).
c. Causes of infant mortality during the neonatal period include
complications of preterm birth, congenital defects, maternal health
conditions, complications of labor and delivery, and lack of access to
care at the of delivery (CDC, 2013)
d. Causes of infant mortality during the post-natal period include injury,
infection, complications of preterm infants who survive the neonatal
period, and sudden unexpected infant death (SUID) which is composed
of three subcategories: accidental suffocation and strangulation in bed
(ASSB), ill-defined deaths, and sudden infant death syndrome (SIDS)
(CDC, 2013). SUID accounts for approximately 4,500 infant deaths/
year (CDC, 2013).
3. (Slide 8) We will now shift our focus to IMR disparities among racial groups in
the United States. To kick off our investigation, can you guess what country’s
IMR most closely resembles that of the African American population in the
United States?
(Slide 9) Answer: Palau. Just to paint the picture for you, this is a third world
country consisting of a large group of small islands that share one national
hospital. Again, the black population in America has about the same infant
survival rate as this third world country.
a. (Slide 10) As previously mentioned, African Americans experience
more infant deaths than any other ethnic or racial group, with rates more
than doubling those of non-Hispanic whites. In 2010, 16.6% of African
American infants were born preterm while the rate for non-hispanic
whites was 10.6% (Cole-Lewis, et al., 2014). In comparison to non-
Hispanic whites, it is estimated that 78% of the excess IMR of non-
Hispanic blacks can be attributed to preterm birth (MacDorman &
Mathews, 2011).
b. (Slide 11) The southern and Midwest states have the highest infant
mortality rates in the United States, ranging anywhere from 6 to >8
deaths per 1000 live births. Minorities in these states make up about one
third of the population and the largest health disparities are seen in these
areas (Zhang et al., 2012). The lowest IMRs are observed mostly in
western states and the northern most New England states (MacDorman,
Hoyert, & Mathews, 2013).
c. (Slide 12) Previously it was thought that genetic factors were the root
cause of the racial disparities in infant mortality seen in American.
Current research on this topic has revealed the cause to be much more
complex and multi-faceted than a simple genetic explanation. A meta-
analysis of 24 studies that compared preterm birth risk for immigrants
and native-born women discovered sub-Sahara African-born black
4
women who immigrate to the US have a risk for preterm birth similar to
that of white women in America. But yet, the female offspring of these
women demonstrate preterm birth rates of U.S. born African Americans
(Kramer, M., Hogue, C., Dunlop, A., & Menon, R, 2011). Although the
exact cause of the IMR disparity remains unclear, the issue seems to be
largely related to the African American experience in America (Kramer,
M., Hogue, C., Dunlop, A., & Menon, R, 2011).
d. (Slide 13) This poses the question, what is happening to African
American women in America, and why are they seeing greater
incidences of infant loss?
C. We will now look at some of the factors that impact the African American population and
how these factors affect their infant outcomes.
1. Socioeconomic Status
a. (Slide 14) It is common knowledge that low SES status is associated
with poor health indicators. Infant outcomes are no different as low SES
is a consistent predictor of poor infant outcomes across racial groups
(Kim & Saada, 2013; Collins, Rankin, Rankin, & David, 2011;
Bravemen, et al., 2015). This is especially significant for African
Americans as nearly one third of their population lives below the
national poverty line (United States Census Bureau, 2013).
b. (Slide 15) What about African Americans in less economically
disadvantaged groups? How do you think increasing SES might
influence infant outcomes?
i. In a retrospective study of 10,400 black and white Californian
women who gave birth between 2003 and 2010, preterm birth rates
decreased as SES status increased for white women, but the same
benefit was not shared by black women, whose PTB rate saw no
measurable improvement (Bravemen, et al., 2015). Another
retrospective study of 11, 265 African American and their infants
found that mothers who were themselves low birth weight did not
experience less rates of preterm birth with economic improvement
(Collins, et al., 2011). Strange, these findings are counter intuitive. I
personally would expect preterm births rates to decrease as life
conditions improve. There are several theories that attempt to
explain these findings:
a. (Slide 16) There is a lot of evidence that suggests increased
stress negatively impacts health overall and as a result leads
to increased risk of poor infant outcomes (David & Collins,
2014; Christoper & Simpson, 2014; Collins, et al., 2011;
Kramer, et al., 2011). We will discuss this in greater detail
later on. It goes without saying that Americans tend to be
hard workers, we value work ethic, and evidence shows
Americans work longer hours than people of equal income
categories in other developed nations (Porter, 2010). It is
suggested that African Americans working in higher
income categories may experience a unique set of stressors.
5
If they are minority in their workplace (a stressor in itself),
they may feel increased pressure to work longer harder
hours than their non-minority colleagues to overcome
possible racial preconceptions or biases (Bravemen, et al,
2015). Especially in a work centric culture like ours, this
could be a significant source of chronic stress (Breavemen,
et al, 2015, Porter, 2010).
b. In addition, in higher income categories (esp. the lower
middle class) African Americans are more likely that
Caucasians to be supporting family members in lower SES
categories. This is a potential source of emotional and
financial stress (Bravemen, et al, 2015).
2. The next factor we will review is the impact of residential segregation on infant
outcomes
a. (Slide 17) Residential segregation is defined as “the extent to which
social groups characterized by income or race/ethnicity are spatially
separated from one another” (Kim & Saada, 2013 p.2311).
b. (Slide 18)Residential segregation is a unique issue in America because
in many ways it was self-imposed (Gotham, 2000). Following the
abolition of slavery after the Civil War, many African Americans
remained in rural areas employed in capacities that allowed them to use
the skills they knew, such as farming (Gotham, 2000).With the onset of
World War I and resulting industrialization, the African American
population underwent a massive migration to urban areas in order to take
advantage of booming job opportunities in the developing metropolitan
areas.
c. (Slide 19) During this time, prejudice and racism led to the belief that
homogenous white communities were safer than mixed communities
(Gotham, 2000). For this reason, white residential areas became more
desired and expensive. As a result, racially restrictive covenants,
“contractual agreements between property owners and neighborhood
associations that prohibited the sale, occupancy or lease of property and
land to certain racial groups” became commonplace (Gotham, 2000
p.617).
d. In turn this led to concentrations of poverty and disadvantage in African
American communities, especially in the densely packed urban areas
(McFarland & Smith, 2011). Although these covenants were deemed
unconstitutional in 1948, they were utilized in many states up until the
1960s (Gotham, 2000). The implications of these covenants have proven
to be long lasting, as highly segregated African American populations
are still observed today throughout metropolitan areas in the United
States (Gotham, 2000).
e. (Slide 14) Part of the issue is white-majority housing areas continue to
hold more value than mixed and predominantly black neighborhoods
(Gotham, 2000). Current studies of realtor audits find that minorities,
especially African Americans still face discrimination in housing and
6
mortgage markets (McFarland & Smith, 2011). These studies show that
given two equally qualified candidates who differ only by minority
status, favor is typically shown to the non-minority candidates
(McFarland & Smith, 2011). This could be interpreted as an attempt of
the realtors to maintain the value of predominantly white neighborhoods
by moderating the entrance of minorities into these communities
(Gotham, 2000). This theory is supported by the observation that a
higher level of educational attainment amongst the African American
population does not translate to decreased residential segregation
(McFarland & Smith, 2011).
f. (Slide 15) A systematic review of social determinants of infant
mortality looked at 12 ecological studies of the impact of residential
segregation on infant mortality, and all of them found a positive
correlation (Kim & Saada, 2013). However, whether the correlation is
positive or negative varies per ethnic group (Kim & Saada, 2013).
g. An analysis of the U.S. metropolitan statistical areas data from 2000
found that residential segregation influenced infant outcomes differently
across ethnic groups (McFarland & Smith, 2011). Segregation of the
white population had no effect on infant outcomes, neither improving
nor decreasing infant mortality or birth weight (McFarland & Smith,
2011). On the other hand, segregation of the African American
population was associated with increased infant mortality and lower
infant birth weights (McFarland & Smith, 2011).
h. Interestingly, in the Hispanic population, another group that tends to be
clustered in low SES urban environments, residential segregation was
found to be protective against infant mortality and in some communities
Hispanic infants also tended to have higher birth weights (McFarland &
Smith, 2011, Shaw & Pickett, 2013). This is a well observed
phenomenon called the “Hispanic Paradox”. The benefits seen in this
ethnic group is thought to be the product of increased social capital and
cohesion in the form of culturally embedded value of support for
mothers and families, strong kin networks, and traditions of healthy
behaviors that are passed down through generations such as the strong
propensity to breastfeed (Kim & Saada, 2013, McFarland & Smith,
2011, Shaw & Pickett, 2013). In addition, an analysis of the US linked
birth and infant death data set from 2000 found a correlation between
Hispanic density in a given county and improved infant outcomes across
the board for all races (Shaw & Pickett, 2013). Given these findings it
could be possible that somehow increasing social capital and cohesion
among the African American population might improve their infant
outcomes.
3. Pregnancy intention, how much a pregnancy is desired and a baby wanted can
greatly impact the physical and emotional health of infants.
a. (Slide 23) American mothers report that 1/3 of pregnancies are
unintended. This includes pregnancies that may be wanted but are
7
mistimed (either slightly (<2yrs) or grossly (>2yrs) as well as unwanted
pregnancies (Kost, & Lindberg, 2015).
b. Historically, unwanted pregnancies have been associated with
“disadvantages on health and school performance” as they have to
“surmount greater social and mental handicaps than their peers” (Kost,
& Lindberg, 2015).
c. (Slide 24) In an analysis of the surveyed pregnancy intentions of 42
hundred (4,297) singleton live births from 1999 to 2010, it was
discovered that mothers with unwanted and grossly mistimed
pregnancies are less likely to receive early prenatal care and less likely
to breastfeed (Kost, & Lindberg, 2015). In addition, unwanted births
were associated with poor infant outcomes including increased risk for
preterm birth and low birth weight infants. Of the unwanted births
reviewed, 62% occurred in third or higher birth order infants amongst
women who had already reached their reproductive goals and did not
desire family expansion (Kost, & Lindberg, 2015). Mothers of grossly
mistimed and unwanted births were more likely to be African American
and to not have graduated from high school (Kost, & Lindberg, 2015).
d. (Slide 25) In a study involving 282 low SES women who were
predominantly African American and received inadequate prenatal care,
93% of these mothers reported their pregnancies as unwanted, and 22%
stated they had not used contraceptives when they became pregnant
(Katz, et al., 2011)
e. These findings indicate that the low SES African American population
may have difficulty in accessing adequate birth control resources (Kost,
& Lindberg, 2015).
4. (Slide 26) Another important issue in the health of babies is Maternity leave. The
World Health Organization (WHO) recommends at least 16 weeks of maternity
leave to promote healthy bonding, optimize infant growth, and allow for full
recovery of the mother prior to returning to work (Vahratian, & Johnson, 2009).
Evidence has found benefits of longer maternity leave such as longer
breastfeeding duration, higher immunization rates, more well-child visits, and
reduced incidence of postpartum depression (Shepherd-Banigan & Bell, 2014;
Dagher, Mcgovern, & Dowd, 2014).
a. (Slide 27) Internationally, the duration and compensation of maternity
leave varies greatly:
i. Residents in France and Spain have a very long duration of maternity
leave, over 300 weeks, but with minimal compensation of 9%
(Vahratian, & Johnson, 2009).
ii. Japan offers shorter duration of a little over a year at about 50%
compensation (Vahratian, & Johnson, 2009).
iii. Swedish residents are offered 18 months of leave with 80%
compensation (Vahratian, & Johnson, 2009).
iv. Germany offers 14 weeks paid maternity leave at 100%
compensation (Vahratian, & Johnson, 2009).
8
b. These countries all boast IMR rates of 3.46/1000 live births or less (CIA,
2014).
c. A review of international social policies found that 178 of the 190
United Nations members offer some degree of paid maternity leave.
Eight of the outliers only offered paid maternity leave only to new
mothers. And the US was among the remaining four who offer no
guaranteed support for new mothers, and the only developed nation in
this group (Shepherd-Banigan, Megan & Bell, Janice, 2013). A cross-
national, cross sectional study of 141 countries found that increasing
maternity leave by 10 weeks predicts a decreased IMR by 10% (Kim &
Saada, 2013).
d. (Slide 28) In the United States women are protected under the Family
and Medical Leave Act (FMLA) of 1993 (Shepherd-Banigan, et al.,
2013).
i. This act offers women in the United States 12 weeks of unpaid
maternity leave if they meet the following criteria:
a. Employed by a firm with greater than 50 employees
b. Must have worked more than 1,760 hours for the company
over the last year (Shepherd-Banigan, et al., 2013).
ii. This ends up only covering 20% of new mothers and only half of
all mothers (Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff,
M. (2014). Working low SES mothers (which include about 1/3 of
the African American population) are more likely to take shorter
durations of maternity leave due to financial inability to take
longer leave (Guendelman, et al., 2014; United Census Bureau,
2013).
e. A cross-sectional study that surveyed 1,500 women from pregnancy to
18 months post-partum. This study found that 81% of women who
returned to work before their infant was 6 months old cited lack of
financial resources as the primary reason (Shepherd-Banigan, et al.,
2013).
5. (Slide 29) Epigenetics and Allostatic Stress Load
a. The risk factors for poor infant outcomes we just discussed are all
related for one important reason, they all increase stress, which can have
a negative impact on an individual’s health and consequently jeopardize
their pregnancy. We have already discussed the fact that preterm birth
accounts for 78% of the infant mortality disparity between African
Americans and Caucasians (MacDorman & Mathews, 2011). Although
the exact causes of preterm birth are not completely understood,
activation of the stress response has been shown to be a pathway that can
lead to preterm labor (Cole-Lewis, et al., 2014, Kramer, et al., 2011).
b. (Slide 30) “Stress is commonly defined as a state of real or perceived
threat to homeostasis” (Smith & Vale, 2006, p383). When the body
anticipates or arrives in a situation that may result in harm, the stress
response activates, causing behavioral and physiological adaptations that
are intended to increase the chance of survival (Kramer, et al., 2011;
9
Martini & Nath, 2009, Smith & Vale, 2006). These adaptations include
increase mental alertness, mobilization of glycogen & lipid reserves to
support increased energy use by cells, increased cardiovascular tone,
increased heart rate & respiratory rate, and inhibition of parasympathetic
functions such as digestion and urine production (Kramer, et al., 2011;
Martini & Nath, 2009, Smith & Vale, 2006).
c. (Slide 31)The body systems responsible for activating and regulating the
stress response are the hypothalamus, anterior lobe of the pituitary gland
& adrenal glands, together referred to at the HPA axis (Kramer, et al.,
2011; Smith & Vale, 2006).
i. (Slide 32) Let’s take a moment to review the hormonal cascade
caused by the HPA axis. When the body perceives a mental or
physical threat or insult, the hypothalamus secretes corticotrophin-
releasing factor (CRF), the primary hormone responsible for
regulating the stress response (Kramer, et al., 2011; Martini &
Nath, 2009; Smith & Vale, 2006). CRF is also known as
corticotrophin-releasing hormone (CRH). CRF then binds to
receptors on the anterior pituitary gland, causing the release of
adrenocorticotropic hormone (ACTH), which as its name suggests,
acts on the adrenal glands causing their release of glucocorticoids
including cortisol and corticosteroids and catecholamines including
epinephrine and norepinephrine (Martini & Nath, 2009; Smith &
Vale, 2006).
ii. (Slide 33) Glucocorticoids cause increased glucose & glycogen
synthesis, increased peripheral utilization of lipids, and decreased
inflammatory response and white blood cell (WBC) function,
creating a vulnerability to infection (Kramer, et al., 2011; Martini
& Nath, 2009; Smith & Vale, 2006). The catecholamines
epinephrine and norepinephrine works synergistically with
glucocorticoids by causing increased glycogen breakdown,
increased blood sugar levels, and elevated lipid release for cortisol
to utilize peripherally. Catecholamines also cause increased heart
rate, contractility of the heart and blood pressure (Martini & Nath,
2009).
iii. (Slide 34) It has been found that peripheral organs besides the
hypothalamus can activate the HPA axis. Studies have found CRF
in the adrenal glands, testis, GI tract, thymus and the placenta
(Bonis, et al., 2012; Smith & Vale, 2006).
iv. The placenta allows for communication between the fetus and
mother via release of endocrine hormones, such as CRF (Bonis, et
al., 2012). A healthy dose of CRF is actually required for a healthy
pregnancy as is decreases the mother’s immune response, allowing
for successful placentation (Bonis, et al., 2012). However, elevated
CRF in the maternal circulation cause the release of
catecholamines which then cause vasoconstriction resulting in
reducing blood flow to the uterus and placenta (Bonis, et al., 2012;
10
Hacker, et al., 2010). Evidence supports this theory, as serum CRF
elevation is consistently observed in pregnant mothers in the weeks
leading up to preterm labor (Bonis, et al., 2012; Hacker, et al.,
2010). In addition, CRF levels in preterm placentas have been
found to be vastly elevated compared to the CRF in term placentas
(Bonis, et al., 2012).
d. Some research has indicated that stress experienced prior to conception
may be just as important as the stressors experienced during pregnancy,
because they prime the hormonal environment of the body (Kramer, et
al., 2011). The literature on this topic identifies three theories for this
occurrence, (1) early life programming of chronic disease (2) the
weathering hypothesis and (3) psychosocial responses to stressors.
i. ( Slide 35) The theory of early life programming of chronic disease
proposes stressful experiences in important development stages over
the course of an individual’s early life, especially in utero and early
childhood, result in a permanently hypersensitive hypothalamic-
pituitary-adrenal (HPA) axis, leading to increased risk of preterm
labor (Kramer, et al., 2011; Smith & Vale, 2006).
a. (Slide 36) This theory is supported by the consistent
observation that women who give birth to preterm infants
are at a significantly increased risk, up to 3.8 times the risk,
of delivering subsequent preterm babies (Kramer, et al.,
2011).
b. It is also supported by the earlier cited study in which
women who were born with low birth weights did not
receive the reduction in preterm birth that other members
experienced as their economic situation improved (Collins,
Rankin, & David, 2011).
c. In addition, animal studies find that the quality of
mothering received by baby rats as well as laboratory
exposure of the mother to injected stress hormones during
pregnancy each result in permanent HPA changes in the
baby rats (Kramer, et al., 2011).
d. This same correlation was seen in women exposed to the
1944 Dutch famine as a fetus. As adults these women
delivered babies with lower birth weights than women who
were not exposed to the famine (Kramer, et al., 2011).
ii. (Slide 37) The weathering hypothesis theorizes that chronic
exposure to stressors such as violent neighborhoods, discrimination,
and poverty gradually wear the body’s stress response system
resulting in permanent dysfunction of the immune and vascular
systems. (Kramer, et al., 2011)
a. Normally, the stress response is activated to allow
individuals to make acute physiological adaptations in
order to overcome short-lived stressors and prevent harm.
Beginning in the mid 1900s, it first theorized that chronic
11
activation of the body’s stress response, which is supposed
to be acute and temporary, may weather body systems, and
result in premature aging of the body (Kramer, et al., 2011).
b. When acutely activated, the stress response suppresses the
inflammatory effects of the immune system (Kramer, et al.,
2011). Whereas in chronic stress conditions, the body
develops a resistance to the anti-inflammatory effects of
glucocorticoids leading to uncontrolled systemic circulation
of pro-inflammatory cytokines, which are often key players
in the onset of preterm labor (Bonis, et al., 2012; Kramer,
et al., 2011; Martini & Nath, 2009).
c. (Slide 38) In the United States, optimal childbearing age
across all populations is represented by a U-curve, in which
at either end of the “U” infant outcomes (PTB, low birth
weight) are poorer (Kramer, et al., 2011). At the valley of
the U, infant outcomes are the best, and therefore this age
range is considered optimal. In the white population in the
United States the optimal age range is 25 to 34, meaning
this group of women experiences the best infant outcomes
(Kramer, et al., 2011). By comparison, the optimal age
range for the entire African American population has a left
shift, with an optimal childbearing age range of 20-24. In
addition, their U-curve is steeper than that of white women,
that is, the optimal childbearing age for African American
women is comparably much shorter (Kramer, et al., 2011).
d. An impaired immune system leaves women at risk for
development infections. One infection that is concerning
during pregnancy due to its association with preterm birth
is bacterial vaginosis (BV). Evidence supports that women
across all races and ethnicities who undergo chronic
stressors develop BV more frequently than those without
expose to chronic stress (Kramer, et al., 2011). In addition,
the presence of BV doubles the chances of preterm labor
and is more prevalent among African American women
than white women (Kramer, et al., 2011).
e. Chronic stress also affects the vascular system, due to
increasing blood pressure which damages the endothelial
cells of the blood vessels and puts mothers at risk for a
variety of pregnancy risk factors such as poor placental
attachment or perfusion, preeclampsia, intrauterine growth
restriction (IUGR), and preterm birth, and fetal demise
(Kramer, et al., 2011).
iii. (Slide 39) A third theory of stress response poses that psychosocial
stressors such as low SES, residence in violent or crime ridden
neighborhoods, sexual or physical abuse, or perceived racism leads
women to adapt unhealthy coping mechanisms to include risky
12
sexual behaviors, smoking, alcohol or illicit drug use, or even
overeating (Fontenot & George, 2012; Gavin, Nurius, & Logan-
Greene, 2012; Kramer et al., 2011). These dysfunctional coping
behaviors negatively impact their health and increase the risk of
harm to the fetus (Kramer, et al., 2011).
iv. These theories of the effects of stress response on pregnancy
outcomes are interesting because African Americans are nearly
twice as likely to live below the national poverty line compared to
Caucasians, and their babies die at more than twice as often
(Kramer, et al., 2011; United States Census Bureau, 2013).
Although stress cannot explain the racial disparities in infant
mortality in itself, it may help explain why the gap is so complex
and resistant to change.
III. INTERVENTIONS
A. (Slide 40) So now that we’ve had a closer look at some of the potential causes of the
racial disparity gap in infant mortality, let’s talk about interventions to shrink the gap. But
before we talk about the specific interventions we’re going to briefly examine pending
trends in the United States in regards to healthcare and social services and how these
trends differ from developed nations.
1. A 2005 comparison of gross domestic product (GDP) expenditure on healthcare
and social services among 30 nations in the organization for economic
cooperation and development (OECD) revealed the US has the highest healthcare
expenditures of the nations reviewed, yet only had better infant mortality rate than
two nations; Poland and Mexico (Bradley, Elkins, Herrin & Elbel, 2011).
2. Social services and healthcare costs together account for 29% of the US GDP.
While the US spends a little over half of this amount on healthcare and a little
under half on social services, the other OECD nations (with the exception of
Mexico) spend approximately 2/3 on social services and only 1/3 on healthcare
expenses (Bradley, et al., 2011).
3. This ratio of greater spending on social services in comparison to healthcare is
associated with increased life expectancy, decreased infant mortality, and a
decrease in potential years of life lost, all of which are important health indicators
of a population (Bradley, et al., 2011).
4. These findings insinuate that a potential key to improving the health of the US
and decreasing the infant mortality rate, might involve a complete restructuring of
our ideas about health and wellness as well as a reprioritization of our spending in
regards to healthcare and social services (Bradley, et al., 2011). Focusing more on
promoting health behaviors and prevention of illness, instead of reacting to co-
morbidities partially caused by harmful behaviors and living conditions may help
promote a culture of responsibility of individual health and could potentially lead
to improved wellness indicators for the country as a whole (Bradley, et al., 2011).
B. (Slide 41) In the United States, we may not invest as heavily in social services as other
developed nations, however, we still have many national efforts to decrease the infant
mortality rate as well as reduce the racial disparity.
13
1. (Slide 42) One national effort to identify health needs is the Pregnancy Risk
Assessment Monitoring System (PRAMS), which is a surveillance program that
collects data used to reduce maternal and infant mortality (CDC, 2013).
a. Information is gathered via telephone and mailed questionnaires that ask
about pregnancy and post-partum practices such as breastfeeding,
prenatal care, behaviors during pregnancy and infant care practices such
as sleep position (CDC, 2013)
b. This assessment has proven to be effective in identifying population
health needs. Here are just a few examples of PRAMS identifying
educational needs of specific population by geographic location:
c. Using PRAMS, West Virginia discovered they had the highest maternal
smoking rates in the country. This finding prompted the launch of the
2009 “Tobacco Free Pregnancy Initiative”, which ultimately resulted in
higher call volume of pregnant women and their family members to
tobacco cessation quit lines (CDC, 2013).
d. In another instance, PRAMS helped Michigan notice that their African
American population was 20% less likely than the rest of their
population to put their infants back to sleep. In response, Michigan
launched the 2004 “Infant Safe Sleep Campaign” which resulted in
requirements for child care centers to practice back to sleep in order to
maintain their licensure (CDC, 2013).
2. (Slide 43) A widely used intervention to decrease health consequences and
improve infant outcomes and child development among vulnerable populations is
home visitation programs. Many of these programs exist, but a few common ones
include Healthy Families America (HFA), Nurse-Family Partnership (NFP),
Parents as Teachers, Home Instruction for Parents of Preschool Youngsters and
the Parent Child Home Program (Azzi-Lessing, 2013). Home-visitation programs
strive to improve the health of families by providing paraprofessionals or
sometimes nurses to visit the homes of at risk families in order to improve infant
care practices, parenting skills and home environment, improve and increase
parent-child interaction, reduce risks of abuse and neglect, and connect families
with community resources especially healthcare (Azzi-Lessing, 2013; Katz, et al.,
2011; Kothari, et al., 2014).
a. (Slide 44) Although home-visitation programs are utilized throughout
the US especially in metropolitan areas with large volumes of vulnerable
populations, the effectiveness of these programs has not been
consistently shown in research with many studies demonstrating
minimal benefits of these programs overall (Azzi-Lessing, 2013).
b. A quasi-experimental study compared infant outcomes among
participants of a prenatal Healthy Start home visitation program in
Kalamazoo, Michigan with propensity score matched non-participants
(Kothari, et al., 2014). Infant outcomes were compared between African
American and White women who were represented in equal numbers in
the participant group, consisting of 294 women (Kothari, et al., 2014).
This study found no difference between gestational age or incidence of
14
preterm birth among African American participants in the Healthy Start
program versus matched non-participants (Kothari, et al., 2014).
c. In addition, some evidence shows a tendency for home-visitation
programs to miss opportunities with the highest risk vulnerable
populations.
i. A study that evaluated the impact of home-visitation on high risk
families found that over half of mothers involved in home-
visitation programs had at least one high risk variable including:
mental health condition(s), struggle with substance abuse, or
domestic violence. 75% of this higher risk population did not
receive social support services to address these issues (Azzi-
Lessing, 2013).
ii. Another study that evaluated the effectiveness of the Pride in
Parenting Program on new mothers who had received inadequate
prenatal care during their pregnancy, found improved ability of
these mothers to create home environments suitable for their
infant’s safety and development age, demonstrated better observed
mothering skills, and reported improved perception of support.
However, these results were only observed in participants who had
thirty or more contacts with paraprofessionals (Katz, et al., 2011).
Typically, mothers with high levels of participation usually have
fewer original risk factors than mothers with the least participation
in home-visitation programs who usually have the greatest risks of
poor infant outcomes (Azzi-Lessing, 2013).
d. (Slide 45) Several factors contribute to the challenges home-visitation
programs face in actively engaging highly vulnerable families and
providing services that meet their needs. These factors include:
i. Potential preoccupation with the level or quality of stressors in the
lives of highly vulnerable families, resulting in greater fewer home
visits and decreased quality of program participation (Azzi-
Lessing, 2013).
ii. Skepticism of home-visitation programs due to negative
experiences with other formal services such as CPS (Azzi-Lessing,
2013).
iii. Possible inability of paraprofessional to meet the needs of these
families. Most, although not all of the home-visitation programs
employ paraprofessionals who usually lack a college education and
receive only a training program of varying length. This training
program is intended to provide paraprofessionals with the skills to
successfully serve high risk populations.
a. Paraprofessionals are expected to be able to identify
difficult issues in the home such as domestic violence,
substance abuse, and depression (Azzi-Lessing, 2013).
b. They must be able to communicate with vulnerable families
in a nonjudgmental and compassion form that builds trust
15
and rapport, as this population is easily disengaged (Azzi-
Lessing, 2013).
c. In addition, they must be knowledgeable about available
resources and have the ability to connect their clients with
these resources (Azzi-Lessing, 2013).
d. This is a very large body of knowledge and skill to gain
from any training program. Social workers earn a
bachelor’s degree and sometimes a master’s degree to do
work requiring a similar knowledge and skill base (Azzi-
Lessing, 2013).
C. (Slide 46) Centering Pregnancy is another intervention that is used to improve infant
outcomes.
1. Before we talk about the benefits of Centering Pregnancy, allow me to take a
moment to explain this program.
a. Centering Pregnancy is an evidenced-based model of prenatal care occurs
in a group setting, unlike traditional prenatal care occurring one on one in
a provider’s office. Each group consists of 8 to 12 women of similar
gestational age, who have ten sessions together throughout their pregnancy
that last one hour to one and a half hours (Rotundo, 2011). During the
sessions the women undergo an individual assessment by a licensed
healthcare provider, accounting for about 30-40 minutes of the session
(Rotundo, 2011). The remaining time, about an hour, is used for group
teaching and discussion of relevant topics pertaining to their specific
gestation (Rotundo, 2011).
b. (Slide 47)The program is patient centered and actively involves women in
their prenatal care. At the beginning of each session women calculate their
own gestational age, and take their own vital signs and weight. This
empowers women to be accountable, acutely attuned, and active partners
in their health. Each woman gets the opportunity to discuss the status of
pregnancy with her provider using the assessment data she collected
herself (Rotundo, 2011).
c. The teaching portion of each session occurs in a circle formation, is causal
and discussion styled, and encourages sharing of knowledge amongst the
members. The group teachers, referred to as facilitators, functions to
provide the relevant discussion topics, keep the group on track, and ensure
accuracy of shared knowledge. Facilitators typically remain consistent
throughout the program to ensure consistency of information and allow
rapport to be built between the group and the instructors (Rotundo, 2011).
d. Before the teaching portion begins, the women are able to socialize while
they wait to be seen by the provider (Rotundo, 2011).
e. New members may be added to the centering group until the third session,
but after this point the members must agree to any new additions. This
gives the centering members a sense of ownership and loyalty to their
group (Rotundo, 2011).
f. Group facilitators track health statistics of their program including preterm
birth rate, low birth weights, patient satisfaction, breastfeeding rates, and
16
adequacy of member attendance. This allows each program to process
improve, in order to meet the needs of their specific population.
2. (Slide 48) The benefits of prenatal care under this model include
a. Increased patient satisfaction (Catling, 2015; Ickovics, et al, 2011)
Rotundo, 2011)
b. Increased breastfeeding rates (Ickovics, et al, 2011; Rotundo, 2011)
c. Increased provider satisfaction, including providers reporting a perceived
deeper connection with their patients (Rotundo, 2011)
d. Improved birth outcomes (Tanner-Smith, Steinka-Fry, & Lipsey, 2013)
e. 20 hours of educational time with providers, which is ten times the amount
of educational time received by women in traditional prenatal care who
get about 2 hours over the course of their pregnancy (Thielen, 2012).
3. (Slide 49) Let’s take a look at what the evidence says:
a. A retrospective study compared 651 patients who used Centering
Pregnancy with statistically matched women who used traditional prenatal
(Tanner-Smith, et al., 2013).
b. This study found that the Centering Pregnancy women were not less likely
to deliver preterm, but when they did, their average gestation age was 2.5
weeks longer and their infants weighed approximately 300g more
compared than premature infants in the traditional prenatal care group.
The Centering pregnancy mothers were also found to have less incidence
of fetal demise than the traditional prenatal care group. (Tanner-Smith, et
al., 2013).
c. Although some studies have found decreased preterm birth rates for
women in Centering Pregnancy groups (Ickovics, 2011), these results are
inconsistent in systematic reviews (Catling, et al., 2015).
d. Centering Pregnancy is unique in that it not only provides women with an
empowering prenatal experience, and more time with healthcare
providers; it also provides a valuable resource, social capital and cohesion
(Ickovics, 2011; Rotundo, 2011). As we previously discussed, these are
areas that can improve infant outcomes despite economic disadvantage
(Kim & Saada, 2013; McFarland & Smith, 2011; Shaw & Pickett, 2013).
IV. NURSING IMPLICATIONS
A. (Slide 50) Although no interventions have been found to improve outcomes specifically
for African Americans, nurses can provide teaching that is known to universally improve
pregnancy and infant outcomes.
1. One way to decrease poor infant outcomes is to prevent unwanted pregnancies (
a. Three pathways leading to unintended pregnancies have been proposed
and include (Thomas, 2012):
i. Individuals are indifference to avoiding risky behavior—having
unprotected sex without thinking or caring about the potential of
pregnancy resulting (Thomas, 2012).
ii. Individuals who have intentions to not get pregnant do not have
accurate information about how to prevent pregnancy—for
17
example they believe withdrawal or breastfeeding are reliable birth
control methods (Thomas, 2012).
iii. Individuals have intentions to not get pregnant and have accurate
information how to prevent pregnancy, but lack access to adequate
birth control (Thomas, 2012).
b. Since unwanted pregnancies are more common among African
Americans with low educational achievement, and are associated with
poor infant outcomes, this population may benefit from sex education,
dispelling myths surrounding pregnancy prevention, and contraceptive
education to include adequacy of different birth control methods (Kost
& Lindberg, 2015).
c. Women should also be educated on how to gain access to providers to
inquire about preferred contraceptive methods. Desire for pregnancy in
the future should be discussed as this may help women decide which
contraceptive method would best fit their life style.
d. Postpartum women should be educated on pregnancy spacing. Women
should be informed that becoming pregnant within 6 months of delivery
is associated with increased risk for significant adverse fetal outcomes,
such as stillbirth, preterm birth, low birth rate early neonatal death
(Wendt, Gibbs, Peters & Hogue, 2012) . The recommended minimum
timeframe between pregnancies is 18 to 23 months in between
pregnancies. This may be an important intervention for decreasing the
IMR gap since studies show African American women have shorter
pregnancy intervals than white women (Nabukera, et al., 2009).
2. (Slide 51) Sexually Transmitted Infection (STI) prevention/treatment
a. It is important to educate women of the significant adverse effects of
STIs on pregnancy and infant outcomes. Women should be educated that
STIs can result in preterm birth, fetal demise, and adverse infant
outcomes such as infection, opthalmia, pneumonia, mental delays or
disabilities, and low birth weight (Fontenot & George, 2014)
b. Nurses should identify patients at increased risk for STIs during sexual
activity assessments and discuss with patients the importance of STI
testing for their partner (Fontenot & George, 2014)
3. (Slide 52) Nutrition
a. Findings from the 2014 Summit on Obesity of African American
Women and Girls found that 60% of African American women are
obese (American Psychological Association [APA], 2014). Obesity is
associated with increased pregnancy risks including gestational diabetes
and preeclampsia (Marshall, Guild, Cheng, Caughey, & Halloran,
2014).
b. African American women may benefit from nutritional counseling on
diet composition, appropriate weight gain during pregnancy and
appropriate caloric consumption per trimester of pregnancy
(Lowdermilk, et al., 2015).
4. (Slide 53) Smoking/Alcohol/Drug Use
18
a. Women should be given counseling on the negative effects of the
substance used on the pregnancy and the development of her baby
(Lowdermilk, Perry, Cashion, & Alden, 2015).
b. Although smoking is less common among low SES African American
women compared to low SES Caucasian women. Studies find African
American women who smoke are at an even higher risk for preeclampsia
and fetal demise than white women who smoke (need source).
c. Women who admit to smoking, alcohol or illicit drug, should be
evaluated for intention to quit (Lowdermilk, et al., 2015).
d. Women who desire to quit should be referred to cessation programs or
rehabilitation programs and provided self-help resources (Lowdermilk,
et al., 2015).
e. With nursing and provider support, women who are unwilling or unable
to quit may be able to cut back even if modestly.
5. (Slide 54) Social Support
a. Patients should be assessed for adequacy of social supports and provided
resources in the event of reported inadequate support. Nurses can inform
patients about the benefits of Centering Pregnancy, as this is a great way
to build social capital (Rotundo, 2011; Tanner-Smith, et al, 2014;
Thielen, 2012).
6. (Slide 55) Depression Screening
a. Maternal depression occurs in approximately 15-20% of pregnant and
post partum women and is shown to have negative impacts on infants in
utero as well as after delivery in the post partum period (Bansil, et al.,
2010; Lefkovics, Baji, & Rigo, 2014). Low SES and women with low
social support are at increased risk of prenatal and post-partum
depression (Lefkovics, et al., 2014).
b.During pregnancy depression is associated with later initiation of prenatal
care, increased incidence of maternal substance abuse, poor and/or
inadequate nutrition, preterm birth, low birth weight, and pre-eclampsia
(Bansil, et al., 2010; Lefkovics, 2014). In the post partum period maternal
depression is associated with impaired infant bonding and dysfunctional
parenting that could have lifelong implications on emotional development
of infants (Bansil, et al., 2010; Lefkovics, 2014).
c. According to a 2003 study, only 44% of obstetrical gynecologists were
found to routinely screen their patients for depression (Bansil, et al.,
2010). Therefore, nurses should assess all pregnant and postpartum
patients for depressive symptoms. The Edinburgh Postnatal Depression
Scale (EPDS) or a simple two question screening tool can be utilized
(Lowdermilk, et al., 2015). A score above 10 for the (EDPS) or a
positive screening for the two question tool should be reported to a
provider for further assessment (Lowdermilk, et al., 2015).
d. It is important to keep in mind that postpartum women are most likely to
show signs of post partum depression (PPD) around 4 weeks
postpartum. Prior to discharge from the hospital patients should be
educated about the signs and symptoms of PPD such as persistent and
19
overwhelming sadness or anxiety, appetite changes, difficulty sleeping,
no or decreased interest in infant care, and thoughts of self or infant
harm (Lowdermilk, et al., 2015).
7. (Slide 56) Breastfeeding
a. All women should be educated about the benefits of breastfeeding. Data
from PRAMS in 2012 revealed that African American women have the
lowest rates of breastfeeding in the United States (Ahluwalia, Morrow,
D’Angelo, & Li, 2012). Breastfeeding reduces the risk of post-neonatal
death from preventable causes such as SIDS and infection (Chen &
Rogan, 2004). Therefore, higher breastfeeding rates among African
American mothers might help decrease the high infant mortality in this
population.
V. SUMMARY
A. (Slide 57) To sum it all up, here is a brief recap of what we covered. First defined terms
related to fetal and infant mortality. We discussed international infant mortality rates and
maternity leave policies and compared them to the United States. Infant outcomes were
compared between the population with the highest poor outcomes, African Americans
and the group with the least poor outcomes, non-Hispanic whites. We reviewed the
effectiveness of some interventions to reduce infant mortality and reduce the racial
disparities in America including Centering Pregnancy, home visitation programs, and
PRAMS. And we discussed how nurses play a key role in improving outcomes for
women and infants, especially those in vulnerable socioeconomic populations.
B. From researching this topic I noticed that cultures and nations that prioritize healthy
pregnancies, infants and families tend to see better outcomes. For instance, Swedish
residents receive 18 months of 80% compensated maternity leave (Vahratian, & Johnson,
2009). This sends the message that maternal-infant bonding, and the health of new
mothers and their newborns are top priorities in Sweden. Every mother in Finland is
provided a maternity box filled with everything needed to take care of the infant for the
first few months of life (Lee, 2013). The package contains onesies, breastfeeding
supplies, diapers, a mattress pad, and even a snowsuit (Lee, 2013). The box is provided to
all mothers from every walk of life to send the message than all infants deserve the same
start in life (Lee, 2013). The message is well received by the Finnish, as they traditionally
use this box as the baby’s first bassinet (Lee, 2013). And oh by the way, they spend the
same percentage of their GDP (30%) on the combined amount of social services and
healthcare as the United States (Bradley, Elkins, Herrin & Elbel, 2011). I’m not saying
that a maternity box would fix the infant mortality gap in America, but from this research
I can concluded that perhaps our nation has some reprioritization to do about how we
think of the health of families, mothers and newborns.
20
REFERNCES
Ahluwalia, I., Morrow, B., D’Angelo, D., & Li, R. (2012). Maternity care practices and
breastfeeding experiences of women in different racial groups and ethnic groups:
pregnancy risk assessment and monitoring system. Maternal Child Health Journal, 16,
1672-1678. http://dx.doi.org/10.1007/s10995-011-0875-0
American Psychological Association. (2014). Obesity in African American women and girls:
final report and action agenda. Washington, DC. Retrieved from
http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=56&sid=2daa08d5-f0f8-
4fe3-b0ae-3224f2e71a45%40sessionmgr4002&hid=4106
Azzi-Lessing, L. (2013). Serving highly vulnerable families in home-visitation programs. Infant
Mental Health Journal, 34(5), 376-390. http://dx.doi.org/10.1002/imhj.21399
Baker, M. & Milligan, K. (2010). Evidence from maternity leave expansions of the impact of
maternal care on early child development. The Journal of Human Resources, 45(1), 1-32.
Bansil, P., Kuklina, E., Meikle, S., Posner, S., Kourtis, A., Ellington, S., & Jamieson, D. (2010).
Maternal and fetal outcomes among women with depression. Journal of Women’s Health,
19(2), 329-334. http://dx.doi.org/10.1089/jwh.2009.1387
Biello, K., Kershaw, T., Nelson, R., Hogben, M., Ickovics, J., & Niccolai, L. (2012). Racial
segregation and rates of gonorrhea in the UnitedS, 2003-2007. American Journal of
Public Health, 102 (7), 1370-1375. http://dx.doi.org/10.2105/AJPH.2011.300516
Bonis, M., Torricelli, M., Severi, F., Luisi, S., Leo, V & Petraglia, F. (2012). Neuroendocrine
aspects of placenta and pregnancy. Gynecological Endocrinology, 28(1), 22-26.
http://dx.doi.org.10.3109/09513590.2012.651933
Braveman, P., Heck, K., Egerter, S., Marchi, K., Dominguez, T., Cubbin, C., Fingar, K., Pearson,
J., Curtis, M. (2015). The role of socioeconomic factors in black-white disparities in
preterm birth. American Journal of Public Health, 105(4), 694-702.
Bradley, E., Elkins, B., Herrin, J., & Elbel, B. (2011). Health and social services expenditures:
associations with health outcomes. BMJ Quality & Safety, 20, 826-831.
http://dx.doi.org/10.1136/bmjqs.2010.048363
Brodribb, W., Zakarija-Grkovic, I., Hawley, G., Mitchell, B., & Mathews, A. (2013). Postpartum
health professional contact for improving maternal and infant outcomes for healthy
women and their infants (protocol). The Cochrane Library, 12, 1-11.
Catling, C., Medley, N., Ryan, C., Leap, N., Teate, A., & Homer, C. (2015). Group versus
conventional antenatal care for women (review). The Cochrane Library, 2, 1-56.
http://dx.doi.org/10.1002/14651858.CD0077622.pub3
Center for Disease Control and Prevention Grand Rounds: Public Health Approaches to
Reducing U.S. Infant Mortality. (2013). MMWR: Morbidity & Mortality Weekly Report,
62(31), 625-628. Retrieved from
21
http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=15&sid=bed050cb-661e-
437f-8dfb-968d309aae42%40sessionmgr113&hid=102
Center for Disease Control and Prevention. (2013). National vital statistics report “deaths: final
data for 2013”, 64(2). Hyattsville, MD: National Center for Health Statistics. Retrieved
from http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm
Center for Disease Control and Prevention. (2014). National vital statistics report “international
comparisons of infant mortality and related factor: United States and Europe, 2010”,
(DHHS Publication No. ADM 2014-1120). Hyattsville, MD: National Center for Health
Statistics.
Center for Disease Control and Prevention. (2015). National vital statistics report “fetal and
perinatal mortality: united states, 2013”, 64(8). Hyattsville, MD: National Center for
Health Statistics. Retrieved from
http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm
Central Intelligence Agency. (2014). Country comparison: infant mortality rate. Retrieved from
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
Cole-Lewis, H., Kershaw, T., Earnshaw, V., Yonkers, K., Lin, H., & Ickovics, J. (2014).
Pregnancy specific stress, preterm birth, and gestational age among high-risk young
women. Health Psychology, 33 (9), 1033-1045. http://dx.doi.org/10.1037/a0034586
Collins, J. Rankin, K., & David, R. (2011). African American women’s lifetime upward
economic mobility and preterm birth: the effect of fetal programming. American Journal
of Public Health, 101(4), 714-719.
Dagher, R., McGovern, P.,& Dowd, B. (2014). Maternity leave duration and postpartum mental
and physical health: implications for leave policies. Journal of Health Politics, Policy
and Law, 39(2), 370-416. http://dx/doi.org/10.1215/03616878-2416247
Fontenot, H., & George, E. (2014). Sexually transmitted infections in pregnancy. Nursing for
Women’s Health, 18(1), 67-72. http://dx/doi.org/ 10.1111/1751-486X.12095
Gavin, A., Nurius, P., & Logan-Greene, P. (2012). Mediators of adverse birth outcomes among
socially disadvantaged women. Journal of Women’s Health, 21(6), 634-640.
http://dx.doi.org/10.1089/jwh.2011.2766
Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff, M. (2014). Work-family balance after
childbirth: the association between employer-offered leave characteristics and maternity
leave duration. Maternal and Child Health Journal, 18, 200-208.
http://dx/doi.org/10.1007/s10995-013-1255-4
Giurgescu, C., McFarlin, B., Lomax, J., Craddock, C., & Albrecht, A. (2011). Racial
discrimination and the black-white gap in adverse birth outcomes: a review. Journal of
Midwifery and Women’s Health, 56, 362-370. http://dx/doi.org. 10.1111/j.1542-
2011.2011.00034x
22
Gotham, K. (2000) Urban space, restrictive covenants and the origins of racial residential
segregation in a US city, 1900-50. International Journal of Urban and Regional
Research, 24(3), 616-633.
Hacker, N. F., Gambone, J.C., Hobel, C.J. (2010). Hacker and Moore’s essentials of obstetrics
and gynecology (5th ed.). Philadelphia, PA: Saunders Elsevier Inc.
Ickovics, J., Reed, E., Magriples, U., Westdahl, C., Rising, S., & Kershaw, T. (2011). Effects of
prenatal care on psychosocial risk in pregnancy: results from a randomized controlled
trial. Psychology and Health, 26(2), 235-250.
http://dx.doi.org/10.1080/08870446.2011.531577
Katz, K., Jarrett, M., El-Mohandes, A., Schneider, S., McNeely-Johnson, D., & Kiely, M.
(2011). Effectiveness of a combined home visiting and group intervention for low income
african american mothers: the pride in parenting program. Maternal Child Health
Journal, 15, 75-84. http://dx.doi.org/10.1007/s10995091109858-x
Kim, D,. 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 (1660-4601), 2296-2317.
http://dx.doi.org/10.3390/ijerph10062296
Kost, K., & Lindberg, L. (2015) Pregnancy intentions, maternal behaviors, and infant health:
investigating relationships with new measure and propensity score analysis. Springer
Science and Business Media B.V., 52, 83-111. http://dx/doi.org/10.1007/s13524-
0140359-9
Kothari, C., Zielinski, R., James, A., Charoth, R., & Sweezy, L. (2014). Improved birth weight
for black infants: outcomes of a healthy start program. American Journal of Public
Health, 104(1), 96-104. http://dx.doi.org/10.2105.AJPH.2013.301359
Kramer, M., Hogue, C., Dunlop, A., & Menon, R. (2011). Preconceptional stress and racial
disparities in preterm birth: an overview. ACTA Obstetricia et Gynecologica
Scandinavica, 90(1307-1316). http://dx/doi.org.10.1111/j.1600-0412.2011.01136.x
Lee, H. (2013, June 4). Why Finnish babies sleep in cardboard boxes. BBC. Retrieved from
http://www.bbc.com/news/magazine-22751415
Lefkovics, E., Baji, I., Rigo, J. (2014). Impact of maternal depression on pregnancies and on
early attachment. Infant Mental Health Journal, 35(4), 354-365.
http://dx.doi.org/10.1002/imhj.21450
Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2015). Maternity & women’s health care
(11th ed.). St. Louis, MO: Elsevier
MacDorman, M., Hoyert, D., & Mathews, T. (2013) Recent declines in infant mortality in the
United States, 2005-2011. Center for Disease Control and Prevention NCHS Data Brief
No. 120. Hyattsville, MD: National Center for Health Statistics.
23
MacDorman, M., & Mathews, T. (2011) Understanding racial and ethnic disparities in U.S.
infant mortality rates. Center for Disease Control and Prevention NCHS Data Brief No.
74. Hyattsville, MD: National Center for Health Statistics.
Marshall, N., Guild, C., Cheng, Y., Caughey, A., & Halloran, D. (2014). Racial disparities in
pregnancy outcomes in obese women. The Journal of Maternal-Fetal & Neonatal
Medicine, 27(2), 122-126. http://dx.doi.org/10.3109/14767058.2013.806478
Martini, F., & Nath, J. (2009). Fundamentals of anatomy and physiology. (8th ed.). San
Francisco, CA: Pearson Education Inc.
McFarland, M., & Smith, C. (2011). Segregation, race, and infant well-being. Population
Research and Policy Review, 30, 467-493. http://dx/doi.org.10.1007/s11113-010-9197-7
Nabukera, S., Wingate, M., Owen, J., Salihu, H., Swaninithan, S., Alexander G., & Kirby, R.
(2009). Racial disparities in perinatal outcomes and pregnancy spacing among women
delaying initiation of childbearing. Maternal Child Health Journal, 13, 81-89.
http://dx.doi.org/10.1007/s10995-008-0330-8
Porter, G. (2010). Work ethic and ethical work: distortions in the American dream. Journal of
Business and Ethics, 96, 535-550. http://dx.doi.org.10.1007/s10551-010-0481-6
Rotundo, G. (2011). Centering pregnancy: the benefits of group prenatal care. Nursing for
Women’s Health, 15(6), 510-516. http://dx/doi.org. 10.1111/j.1751-486X.2011.01678.x
Shaw, R., & Pickett, K. (2013). The health benefits of Hispanic communities for non-Hispanic
mothers and infants: another Hispanic paradox. American Journal of Public Health, e1-
e6. http://dx.doi.org.10.2105/ALPH.2012.300985
Shepherd-Banigan, Megan & Bell, Janice. (2013). Paid leave benefits among a national sample
of working mothers with infants in the United States. Maternal and Child Health
Journal, 18, 286-295. http://dx/doi.org.10.1007/s10995-013-1264-3
Smith, S., & Vale, A. (2006). The role of the hypothalamic-pituitary-adrenal axis in
neuroendocrine responses to stress. Dialogues in Clinical Neuroscience, 8(4), 383-393.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181830/
Tanner-Smith, E., Steinka-Fry, K., & Lipsey, M. (2014). The effects of CenteringPregnancy
group prenatal care on gestational age, birth weight, and fetal demise. Maternal & Child
Health Journal, 18, 801-809. http://dx.doi.org/10.1007/s10995-013-1304-z
Thielen, K. (2012). Exploring the group prenatal care model: a critical review of the literature.
Journal of Perinatal Education, 21(4), 209-218. http://dx.doi.org/10.1891/1058-
1243.21.4.209
Thomas, Adam (2012). Three Strategies to prevent unintended pregnancies. Journal of Policy
Analysis and Management, 31(2), 280-311. http://dx.doi.org/10.1002/pam.21614
24
United States Census Bureau. (2013). Poverty status in the past 12 months. Retrieved From:
http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_1
3_1YR_S1701&prodType=table
Vahratian, A., & Johnson, T. (2009) Maternity leave benefits in the United States: today’s
economic climate underlines deficiencies. Birth: Issues in Perinatal Care, 36(3), 177-
179.
Ward, T., Mazul, M., Ngui, E., Bridgewater, F., & Harley, A. (2013). Maternal and Child Health
Journal, 17, 1753-1759. http://dx.doi.org.10.1007/s10995-012-1194-5
Wendt, A., Gibbs, C., Peters, S., & Hogue, C. (2012). Impact of increasing inter-pregnancy
interval on maternal and infant health. Paediatric & Perinatal Epidemiology, 23, 239-
258. http://dx.doi.org. 10.1111/j.1365-3016.2012.01285.x
Zhang, S., Cardarelli, K., Shim, R., Ye, J., Booker, K., & Rust, G. (2013) Racial disparities in
economic and clinical outcomes of pregnancy among Medicaid recipients. Maternal and
Child Health Journal, 17, 1518-1525. http://dx.doi.org.10.1007/s10995-012-1162-0

More Related Content

What's hot

Migrants Effects on Age Structure and Fertility in the USA
Migrants Effects on Age Structure and Fertility in the USAMigrants Effects on Age Structure and Fertility in the USA
Migrants Effects on Age Structure and Fertility in the USANed Baring
 
Introduction at the workshop theme: Nutrition
Introduction at the workshop theme: NutritionIntroduction at the workshop theme: Nutrition
Introduction at the workshop theme: NutritionFondazioneAndreaBocelli
 
THE PILL TO END POVERTY1
THE PILL TO END POVERTY1THE PILL TO END POVERTY1
THE PILL TO END POVERTY1Anna Fullerton
 
Poverty & world hunger final pp
Poverty & world hunger final ppPoverty & world hunger final pp
Poverty & world hunger final ppmboushka
 
Hunger Awareness
Hunger AwarenessHunger Awareness
Hunger Awarenessapetraglia
 
Sex ratio and mortality rate 2
Sex ratio and mortality rate 2Sex ratio and mortality rate 2
Sex ratio and mortality rate 2dpsaligarh
 
Fighting Poverty by enhancing women role in agriculture
Fighting Poverty by enhancing women role in agricultureFighting Poverty by enhancing women role in agriculture
Fighting Poverty by enhancing women role in agricultureCynthia Sumaili
 
Ade 421 population growth qt final
Ade 421 population growth qt finalAde 421 population growth qt final
Ade 421 population growth qt finalYe Qianyi
 
NUTR334 Media Project
NUTR334 Media ProjectNUTR334 Media Project
NUTR334 Media ProjectSamara Heller
 
Ldr 625 m7 red team clc assignment final
Ldr 625 m7 red team clc assignment finalLdr 625 m7 red team clc assignment final
Ldr 625 m7 red team clc assignment finalDeliciouscrisp
 
LDR 625 M7 RED TEAM CLC Assignment with Notes
LDR 625 M7 RED TEAM CLC Assignment with NotesLDR 625 M7 RED TEAM CLC Assignment with Notes
LDR 625 M7 RED TEAM CLC Assignment with NotesDeliciouscrisp
 
Pew research new demography of mothers (5.20.10)
Pew research   new demography of mothers (5.20.10)Pew research   new demography of mothers (5.20.10)
Pew research new demography of mothers (5.20.10)irishdem2
 
Child Mortality among Teenage Mothers in OJU Metropolis
Child Mortality among Teenage Mothers in OJU MetropolisChild Mortality among Teenage Mothers in OJU Metropolis
Child Mortality among Teenage Mothers in OJU Metropolisiosrjce
 
Hunger Awareness
Hunger AwarenessHunger Awareness
Hunger Awarenessapetraglia
 
Hunger slides
Hunger slides Hunger slides
Hunger slides apetraglia
 
Food Security in Africa: challenges and policy options to ensure Africa's future
Food Security in Africa: challenges and policy options to ensure Africa's futureFood Security in Africa: challenges and policy options to ensure Africa's future
Food Security in Africa: challenges and policy options to ensure Africa's futureCIMMYT
 
First food forum 2014 presentation
First food forum 2014 presentationFirst food forum 2014 presentation
First food forum 2014 presentationdchin
 

What's hot (20)

Migrants Effects on Age Structure and Fertility in the USA
Migrants Effects on Age Structure and Fertility in the USAMigrants Effects on Age Structure and Fertility in the USA
Migrants Effects on Age Structure and Fertility in the USA
 
Introduction at the workshop theme: Nutrition
Introduction at the workshop theme: NutritionIntroduction at the workshop theme: Nutrition
Introduction at the workshop theme: Nutrition
 
THE PILL TO END POVERTY1
THE PILL TO END POVERTY1THE PILL TO END POVERTY1
THE PILL TO END POVERTY1
 
Poverty & world hunger final pp
Poverty & world hunger final ppPoverty & world hunger final pp
Poverty & world hunger final pp
 
Hunger Awareness
Hunger AwarenessHunger Awareness
Hunger Awareness
 
Sex ratio and mortality rate 2
Sex ratio and mortality rate 2Sex ratio and mortality rate 2
Sex ratio and mortality rate 2
 
Fighting Poverty by enhancing women role in agriculture
Fighting Poverty by enhancing women role in agricultureFighting Poverty by enhancing women role in agriculture
Fighting Poverty by enhancing women role in agriculture
 
ChildObesityNJ2015
ChildObesityNJ2015ChildObesityNJ2015
ChildObesityNJ2015
 
Ade 421 population growth qt final
Ade 421 population growth qt finalAde 421 population growth qt final
Ade 421 population growth qt final
 
NUTR334 Media Project
NUTR334 Media ProjectNUTR334 Media Project
NUTR334 Media Project
 
Ldr 625 m7 red team clc assignment final
Ldr 625 m7 red team clc assignment finalLdr 625 m7 red team clc assignment final
Ldr 625 m7 red team clc assignment final
 
LDR 625 M7 RED TEAM CLC Assignment with Notes
LDR 625 M7 RED TEAM CLC Assignment with NotesLDR 625 M7 RED TEAM CLC Assignment with Notes
LDR 625 M7 RED TEAM CLC Assignment with Notes
 
World hunger
World hungerWorld hunger
World hunger
 
Pew research new demography of mothers (5.20.10)
Pew research   new demography of mothers (5.20.10)Pew research   new demography of mothers (5.20.10)
Pew research new demography of mothers (5.20.10)
 
Child Mortality among Teenage Mothers in OJU Metropolis
Child Mortality among Teenage Mothers in OJU MetropolisChild Mortality among Teenage Mothers in OJU Metropolis
Child Mortality among Teenage Mothers in OJU Metropolis
 
Hunger Awareness
Hunger AwarenessHunger Awareness
Hunger Awareness
 
Hunger slides
Hunger slides Hunger slides
Hunger slides
 
Food Security in Africa: challenges and policy options to ensure Africa's future
Food Security in Africa: challenges and policy options to ensure Africa's futureFood Security in Africa: challenges and policy options to ensure Africa's future
Food Security in Africa: challenges and policy options to ensure Africa's future
 
Brigitte bagnol gender_food_and_nutrition_security
Brigitte bagnol gender_food_and_nutrition_securityBrigitte bagnol gender_food_and_nutrition_security
Brigitte bagnol gender_food_and_nutrition_security
 
First food forum 2014 presentation
First food forum 2014 presentationFirst food forum 2014 presentation
First food forum 2014 presentation
 

Viewers also liked

20101110十字繡教學_完成聖誕禮盒
20101110十字繡教學_完成聖誕禮盒20101110十字繡教學_完成聖誕禮盒
20101110十字繡教學_完成聖誕禮盒miaoniguo
 
韓國數學教育的分享
韓國數學教育的分享韓國數學教育的分享
韓國數學教育的分享miaoniguo
 
20110622數基五分享
20110622數基五分享20110622數基五分享
20110622數基五分享miaoniguo
 
Climate Change and the Distant Future
Climate Change and the Distant FutureClimate Change and the Distant Future
Climate Change and the Distant FutureGiulia Rosato
 
Cesar Chavez (by Mingyu Kang)
Cesar Chavez (by Mingyu Kang)Cesar Chavez (by Mingyu Kang)
Cesar Chavez (by Mingyu Kang)Joon-Myung Kang
 
Cuaderno de-caligrafia-didactalia
Cuaderno de-caligrafia-didactaliaCuaderno de-caligrafia-didactalia
Cuaderno de-caligrafia-didactaliaCayetana Sanchez
 
Trivial matemático samuel pereira 3º eso a
Trivial matemático samuel pereira 3º eso aTrivial matemático samuel pereira 3º eso a
Trivial matemático samuel pereira 3º eso aMaría José Mendoza
 
Year of the Rooster 2017 - Introspection
Year of the Rooster 2017 - IntrospectionYear of the Rooster 2017 - Introspection
Year of the Rooster 2017 - IntrospectionOH TEIK BIN
 
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017Roman Radchenko
 

Viewers also liked (14)

20101110十字繡教學_完成聖誕禮盒
20101110十字繡教學_完成聖誕禮盒20101110十字繡教學_完成聖誕禮盒
20101110十字繡教學_完成聖誕禮盒
 
韓國數學教育的分享
韓國數學教育的分享韓國數學教育的分享
韓國數學教育的分享
 
แสงกระจาย
แสงกระจายแสงกระจาย
แสงกระจาย
 
Lancôme ad
Lancôme adLancôme ad
Lancôme ad
 
CV Ashhad khan
CV Ashhad khanCV Ashhad khan
CV Ashhad khan
 
20110622數基五分享
20110622數基五分享20110622數基五分享
20110622數基五分享
 
Climate Change and the Distant Future
Climate Change and the Distant FutureClimate Change and the Distant Future
Climate Change and the Distant Future
 
Quintos
QuintosQuintos
Quintos
 
AREAS
AREASAREAS
AREAS
 
Cesar Chavez (by Mingyu Kang)
Cesar Chavez (by Mingyu Kang)Cesar Chavez (by Mingyu Kang)
Cesar Chavez (by Mingyu Kang)
 
Cuaderno de-caligrafia-didactalia
Cuaderno de-caligrafia-didactaliaCuaderno de-caligrafia-didactalia
Cuaderno de-caligrafia-didactalia
 
Trivial matemático samuel pereira 3º eso a
Trivial matemático samuel pereira 3º eso aTrivial matemático samuel pereira 3º eso a
Trivial matemático samuel pereira 3º eso a
 
Year of the Rooster 2017 - Introspection
Year of the Rooster 2017 - IntrospectionYear of the Rooster 2017 - Introspection
Year of the Rooster 2017 - Introspection
 
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017
Законопроект про аудит, внесений до КМУ Мінфіном 16.01.2017
 

Similar to Final Draft (1)

Infant Mortality Rate in the US Compared to Sweden
Infant Mortality Rate in the US Compared to SwedenInfant Mortality Rate in the US Compared to Sweden
Infant Mortality Rate in the US Compared to SwedenKarissa Braden
 
Exploring Infant Mortality
Exploring Infant Mortality Exploring Infant Mortality
Exploring Infant Mortality KenadiDavis
 
Teen Pregnancy And Birth Rates
Teen Pregnancy And Birth RatesTeen Pregnancy And Birth Rates
Teen Pregnancy And Birth RatesChristina Boetel
 
Teen Pregnancy, Abortion Rates, And Hiv Statistics
Teen Pregnancy, Abortion Rates, And Hiv StatisticsTeen Pregnancy, Abortion Rates, And Hiv Statistics
Teen Pregnancy, Abortion Rates, And Hiv StatisticsPawpaw Tran
 
The Pregnancy Of The Fetal Heart Rate
The Pregnancy Of The Fetal Heart RateThe Pregnancy Of The Fetal Heart Rate
The Pregnancy Of The Fetal Heart RateSusan Kennedy
 
Teen Pregnancy Causes
Teen Pregnancy CausesTeen Pregnancy Causes
Teen Pregnancy CausesApril Blount
 
The Infant Mortality Rate For African Americans
The Infant Mortality Rate For African AmericansThe Infant Mortality Rate For African Americans
The Infant Mortality Rate For African AmericansKatrina Green
 
4.2 - Population Geography
4.2 - Population Geography4.2 - Population Geography
4.2 - Population GeographyDan Ewert
 
Running head MATERNAL, INFANT AND CHILD HEALTH .docx
Running head MATERNAL, INFANT AND CHILD HEALTH                   .docxRunning head MATERNAL, INFANT AND CHILD HEALTH                   .docx
Running head MATERNAL, INFANT AND CHILD HEALTH .docxcowinhelen
 
Infant Mortality Rate
Infant Mortality RateInfant Mortality Rate
Infant Mortality Rateaavi241
 
Teen Pregnancy Prevention Intervention (TPPI)
Teen Pregnancy Prevention Intervention (TPPI)Teen Pregnancy Prevention Intervention (TPPI)
Teen Pregnancy Prevention Intervention (TPPI)Misty Harris
 
Infant Mortality Rate ( Imr )
Infant Mortality Rate ( Imr )Infant Mortality Rate ( Imr )
Infant Mortality Rate ( Imr )Cynthia Wilson
 
Increased Rates Of Teen Pregnancy Among Minorities
Increased Rates Of Teen Pregnancy Among MinoritiesIncreased Rates Of Teen Pregnancy Among Minorities
Increased Rates Of Teen Pregnancy Among MinoritiesMary Stevenson
 
Respond to the following  posts in a state different than your own. .docx
Respond to the following  posts in a state different than your own. .docxRespond to the following  posts in a state different than your own. .docx
Respond to the following  posts in a state different than your own. .docxcwilliam4
 
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docx
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docxCh. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docx
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docxcravennichole326
 
Health disparity final
Health disparity finalHealth disparity final
Health disparity finaltrenaa123
 
Literature Review Childhood Obesity
Literature Review Childhood ObesityLiterature Review Childhood Obesity
Literature Review Childhood ObesityJean Galiana
 
How Divorce Is A Common Family Problem Essay
How Divorce Is A Common Family Problem EssayHow Divorce Is A Common Family Problem Essay
How Divorce Is A Common Family Problem EssayKristen Lee
 
Teen Mothers And The Rates Of Teen Pregnancy
Teen Mothers And The Rates Of Teen PregnancyTeen Mothers And The Rates Of Teen Pregnancy
Teen Mothers And The Rates Of Teen PregnancyEbony Bates
 

Similar to Final Draft (1) (20)

Infant Mortality Rate in the US Compared to Sweden
Infant Mortality Rate in the US Compared to SwedenInfant Mortality Rate in the US Compared to Sweden
Infant Mortality Rate in the US Compared to Sweden
 
Exploring Infant Mortality
Exploring Infant Mortality Exploring Infant Mortality
Exploring Infant Mortality
 
Teen Pregnancy And Birth Rates
Teen Pregnancy And Birth RatesTeen Pregnancy And Birth Rates
Teen Pregnancy And Birth Rates
 
Teen Pregnancy, Abortion Rates, And Hiv Statistics
Teen Pregnancy, Abortion Rates, And Hiv StatisticsTeen Pregnancy, Abortion Rates, And Hiv Statistics
Teen Pregnancy, Abortion Rates, And Hiv Statistics
 
The Pregnancy Of The Fetal Heart Rate
The Pregnancy Of The Fetal Heart RateThe Pregnancy Of The Fetal Heart Rate
The Pregnancy Of The Fetal Heart Rate
 
Thesis Final Draft
Thesis Final DraftThesis Final Draft
Thesis Final Draft
 
Teen Pregnancy Causes
Teen Pregnancy CausesTeen Pregnancy Causes
Teen Pregnancy Causes
 
The Infant Mortality Rate For African Americans
The Infant Mortality Rate For African AmericansThe Infant Mortality Rate For African Americans
The Infant Mortality Rate For African Americans
 
4.2 - Population Geography
4.2 - Population Geography4.2 - Population Geography
4.2 - Population Geography
 
Running head MATERNAL, INFANT AND CHILD HEALTH .docx
Running head MATERNAL, INFANT AND CHILD HEALTH                   .docxRunning head MATERNAL, INFANT AND CHILD HEALTH                   .docx
Running head MATERNAL, INFANT AND CHILD HEALTH .docx
 
Infant Mortality Rate
Infant Mortality RateInfant Mortality Rate
Infant Mortality Rate
 
Teen Pregnancy Prevention Intervention (TPPI)
Teen Pregnancy Prevention Intervention (TPPI)Teen Pregnancy Prevention Intervention (TPPI)
Teen Pregnancy Prevention Intervention (TPPI)
 
Infant Mortality Rate ( Imr )
Infant Mortality Rate ( Imr )Infant Mortality Rate ( Imr )
Infant Mortality Rate ( Imr )
 
Increased Rates Of Teen Pregnancy Among Minorities
Increased Rates Of Teen Pregnancy Among MinoritiesIncreased Rates Of Teen Pregnancy Among Minorities
Increased Rates Of Teen Pregnancy Among Minorities
 
Respond to the following  posts in a state different than your own. .docx
Respond to the following  posts in a state different than your own. .docxRespond to the following  posts in a state different than your own. .docx
Respond to the following  posts in a state different than your own. .docx
 
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docx
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docxCh. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docx
Ch. 2 Comparing Vulnerable GroupsLearning ObjectivesAfter re.docx
 
Health disparity final
Health disparity finalHealth disparity final
Health disparity final
 
Literature Review Childhood Obesity
Literature Review Childhood ObesityLiterature Review Childhood Obesity
Literature Review Childhood Obesity
 
How Divorce Is A Common Family Problem Essay
How Divorce Is A Common Family Problem EssayHow Divorce Is A Common Family Problem Essay
How Divorce Is A Common Family Problem Essay
 
Teen Mothers And The Rates Of Teen Pregnancy
Teen Mothers And The Rates Of Teen PregnancyTeen Mothers And The Rates Of Teen Pregnancy
Teen Mothers And The Rates Of Teen Pregnancy
 

Final Draft (1)

  • 1. 1 Infant Mortality Rate Disparities in America: A Closer Look at infant loss in the African American Population I. INTRODUCTION: (Slide 1 Title) Good Afternoon, my name is LT Rickenbach. Today we will be exploring infant mortality rates in America. Infant mortality is a commonly cited indicator of the health of a society as a whole (Kim and Saada, 2011). Although infant mortality rates (IMR) in the United States have improved dramatically since 1960, they continue to lag behind other developed countries (Center for Disease Control and Prevention [CDC] Grand Rounds, 2013). In 2010, IMRs were compared among developed nations involved in the Organization for Economic Co- Operation and Development (OECD) in which the US ranked 26th of the 29 nations. The overall US infant mortality rate may be high, but some sub-populations within the country are even worse off. Despite improvements in recent years, in the United States, African American infants die at rate of 11 per 1000 live births. This is more than twice the rate of infant deaths among non- hispanic whites with a rate of 5 per 1000 live births (CDC, 2013). There are a myriad of factors that contribute to infant mortality, as well as a broad spectrum of research that has found links between certain factors and infant mortality among the African American population. Despite the large body of literature on the topic, the exact cause of the large disparity in infant deaths between racial groups remains unknown and resistant to efforts of reduction. Due to the vastness of this topic, this presentation will focus on the socioeconomic status (SES), interaction of environmental factors and genetics, and women’s health legislation as it applies to maternity leave and how these factors may impact infant outcomes in the African American population in the United States. II. (Slide 2) LIST OF OBJECTIVES Objective 1: Define infant mortality, fetal mortality, neonatal mortality and post neonatal mortality. Objective 2: Discuss how the IMR in the United States compares internationally and racial disparities in regards to IMR within the US Objective 3: Analyze factors that predispose the African American Population to Infant Mortality Objective 4: Discuss interventions aimed at reducing infant mortality Objective 5: Discuss nursing interventions that promote wanted pregnancies, term gestation, infant survival and wellness III. (Slide 3) DEFINITION OF TERMS A. Before we get started, I would like to take a moment to review some terms that will be used throughout this presentation. 1. Infant Mortality Rate (IMR): The number of infant deaths per 1,000 live births (Kim & Saada, 2013) 2. Fetal Mortality Rate (FMR): Spontaneous intrauterine deaths occurring at >/= 20 weeks of gestation (Kim & Saada, 2013)
  • 2. 2 3. Neonatal Mortality Rate (NMR): Infant deaths occurring at </= 28 days of life (Kim & Saada, 2013) 4. Post-Neonatal Mortality Rate (PNMR): Infant deaths after 28 days of life, but within the first year of life (Kim & Saada, 2013) 5. Pre-Term Birth (PTB): <37 weeks gestation (Kim & Saada, 2013) 6. Very Pre-Term Birth (VPTB): <32 weeks (Kim & Saada, 2013) 7. Low Birth Weight (LBW): Less than 2,500g (Kim & Saada, 2013) 8. Very Low Birth Weight (VLBW): less than 1,500g (Kim & Saada, 2013) B. All of these categories are associated with poor infant outcomes. Consistently around the globe, the biggest predictor of infant outcomes is gestational age. The majority of infant mortalities are related to preterm or very preterm birth (Kim & Saada, 2013). In addition, low birth weight infants are twenty times more likely to die than infants weighing more than 2,500g (Kim & Saada, 2013). Given this correlation, throughout the presentation many of the variables that will be discussed will relate to pre-term birth or low birth weight infants since they are so closely linked to infant morbidity and mortality. III. EXPLANATION A. (Slide 4) We will now discuss how the IMR in the United States compares internationally and as well as within racial subgroups in the United States 1. International Comparison of IMR a. First off, out of the 224 nations worldwide, where do you think the United States ranks in terms of infant mortality rate? i. Answer—as of 2014, 56th with an infant mortality rate of 6.17/1000 live births (CIA, 2014) b. Raise your hand if you think the United States has better infant mortalities rates than the following countries: i. Finland—if you didn’t raise your hand, you’re correct. With a rate of 3.36, Finland has the 14th lowest IMR in the world reported by the Central Intelligence Agency (CIA) in 2014. ii. Cuba—Again, if you have your hand down you win. Cuba is ranked 42nd with a rate of 4.70. (CIA, 2014) iii. Kuwait—You guessed right if you raised your hand. Kuwait is ranked 66th with a rate of 7.51 (CIA, 2014) iv. Russia—is 65th with a rate of 7.08 (CIA, 2014) v. Japan—Sweden is 2ndwith a rate of 2.13/1000 live births (CIA, 2014) c. (Slide 5)According to a 2014 National Vital Statistics Report that compared IMR among developed nations, the United States had the highest percentage of preterm births, 9.8%, of the 19 countries compared (CDC, 2014). Preterm births account for approximately 19% of annual infant mortalities in the United States (CDC, 2014). 2. (Slide 6) We will not take a closer look at the breakdown of when infant deaths occur in the United States a. Fetal death, or demise beyond 20 weeks of gestation, accounts for nearly half of all reproductive loss in the United States. The other half of
  • 3. 3 reproductive loss consists of infants who are born alive but later die (CDC, 2015). b. (Slide 7) Of these infants, 2/3 of their deaths occur during the neonatal period (the first 28 days of life), and 1/3 occur in the post-natal period (after 28 days but before 1 year of life) (CDC, 2015). c. Causes of infant mortality during the neonatal period include complications of preterm birth, congenital defects, maternal health conditions, complications of labor and delivery, and lack of access to care at the of delivery (CDC, 2013) d. Causes of infant mortality during the post-natal period include injury, infection, complications of preterm infants who survive the neonatal period, and sudden unexpected infant death (SUID) which is composed of three subcategories: accidental suffocation and strangulation in bed (ASSB), ill-defined deaths, and sudden infant death syndrome (SIDS) (CDC, 2013). SUID accounts for approximately 4,500 infant deaths/ year (CDC, 2013). 3. (Slide 8) We will now shift our focus to IMR disparities among racial groups in the United States. To kick off our investigation, can you guess what country’s IMR most closely resembles that of the African American population in the United States? (Slide 9) Answer: Palau. Just to paint the picture for you, this is a third world country consisting of a large group of small islands that share one national hospital. Again, the black population in America has about the same infant survival rate as this third world country. a. (Slide 10) As previously mentioned, African Americans experience more infant deaths than any other ethnic or racial group, with rates more than doubling those of non-Hispanic whites. In 2010, 16.6% of African American infants were born preterm while the rate for non-hispanic whites was 10.6% (Cole-Lewis, et al., 2014). In comparison to non- Hispanic whites, it is estimated that 78% of the excess IMR of non- Hispanic blacks can be attributed to preterm birth (MacDorman & Mathews, 2011). b. (Slide 11) The southern and Midwest states have the highest infant mortality rates in the United States, ranging anywhere from 6 to >8 deaths per 1000 live births. Minorities in these states make up about one third of the population and the largest health disparities are seen in these areas (Zhang et al., 2012). The lowest IMRs are observed mostly in western states and the northern most New England states (MacDorman, Hoyert, & Mathews, 2013). c. (Slide 12) Previously it was thought that genetic factors were the root cause of the racial disparities in infant mortality seen in American. Current research on this topic has revealed the cause to be much more complex and multi-faceted than a simple genetic explanation. A meta- analysis of 24 studies that compared preterm birth risk for immigrants and native-born women discovered sub-Sahara African-born black
  • 4. 4 women who immigrate to the US have a risk for preterm birth similar to that of white women in America. But yet, the female offspring of these women demonstrate preterm birth rates of U.S. born African Americans (Kramer, M., Hogue, C., Dunlop, A., & Menon, R, 2011). Although the exact cause of the IMR disparity remains unclear, the issue seems to be largely related to the African American experience in America (Kramer, M., Hogue, C., Dunlop, A., & Menon, R, 2011). d. (Slide 13) This poses the question, what is happening to African American women in America, and why are they seeing greater incidences of infant loss? C. We will now look at some of the factors that impact the African American population and how these factors affect their infant outcomes. 1. Socioeconomic Status a. (Slide 14) It is common knowledge that low SES status is associated with poor health indicators. Infant outcomes are no different as low SES is a consistent predictor of poor infant outcomes across racial groups (Kim & Saada, 2013; Collins, Rankin, Rankin, & David, 2011; Bravemen, et al., 2015). This is especially significant for African Americans as nearly one third of their population lives below the national poverty line (United States Census Bureau, 2013). b. (Slide 15) What about African Americans in less economically disadvantaged groups? How do you think increasing SES might influence infant outcomes? i. In a retrospective study of 10,400 black and white Californian women who gave birth between 2003 and 2010, preterm birth rates decreased as SES status increased for white women, but the same benefit was not shared by black women, whose PTB rate saw no measurable improvement (Bravemen, et al., 2015). Another retrospective study of 11, 265 African American and their infants found that mothers who were themselves low birth weight did not experience less rates of preterm birth with economic improvement (Collins, et al., 2011). Strange, these findings are counter intuitive. I personally would expect preterm births rates to decrease as life conditions improve. There are several theories that attempt to explain these findings: a. (Slide 16) There is a lot of evidence that suggests increased stress negatively impacts health overall and as a result leads to increased risk of poor infant outcomes (David & Collins, 2014; Christoper & Simpson, 2014; Collins, et al., 2011; Kramer, et al., 2011). We will discuss this in greater detail later on. It goes without saying that Americans tend to be hard workers, we value work ethic, and evidence shows Americans work longer hours than people of equal income categories in other developed nations (Porter, 2010). It is suggested that African Americans working in higher income categories may experience a unique set of stressors.
  • 5. 5 If they are minority in their workplace (a stressor in itself), they may feel increased pressure to work longer harder hours than their non-minority colleagues to overcome possible racial preconceptions or biases (Bravemen, et al, 2015). Especially in a work centric culture like ours, this could be a significant source of chronic stress (Breavemen, et al, 2015, Porter, 2010). b. In addition, in higher income categories (esp. the lower middle class) African Americans are more likely that Caucasians to be supporting family members in lower SES categories. This is a potential source of emotional and financial stress (Bravemen, et al, 2015). 2. The next factor we will review is the impact of residential segregation on infant outcomes a. (Slide 17) Residential segregation is defined as “the extent to which social groups characterized by income or race/ethnicity are spatially separated from one another” (Kim & Saada, 2013 p.2311). b. (Slide 18)Residential segregation is a unique issue in America because in many ways it was self-imposed (Gotham, 2000). Following the abolition of slavery after the Civil War, many African Americans remained in rural areas employed in capacities that allowed them to use the skills they knew, such as farming (Gotham, 2000).With the onset of World War I and resulting industrialization, the African American population underwent a massive migration to urban areas in order to take advantage of booming job opportunities in the developing metropolitan areas. c. (Slide 19) During this time, prejudice and racism led to the belief that homogenous white communities were safer than mixed communities (Gotham, 2000). For this reason, white residential areas became more desired and expensive. As a result, racially restrictive covenants, “contractual agreements between property owners and neighborhood associations that prohibited the sale, occupancy or lease of property and land to certain racial groups” became commonplace (Gotham, 2000 p.617). d. In turn this led to concentrations of poverty and disadvantage in African American communities, especially in the densely packed urban areas (McFarland & Smith, 2011). Although these covenants were deemed unconstitutional in 1948, they were utilized in many states up until the 1960s (Gotham, 2000). The implications of these covenants have proven to be long lasting, as highly segregated African American populations are still observed today throughout metropolitan areas in the United States (Gotham, 2000). e. (Slide 14) Part of the issue is white-majority housing areas continue to hold more value than mixed and predominantly black neighborhoods (Gotham, 2000). Current studies of realtor audits find that minorities, especially African Americans still face discrimination in housing and
  • 6. 6 mortgage markets (McFarland & Smith, 2011). These studies show that given two equally qualified candidates who differ only by minority status, favor is typically shown to the non-minority candidates (McFarland & Smith, 2011). This could be interpreted as an attempt of the realtors to maintain the value of predominantly white neighborhoods by moderating the entrance of minorities into these communities (Gotham, 2000). This theory is supported by the observation that a higher level of educational attainment amongst the African American population does not translate to decreased residential segregation (McFarland & Smith, 2011). f. (Slide 15) A systematic review of social determinants of infant mortality looked at 12 ecological studies of the impact of residential segregation on infant mortality, and all of them found a positive correlation (Kim & Saada, 2013). However, whether the correlation is positive or negative varies per ethnic group (Kim & Saada, 2013). g. An analysis of the U.S. metropolitan statistical areas data from 2000 found that residential segregation influenced infant outcomes differently across ethnic groups (McFarland & Smith, 2011). Segregation of the white population had no effect on infant outcomes, neither improving nor decreasing infant mortality or birth weight (McFarland & Smith, 2011). On the other hand, segregation of the African American population was associated with increased infant mortality and lower infant birth weights (McFarland & Smith, 2011). h. Interestingly, in the Hispanic population, another group that tends to be clustered in low SES urban environments, residential segregation was found to be protective against infant mortality and in some communities Hispanic infants also tended to have higher birth weights (McFarland & Smith, 2011, Shaw & Pickett, 2013). This is a well observed phenomenon called the “Hispanic Paradox”. The benefits seen in this ethnic group is thought to be the product of increased social capital and cohesion in the form of culturally embedded value of support for mothers and families, strong kin networks, and traditions of healthy behaviors that are passed down through generations such as the strong propensity to breastfeed (Kim & Saada, 2013, McFarland & Smith, 2011, Shaw & Pickett, 2013). In addition, an analysis of the US linked birth and infant death data set from 2000 found a correlation between Hispanic density in a given county and improved infant outcomes across the board for all races (Shaw & Pickett, 2013). Given these findings it could be possible that somehow increasing social capital and cohesion among the African American population might improve their infant outcomes. 3. Pregnancy intention, how much a pregnancy is desired and a baby wanted can greatly impact the physical and emotional health of infants. a. (Slide 23) American mothers report that 1/3 of pregnancies are unintended. This includes pregnancies that may be wanted but are
  • 7. 7 mistimed (either slightly (<2yrs) or grossly (>2yrs) as well as unwanted pregnancies (Kost, & Lindberg, 2015). b. Historically, unwanted pregnancies have been associated with “disadvantages on health and school performance” as they have to “surmount greater social and mental handicaps than their peers” (Kost, & Lindberg, 2015). c. (Slide 24) In an analysis of the surveyed pregnancy intentions of 42 hundred (4,297) singleton live births from 1999 to 2010, it was discovered that mothers with unwanted and grossly mistimed pregnancies are less likely to receive early prenatal care and less likely to breastfeed (Kost, & Lindberg, 2015). In addition, unwanted births were associated with poor infant outcomes including increased risk for preterm birth and low birth weight infants. Of the unwanted births reviewed, 62% occurred in third or higher birth order infants amongst women who had already reached their reproductive goals and did not desire family expansion (Kost, & Lindberg, 2015). Mothers of grossly mistimed and unwanted births were more likely to be African American and to not have graduated from high school (Kost, & Lindberg, 2015). d. (Slide 25) In a study involving 282 low SES women who were predominantly African American and received inadequate prenatal care, 93% of these mothers reported their pregnancies as unwanted, and 22% stated they had not used contraceptives when they became pregnant (Katz, et al., 2011) e. These findings indicate that the low SES African American population may have difficulty in accessing adequate birth control resources (Kost, & Lindberg, 2015). 4. (Slide 26) Another important issue in the health of babies is Maternity leave. The World Health Organization (WHO) recommends at least 16 weeks of maternity leave to promote healthy bonding, optimize infant growth, and allow for full recovery of the mother prior to returning to work (Vahratian, & Johnson, 2009). Evidence has found benefits of longer maternity leave such as longer breastfeeding duration, higher immunization rates, more well-child visits, and reduced incidence of postpartum depression (Shepherd-Banigan & Bell, 2014; Dagher, Mcgovern, & Dowd, 2014). a. (Slide 27) Internationally, the duration and compensation of maternity leave varies greatly: i. Residents in France and Spain have a very long duration of maternity leave, over 300 weeks, but with minimal compensation of 9% (Vahratian, & Johnson, 2009). ii. Japan offers shorter duration of a little over a year at about 50% compensation (Vahratian, & Johnson, 2009). iii. Swedish residents are offered 18 months of leave with 80% compensation (Vahratian, & Johnson, 2009). iv. Germany offers 14 weeks paid maternity leave at 100% compensation (Vahratian, & Johnson, 2009).
  • 8. 8 b. These countries all boast IMR rates of 3.46/1000 live births or less (CIA, 2014). c. A review of international social policies found that 178 of the 190 United Nations members offer some degree of paid maternity leave. Eight of the outliers only offered paid maternity leave only to new mothers. And the US was among the remaining four who offer no guaranteed support for new mothers, and the only developed nation in this group (Shepherd-Banigan, Megan & Bell, Janice, 2013). A cross- national, cross sectional study of 141 countries found that increasing maternity leave by 10 weeks predicts a decreased IMR by 10% (Kim & Saada, 2013). d. (Slide 28) In the United States women are protected under the Family and Medical Leave Act (FMLA) of 1993 (Shepherd-Banigan, et al., 2013). i. This act offers women in the United States 12 weeks of unpaid maternity leave if they meet the following criteria: a. Employed by a firm with greater than 50 employees b. Must have worked more than 1,760 hours for the company over the last year (Shepherd-Banigan, et al., 2013). ii. This ends up only covering 20% of new mothers and only half of all mothers (Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff, M. (2014). Working low SES mothers (which include about 1/3 of the African American population) are more likely to take shorter durations of maternity leave due to financial inability to take longer leave (Guendelman, et al., 2014; United Census Bureau, 2013). e. A cross-sectional study that surveyed 1,500 women from pregnancy to 18 months post-partum. This study found that 81% of women who returned to work before their infant was 6 months old cited lack of financial resources as the primary reason (Shepherd-Banigan, et al., 2013). 5. (Slide 29) Epigenetics and Allostatic Stress Load a. The risk factors for poor infant outcomes we just discussed are all related for one important reason, they all increase stress, which can have a negative impact on an individual’s health and consequently jeopardize their pregnancy. We have already discussed the fact that preterm birth accounts for 78% of the infant mortality disparity between African Americans and Caucasians (MacDorman & Mathews, 2011). Although the exact causes of preterm birth are not completely understood, activation of the stress response has been shown to be a pathway that can lead to preterm labor (Cole-Lewis, et al., 2014, Kramer, et al., 2011). b. (Slide 30) “Stress is commonly defined as a state of real or perceived threat to homeostasis” (Smith & Vale, 2006, p383). When the body anticipates or arrives in a situation that may result in harm, the stress response activates, causing behavioral and physiological adaptations that are intended to increase the chance of survival (Kramer, et al., 2011;
  • 9. 9 Martini & Nath, 2009, Smith & Vale, 2006). These adaptations include increase mental alertness, mobilization of glycogen & lipid reserves to support increased energy use by cells, increased cardiovascular tone, increased heart rate & respiratory rate, and inhibition of parasympathetic functions such as digestion and urine production (Kramer, et al., 2011; Martini & Nath, 2009, Smith & Vale, 2006). c. (Slide 31)The body systems responsible for activating and regulating the stress response are the hypothalamus, anterior lobe of the pituitary gland & adrenal glands, together referred to at the HPA axis (Kramer, et al., 2011; Smith & Vale, 2006). i. (Slide 32) Let’s take a moment to review the hormonal cascade caused by the HPA axis. When the body perceives a mental or physical threat or insult, the hypothalamus secretes corticotrophin- releasing factor (CRF), the primary hormone responsible for regulating the stress response (Kramer, et al., 2011; Martini & Nath, 2009; Smith & Vale, 2006). CRF is also known as corticotrophin-releasing hormone (CRH). CRF then binds to receptors on the anterior pituitary gland, causing the release of adrenocorticotropic hormone (ACTH), which as its name suggests, acts on the adrenal glands causing their release of glucocorticoids including cortisol and corticosteroids and catecholamines including epinephrine and norepinephrine (Martini & Nath, 2009; Smith & Vale, 2006). ii. (Slide 33) Glucocorticoids cause increased glucose & glycogen synthesis, increased peripheral utilization of lipids, and decreased inflammatory response and white blood cell (WBC) function, creating a vulnerability to infection (Kramer, et al., 2011; Martini & Nath, 2009; Smith & Vale, 2006). The catecholamines epinephrine and norepinephrine works synergistically with glucocorticoids by causing increased glycogen breakdown, increased blood sugar levels, and elevated lipid release for cortisol to utilize peripherally. Catecholamines also cause increased heart rate, contractility of the heart and blood pressure (Martini & Nath, 2009). iii. (Slide 34) It has been found that peripheral organs besides the hypothalamus can activate the HPA axis. Studies have found CRF in the adrenal glands, testis, GI tract, thymus and the placenta (Bonis, et al., 2012; Smith & Vale, 2006). iv. The placenta allows for communication between the fetus and mother via release of endocrine hormones, such as CRF (Bonis, et al., 2012). A healthy dose of CRF is actually required for a healthy pregnancy as is decreases the mother’s immune response, allowing for successful placentation (Bonis, et al., 2012). However, elevated CRF in the maternal circulation cause the release of catecholamines which then cause vasoconstriction resulting in reducing blood flow to the uterus and placenta (Bonis, et al., 2012;
  • 10. 10 Hacker, et al., 2010). Evidence supports this theory, as serum CRF elevation is consistently observed in pregnant mothers in the weeks leading up to preterm labor (Bonis, et al., 2012; Hacker, et al., 2010). In addition, CRF levels in preterm placentas have been found to be vastly elevated compared to the CRF in term placentas (Bonis, et al., 2012). d. Some research has indicated that stress experienced prior to conception may be just as important as the stressors experienced during pregnancy, because they prime the hormonal environment of the body (Kramer, et al., 2011). The literature on this topic identifies three theories for this occurrence, (1) early life programming of chronic disease (2) the weathering hypothesis and (3) psychosocial responses to stressors. i. ( Slide 35) The theory of early life programming of chronic disease proposes stressful experiences in important development stages over the course of an individual’s early life, especially in utero and early childhood, result in a permanently hypersensitive hypothalamic- pituitary-adrenal (HPA) axis, leading to increased risk of preterm labor (Kramer, et al., 2011; Smith & Vale, 2006). a. (Slide 36) This theory is supported by the consistent observation that women who give birth to preterm infants are at a significantly increased risk, up to 3.8 times the risk, of delivering subsequent preterm babies (Kramer, et al., 2011). b. It is also supported by the earlier cited study in which women who were born with low birth weights did not receive the reduction in preterm birth that other members experienced as their economic situation improved (Collins, Rankin, & David, 2011). c. In addition, animal studies find that the quality of mothering received by baby rats as well as laboratory exposure of the mother to injected stress hormones during pregnancy each result in permanent HPA changes in the baby rats (Kramer, et al., 2011). d. This same correlation was seen in women exposed to the 1944 Dutch famine as a fetus. As adults these women delivered babies with lower birth weights than women who were not exposed to the famine (Kramer, et al., 2011). ii. (Slide 37) The weathering hypothesis theorizes that chronic exposure to stressors such as violent neighborhoods, discrimination, and poverty gradually wear the body’s stress response system resulting in permanent dysfunction of the immune and vascular systems. (Kramer, et al., 2011) a. Normally, the stress response is activated to allow individuals to make acute physiological adaptations in order to overcome short-lived stressors and prevent harm. Beginning in the mid 1900s, it first theorized that chronic
  • 11. 11 activation of the body’s stress response, which is supposed to be acute and temporary, may weather body systems, and result in premature aging of the body (Kramer, et al., 2011). b. When acutely activated, the stress response suppresses the inflammatory effects of the immune system (Kramer, et al., 2011). Whereas in chronic stress conditions, the body develops a resistance to the anti-inflammatory effects of glucocorticoids leading to uncontrolled systemic circulation of pro-inflammatory cytokines, which are often key players in the onset of preterm labor (Bonis, et al., 2012; Kramer, et al., 2011; Martini & Nath, 2009). c. (Slide 38) In the United States, optimal childbearing age across all populations is represented by a U-curve, in which at either end of the “U” infant outcomes (PTB, low birth weight) are poorer (Kramer, et al., 2011). At the valley of the U, infant outcomes are the best, and therefore this age range is considered optimal. In the white population in the United States the optimal age range is 25 to 34, meaning this group of women experiences the best infant outcomes (Kramer, et al., 2011). By comparison, the optimal age range for the entire African American population has a left shift, with an optimal childbearing age range of 20-24. In addition, their U-curve is steeper than that of white women, that is, the optimal childbearing age for African American women is comparably much shorter (Kramer, et al., 2011). d. An impaired immune system leaves women at risk for development infections. One infection that is concerning during pregnancy due to its association with preterm birth is bacterial vaginosis (BV). Evidence supports that women across all races and ethnicities who undergo chronic stressors develop BV more frequently than those without expose to chronic stress (Kramer, et al., 2011). In addition, the presence of BV doubles the chances of preterm labor and is more prevalent among African American women than white women (Kramer, et al., 2011). e. Chronic stress also affects the vascular system, due to increasing blood pressure which damages the endothelial cells of the blood vessels and puts mothers at risk for a variety of pregnancy risk factors such as poor placental attachment or perfusion, preeclampsia, intrauterine growth restriction (IUGR), and preterm birth, and fetal demise (Kramer, et al., 2011). iii. (Slide 39) A third theory of stress response poses that psychosocial stressors such as low SES, residence in violent or crime ridden neighborhoods, sexual or physical abuse, or perceived racism leads women to adapt unhealthy coping mechanisms to include risky
  • 12. 12 sexual behaviors, smoking, alcohol or illicit drug use, or even overeating (Fontenot & George, 2012; Gavin, Nurius, & Logan- Greene, 2012; Kramer et al., 2011). These dysfunctional coping behaviors negatively impact their health and increase the risk of harm to the fetus (Kramer, et al., 2011). iv. These theories of the effects of stress response on pregnancy outcomes are interesting because African Americans are nearly twice as likely to live below the national poverty line compared to Caucasians, and their babies die at more than twice as often (Kramer, et al., 2011; United States Census Bureau, 2013). Although stress cannot explain the racial disparities in infant mortality in itself, it may help explain why the gap is so complex and resistant to change. III. INTERVENTIONS A. (Slide 40) So now that we’ve had a closer look at some of the potential causes of the racial disparity gap in infant mortality, let’s talk about interventions to shrink the gap. But before we talk about the specific interventions we’re going to briefly examine pending trends in the United States in regards to healthcare and social services and how these trends differ from developed nations. 1. A 2005 comparison of gross domestic product (GDP) expenditure on healthcare and social services among 30 nations in the organization for economic cooperation and development (OECD) revealed the US has the highest healthcare expenditures of the nations reviewed, yet only had better infant mortality rate than two nations; Poland and Mexico (Bradley, Elkins, Herrin & Elbel, 2011). 2. Social services and healthcare costs together account for 29% of the US GDP. While the US spends a little over half of this amount on healthcare and a little under half on social services, the other OECD nations (with the exception of Mexico) spend approximately 2/3 on social services and only 1/3 on healthcare expenses (Bradley, et al., 2011). 3. This ratio of greater spending on social services in comparison to healthcare is associated with increased life expectancy, decreased infant mortality, and a decrease in potential years of life lost, all of which are important health indicators of a population (Bradley, et al., 2011). 4. These findings insinuate that a potential key to improving the health of the US and decreasing the infant mortality rate, might involve a complete restructuring of our ideas about health and wellness as well as a reprioritization of our spending in regards to healthcare and social services (Bradley, et al., 2011). Focusing more on promoting health behaviors and prevention of illness, instead of reacting to co- morbidities partially caused by harmful behaviors and living conditions may help promote a culture of responsibility of individual health and could potentially lead to improved wellness indicators for the country as a whole (Bradley, et al., 2011). B. (Slide 41) In the United States, we may not invest as heavily in social services as other developed nations, however, we still have many national efforts to decrease the infant mortality rate as well as reduce the racial disparity.
  • 13. 13 1. (Slide 42) One national effort to identify health needs is the Pregnancy Risk Assessment Monitoring System (PRAMS), which is a surveillance program that collects data used to reduce maternal and infant mortality (CDC, 2013). a. Information is gathered via telephone and mailed questionnaires that ask about pregnancy and post-partum practices such as breastfeeding, prenatal care, behaviors during pregnancy and infant care practices such as sleep position (CDC, 2013) b. This assessment has proven to be effective in identifying population health needs. Here are just a few examples of PRAMS identifying educational needs of specific population by geographic location: c. Using PRAMS, West Virginia discovered they had the highest maternal smoking rates in the country. This finding prompted the launch of the 2009 “Tobacco Free Pregnancy Initiative”, which ultimately resulted in higher call volume of pregnant women and their family members to tobacco cessation quit lines (CDC, 2013). d. In another instance, PRAMS helped Michigan notice that their African American population was 20% less likely than the rest of their population to put their infants back to sleep. In response, Michigan launched the 2004 “Infant Safe Sleep Campaign” which resulted in requirements for child care centers to practice back to sleep in order to maintain their licensure (CDC, 2013). 2. (Slide 43) A widely used intervention to decrease health consequences and improve infant outcomes and child development among vulnerable populations is home visitation programs. Many of these programs exist, but a few common ones include Healthy Families America (HFA), Nurse-Family Partnership (NFP), Parents as Teachers, Home Instruction for Parents of Preschool Youngsters and the Parent Child Home Program (Azzi-Lessing, 2013). Home-visitation programs strive to improve the health of families by providing paraprofessionals or sometimes nurses to visit the homes of at risk families in order to improve infant care practices, parenting skills and home environment, improve and increase parent-child interaction, reduce risks of abuse and neglect, and connect families with community resources especially healthcare (Azzi-Lessing, 2013; Katz, et al., 2011; Kothari, et al., 2014). a. (Slide 44) Although home-visitation programs are utilized throughout the US especially in metropolitan areas with large volumes of vulnerable populations, the effectiveness of these programs has not been consistently shown in research with many studies demonstrating minimal benefits of these programs overall (Azzi-Lessing, 2013). b. A quasi-experimental study compared infant outcomes among participants of a prenatal Healthy Start home visitation program in Kalamazoo, Michigan with propensity score matched non-participants (Kothari, et al., 2014). Infant outcomes were compared between African American and White women who were represented in equal numbers in the participant group, consisting of 294 women (Kothari, et al., 2014). This study found no difference between gestational age or incidence of
  • 14. 14 preterm birth among African American participants in the Healthy Start program versus matched non-participants (Kothari, et al., 2014). c. In addition, some evidence shows a tendency for home-visitation programs to miss opportunities with the highest risk vulnerable populations. i. A study that evaluated the impact of home-visitation on high risk families found that over half of mothers involved in home- visitation programs had at least one high risk variable including: mental health condition(s), struggle with substance abuse, or domestic violence. 75% of this higher risk population did not receive social support services to address these issues (Azzi- Lessing, 2013). ii. Another study that evaluated the effectiveness of the Pride in Parenting Program on new mothers who had received inadequate prenatal care during their pregnancy, found improved ability of these mothers to create home environments suitable for their infant’s safety and development age, demonstrated better observed mothering skills, and reported improved perception of support. However, these results were only observed in participants who had thirty or more contacts with paraprofessionals (Katz, et al., 2011). Typically, mothers with high levels of participation usually have fewer original risk factors than mothers with the least participation in home-visitation programs who usually have the greatest risks of poor infant outcomes (Azzi-Lessing, 2013). d. (Slide 45) Several factors contribute to the challenges home-visitation programs face in actively engaging highly vulnerable families and providing services that meet their needs. These factors include: i. Potential preoccupation with the level or quality of stressors in the lives of highly vulnerable families, resulting in greater fewer home visits and decreased quality of program participation (Azzi- Lessing, 2013). ii. Skepticism of home-visitation programs due to negative experiences with other formal services such as CPS (Azzi-Lessing, 2013). iii. Possible inability of paraprofessional to meet the needs of these families. Most, although not all of the home-visitation programs employ paraprofessionals who usually lack a college education and receive only a training program of varying length. This training program is intended to provide paraprofessionals with the skills to successfully serve high risk populations. a. Paraprofessionals are expected to be able to identify difficult issues in the home such as domestic violence, substance abuse, and depression (Azzi-Lessing, 2013). b. They must be able to communicate with vulnerable families in a nonjudgmental and compassion form that builds trust
  • 15. 15 and rapport, as this population is easily disengaged (Azzi- Lessing, 2013). c. In addition, they must be knowledgeable about available resources and have the ability to connect their clients with these resources (Azzi-Lessing, 2013). d. This is a very large body of knowledge and skill to gain from any training program. Social workers earn a bachelor’s degree and sometimes a master’s degree to do work requiring a similar knowledge and skill base (Azzi- Lessing, 2013). C. (Slide 46) Centering Pregnancy is another intervention that is used to improve infant outcomes. 1. Before we talk about the benefits of Centering Pregnancy, allow me to take a moment to explain this program. a. Centering Pregnancy is an evidenced-based model of prenatal care occurs in a group setting, unlike traditional prenatal care occurring one on one in a provider’s office. Each group consists of 8 to 12 women of similar gestational age, who have ten sessions together throughout their pregnancy that last one hour to one and a half hours (Rotundo, 2011). During the sessions the women undergo an individual assessment by a licensed healthcare provider, accounting for about 30-40 minutes of the session (Rotundo, 2011). The remaining time, about an hour, is used for group teaching and discussion of relevant topics pertaining to their specific gestation (Rotundo, 2011). b. (Slide 47)The program is patient centered and actively involves women in their prenatal care. At the beginning of each session women calculate their own gestational age, and take their own vital signs and weight. This empowers women to be accountable, acutely attuned, and active partners in their health. Each woman gets the opportunity to discuss the status of pregnancy with her provider using the assessment data she collected herself (Rotundo, 2011). c. The teaching portion of each session occurs in a circle formation, is causal and discussion styled, and encourages sharing of knowledge amongst the members. The group teachers, referred to as facilitators, functions to provide the relevant discussion topics, keep the group on track, and ensure accuracy of shared knowledge. Facilitators typically remain consistent throughout the program to ensure consistency of information and allow rapport to be built between the group and the instructors (Rotundo, 2011). d. Before the teaching portion begins, the women are able to socialize while they wait to be seen by the provider (Rotundo, 2011). e. New members may be added to the centering group until the third session, but after this point the members must agree to any new additions. This gives the centering members a sense of ownership and loyalty to their group (Rotundo, 2011). f. Group facilitators track health statistics of their program including preterm birth rate, low birth weights, patient satisfaction, breastfeeding rates, and
  • 16. 16 adequacy of member attendance. This allows each program to process improve, in order to meet the needs of their specific population. 2. (Slide 48) The benefits of prenatal care under this model include a. Increased patient satisfaction (Catling, 2015; Ickovics, et al, 2011) Rotundo, 2011) b. Increased breastfeeding rates (Ickovics, et al, 2011; Rotundo, 2011) c. Increased provider satisfaction, including providers reporting a perceived deeper connection with their patients (Rotundo, 2011) d. Improved birth outcomes (Tanner-Smith, Steinka-Fry, & Lipsey, 2013) e. 20 hours of educational time with providers, which is ten times the amount of educational time received by women in traditional prenatal care who get about 2 hours over the course of their pregnancy (Thielen, 2012). 3. (Slide 49) Let’s take a look at what the evidence says: a. A retrospective study compared 651 patients who used Centering Pregnancy with statistically matched women who used traditional prenatal (Tanner-Smith, et al., 2013). b. This study found that the Centering Pregnancy women were not less likely to deliver preterm, but when they did, their average gestation age was 2.5 weeks longer and their infants weighed approximately 300g more compared than premature infants in the traditional prenatal care group. The Centering pregnancy mothers were also found to have less incidence of fetal demise than the traditional prenatal care group. (Tanner-Smith, et al., 2013). c. Although some studies have found decreased preterm birth rates for women in Centering Pregnancy groups (Ickovics, 2011), these results are inconsistent in systematic reviews (Catling, et al., 2015). d. Centering Pregnancy is unique in that it not only provides women with an empowering prenatal experience, and more time with healthcare providers; it also provides a valuable resource, social capital and cohesion (Ickovics, 2011; Rotundo, 2011). As we previously discussed, these are areas that can improve infant outcomes despite economic disadvantage (Kim & Saada, 2013; McFarland & Smith, 2011; Shaw & Pickett, 2013). IV. NURSING IMPLICATIONS A. (Slide 50) Although no interventions have been found to improve outcomes specifically for African Americans, nurses can provide teaching that is known to universally improve pregnancy and infant outcomes. 1. One way to decrease poor infant outcomes is to prevent unwanted pregnancies ( a. Three pathways leading to unintended pregnancies have been proposed and include (Thomas, 2012): i. Individuals are indifference to avoiding risky behavior—having unprotected sex without thinking or caring about the potential of pregnancy resulting (Thomas, 2012). ii. Individuals who have intentions to not get pregnant do not have accurate information about how to prevent pregnancy—for
  • 17. 17 example they believe withdrawal or breastfeeding are reliable birth control methods (Thomas, 2012). iii. Individuals have intentions to not get pregnant and have accurate information how to prevent pregnancy, but lack access to adequate birth control (Thomas, 2012). b. Since unwanted pregnancies are more common among African Americans with low educational achievement, and are associated with poor infant outcomes, this population may benefit from sex education, dispelling myths surrounding pregnancy prevention, and contraceptive education to include adequacy of different birth control methods (Kost & Lindberg, 2015). c. Women should also be educated on how to gain access to providers to inquire about preferred contraceptive methods. Desire for pregnancy in the future should be discussed as this may help women decide which contraceptive method would best fit their life style. d. Postpartum women should be educated on pregnancy spacing. Women should be informed that becoming pregnant within 6 months of delivery is associated with increased risk for significant adverse fetal outcomes, such as stillbirth, preterm birth, low birth rate early neonatal death (Wendt, Gibbs, Peters & Hogue, 2012) . The recommended minimum timeframe between pregnancies is 18 to 23 months in between pregnancies. This may be an important intervention for decreasing the IMR gap since studies show African American women have shorter pregnancy intervals than white women (Nabukera, et al., 2009). 2. (Slide 51) Sexually Transmitted Infection (STI) prevention/treatment a. It is important to educate women of the significant adverse effects of STIs on pregnancy and infant outcomes. Women should be educated that STIs can result in preterm birth, fetal demise, and adverse infant outcomes such as infection, opthalmia, pneumonia, mental delays or disabilities, and low birth weight (Fontenot & George, 2014) b. Nurses should identify patients at increased risk for STIs during sexual activity assessments and discuss with patients the importance of STI testing for their partner (Fontenot & George, 2014) 3. (Slide 52) Nutrition a. Findings from the 2014 Summit on Obesity of African American Women and Girls found that 60% of African American women are obese (American Psychological Association [APA], 2014). Obesity is associated with increased pregnancy risks including gestational diabetes and preeclampsia (Marshall, Guild, Cheng, Caughey, & Halloran, 2014). b. African American women may benefit from nutritional counseling on diet composition, appropriate weight gain during pregnancy and appropriate caloric consumption per trimester of pregnancy (Lowdermilk, et al., 2015). 4. (Slide 53) Smoking/Alcohol/Drug Use
  • 18. 18 a. Women should be given counseling on the negative effects of the substance used on the pregnancy and the development of her baby (Lowdermilk, Perry, Cashion, & Alden, 2015). b. Although smoking is less common among low SES African American women compared to low SES Caucasian women. Studies find African American women who smoke are at an even higher risk for preeclampsia and fetal demise than white women who smoke (need source). c. Women who admit to smoking, alcohol or illicit drug, should be evaluated for intention to quit (Lowdermilk, et al., 2015). d. Women who desire to quit should be referred to cessation programs or rehabilitation programs and provided self-help resources (Lowdermilk, et al., 2015). e. With nursing and provider support, women who are unwilling or unable to quit may be able to cut back even if modestly. 5. (Slide 54) Social Support a. Patients should be assessed for adequacy of social supports and provided resources in the event of reported inadequate support. Nurses can inform patients about the benefits of Centering Pregnancy, as this is a great way to build social capital (Rotundo, 2011; Tanner-Smith, et al, 2014; Thielen, 2012). 6. (Slide 55) Depression Screening a. Maternal depression occurs in approximately 15-20% of pregnant and post partum women and is shown to have negative impacts on infants in utero as well as after delivery in the post partum period (Bansil, et al., 2010; Lefkovics, Baji, & Rigo, 2014). Low SES and women with low social support are at increased risk of prenatal and post-partum depression (Lefkovics, et al., 2014). b.During pregnancy depression is associated with later initiation of prenatal care, increased incidence of maternal substance abuse, poor and/or inadequate nutrition, preterm birth, low birth weight, and pre-eclampsia (Bansil, et al., 2010; Lefkovics, 2014). In the post partum period maternal depression is associated with impaired infant bonding and dysfunctional parenting that could have lifelong implications on emotional development of infants (Bansil, et al., 2010; Lefkovics, 2014). c. According to a 2003 study, only 44% of obstetrical gynecologists were found to routinely screen their patients for depression (Bansil, et al., 2010). Therefore, nurses should assess all pregnant and postpartum patients for depressive symptoms. The Edinburgh Postnatal Depression Scale (EPDS) or a simple two question screening tool can be utilized (Lowdermilk, et al., 2015). A score above 10 for the (EDPS) or a positive screening for the two question tool should be reported to a provider for further assessment (Lowdermilk, et al., 2015). d. It is important to keep in mind that postpartum women are most likely to show signs of post partum depression (PPD) around 4 weeks postpartum. Prior to discharge from the hospital patients should be educated about the signs and symptoms of PPD such as persistent and
  • 19. 19 overwhelming sadness or anxiety, appetite changes, difficulty sleeping, no or decreased interest in infant care, and thoughts of self or infant harm (Lowdermilk, et al., 2015). 7. (Slide 56) Breastfeeding a. All women should be educated about the benefits of breastfeeding. Data from PRAMS in 2012 revealed that African American women have the lowest rates of breastfeeding in the United States (Ahluwalia, Morrow, D’Angelo, & Li, 2012). Breastfeeding reduces the risk of post-neonatal death from preventable causes such as SIDS and infection (Chen & Rogan, 2004). Therefore, higher breastfeeding rates among African American mothers might help decrease the high infant mortality in this population. V. SUMMARY A. (Slide 57) To sum it all up, here is a brief recap of what we covered. First defined terms related to fetal and infant mortality. We discussed international infant mortality rates and maternity leave policies and compared them to the United States. Infant outcomes were compared between the population with the highest poor outcomes, African Americans and the group with the least poor outcomes, non-Hispanic whites. We reviewed the effectiveness of some interventions to reduce infant mortality and reduce the racial disparities in America including Centering Pregnancy, home visitation programs, and PRAMS. And we discussed how nurses play a key role in improving outcomes for women and infants, especially those in vulnerable socioeconomic populations. B. From researching this topic I noticed that cultures and nations that prioritize healthy pregnancies, infants and families tend to see better outcomes. For instance, Swedish residents receive 18 months of 80% compensated maternity leave (Vahratian, & Johnson, 2009). This sends the message that maternal-infant bonding, and the health of new mothers and their newborns are top priorities in Sweden. Every mother in Finland is provided a maternity box filled with everything needed to take care of the infant for the first few months of life (Lee, 2013). The package contains onesies, breastfeeding supplies, diapers, a mattress pad, and even a snowsuit (Lee, 2013). The box is provided to all mothers from every walk of life to send the message than all infants deserve the same start in life (Lee, 2013). The message is well received by the Finnish, as they traditionally use this box as the baby’s first bassinet (Lee, 2013). And oh by the way, they spend the same percentage of their GDP (30%) on the combined amount of social services and healthcare as the United States (Bradley, Elkins, Herrin & Elbel, 2011). I’m not saying that a maternity box would fix the infant mortality gap in America, but from this research I can concluded that perhaps our nation has some reprioritization to do about how we think of the health of families, mothers and newborns.
  • 20. 20 REFERNCES Ahluwalia, I., Morrow, B., D’Angelo, D., & Li, R. (2012). Maternity care practices and breastfeeding experiences of women in different racial groups and ethnic groups: pregnancy risk assessment and monitoring system. Maternal Child Health Journal, 16, 1672-1678. http://dx.doi.org/10.1007/s10995-011-0875-0 American Psychological Association. (2014). Obesity in African American women and girls: final report and action agenda. Washington, DC. Retrieved from http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=56&sid=2daa08d5-f0f8- 4fe3-b0ae-3224f2e71a45%40sessionmgr4002&hid=4106 Azzi-Lessing, L. (2013). Serving highly vulnerable families in home-visitation programs. Infant Mental Health Journal, 34(5), 376-390. http://dx.doi.org/10.1002/imhj.21399 Baker, M. & Milligan, K. (2010). Evidence from maternity leave expansions of the impact of maternal care on early child development. The Journal of Human Resources, 45(1), 1-32. Bansil, P., Kuklina, E., Meikle, S., Posner, S., Kourtis, A., Ellington, S., & Jamieson, D. (2010). Maternal and fetal outcomes among women with depression. Journal of Women’s Health, 19(2), 329-334. http://dx.doi.org/10.1089/jwh.2009.1387 Biello, K., Kershaw, T., Nelson, R., Hogben, M., Ickovics, J., & Niccolai, L. (2012). Racial segregation and rates of gonorrhea in the UnitedS, 2003-2007. American Journal of Public Health, 102 (7), 1370-1375. http://dx.doi.org/10.2105/AJPH.2011.300516 Bonis, M., Torricelli, M., Severi, F., Luisi, S., Leo, V & Petraglia, F. (2012). Neuroendocrine aspects of placenta and pregnancy. Gynecological Endocrinology, 28(1), 22-26. http://dx.doi.org.10.3109/09513590.2012.651933 Braveman, P., Heck, K., Egerter, S., Marchi, K., Dominguez, T., Cubbin, C., Fingar, K., Pearson, J., Curtis, M. (2015). The role of socioeconomic factors in black-white disparities in preterm birth. American Journal of Public Health, 105(4), 694-702. Bradley, E., Elkins, B., Herrin, J., & Elbel, B. (2011). Health and social services expenditures: associations with health outcomes. BMJ Quality & Safety, 20, 826-831. http://dx.doi.org/10.1136/bmjqs.2010.048363 Brodribb, W., Zakarija-Grkovic, I., Hawley, G., Mitchell, B., & Mathews, A. (2013). Postpartum health professional contact for improving maternal and infant outcomes for healthy women and their infants (protocol). The Cochrane Library, 12, 1-11. Catling, C., Medley, N., Ryan, C., Leap, N., Teate, A., & Homer, C. (2015). Group versus conventional antenatal care for women (review). The Cochrane Library, 2, 1-56. http://dx.doi.org/10.1002/14651858.CD0077622.pub3 Center for Disease Control and Prevention Grand Rounds: Public Health Approaches to Reducing U.S. Infant Mortality. (2013). MMWR: Morbidity & Mortality Weekly Report, 62(31), 625-628. Retrieved from
  • 21. 21 http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=15&sid=bed050cb-661e- 437f-8dfb-968d309aae42%40sessionmgr113&hid=102 Center for Disease Control and Prevention. (2013). National vital statistics report “deaths: final data for 2013”, 64(2). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm Center for Disease Control and Prevention. (2014). National vital statistics report “international comparisons of infant mortality and related factor: United States and Europe, 2010”, (DHHS Publication No. ADM 2014-1120). Hyattsville, MD: National Center for Health Statistics. Center for Disease Control and Prevention. (2015). National vital statistics report “fetal and perinatal mortality: united states, 2013”, 64(8). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/dataaccess/vitalstatisticsonline.htm Central Intelligence Agency. (2014). Country comparison: infant mortality rate. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html Cole-Lewis, H., Kershaw, T., Earnshaw, V., Yonkers, K., Lin, H., & Ickovics, J. (2014). Pregnancy specific stress, preterm birth, and gestational age among high-risk young women. Health Psychology, 33 (9), 1033-1045. http://dx.doi.org/10.1037/a0034586 Collins, J. Rankin, K., & David, R. (2011). African American women’s lifetime upward economic mobility and preterm birth: the effect of fetal programming. American Journal of Public Health, 101(4), 714-719. Dagher, R., McGovern, P.,& Dowd, B. (2014). Maternity leave duration and postpartum mental and physical health: implications for leave policies. Journal of Health Politics, Policy and Law, 39(2), 370-416. http://dx/doi.org/10.1215/03616878-2416247 Fontenot, H., & George, E. (2014). Sexually transmitted infections in pregnancy. Nursing for Women’s Health, 18(1), 67-72. http://dx/doi.org/ 10.1111/1751-486X.12095 Gavin, A., Nurius, P., & Logan-Greene, P. (2012). Mediators of adverse birth outcomes among socially disadvantaged women. Journal of Women’s Health, 21(6), 634-640. http://dx.doi.org/10.1089/jwh.2011.2766 Guendelman, S., Goodman, J., Kharrazi, M., & Lahiff, M. (2014). Work-family balance after childbirth: the association between employer-offered leave characteristics and maternity leave duration. Maternal and Child Health Journal, 18, 200-208. http://dx/doi.org/10.1007/s10995-013-1255-4 Giurgescu, C., McFarlin, B., Lomax, J., Craddock, C., & Albrecht, A. (2011). Racial discrimination and the black-white gap in adverse birth outcomes: a review. Journal of Midwifery and Women’s Health, 56, 362-370. http://dx/doi.org. 10.1111/j.1542- 2011.2011.00034x
  • 22. 22 Gotham, K. (2000) Urban space, restrictive covenants and the origins of racial residential segregation in a US city, 1900-50. International Journal of Urban and Regional Research, 24(3), 616-633. Hacker, N. F., Gambone, J.C., Hobel, C.J. (2010). Hacker and Moore’s essentials of obstetrics and gynecology (5th ed.). Philadelphia, PA: Saunders Elsevier Inc. Ickovics, J., Reed, E., Magriples, U., Westdahl, C., Rising, S., & Kershaw, T. (2011). Effects of prenatal care on psychosocial risk in pregnancy: results from a randomized controlled trial. Psychology and Health, 26(2), 235-250. http://dx.doi.org/10.1080/08870446.2011.531577 Katz, K., Jarrett, M., El-Mohandes, A., Schneider, S., McNeely-Johnson, D., & Kiely, M. (2011). Effectiveness of a combined home visiting and group intervention for low income african american mothers: the pride in parenting program. Maternal Child Health Journal, 15, 75-84. http://dx.doi.org/10.1007/s10995091109858-x Kim, D,. 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 (1660-4601), 2296-2317. http://dx.doi.org/10.3390/ijerph10062296 Kost, K., & Lindberg, L. (2015) Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measure and propensity score analysis. Springer Science and Business Media B.V., 52, 83-111. http://dx/doi.org/10.1007/s13524- 0140359-9 Kothari, C., Zielinski, R., James, A., Charoth, R., & Sweezy, L. (2014). Improved birth weight for black infants: outcomes of a healthy start program. American Journal of Public Health, 104(1), 96-104. http://dx.doi.org/10.2105.AJPH.2013.301359 Kramer, M., Hogue, C., Dunlop, A., & Menon, R. (2011). Preconceptional stress and racial disparities in preterm birth: an overview. ACTA Obstetricia et Gynecologica Scandinavica, 90(1307-1316). http://dx/doi.org.10.1111/j.1600-0412.2011.01136.x Lee, H. (2013, June 4). Why Finnish babies sleep in cardboard boxes. BBC. Retrieved from http://www.bbc.com/news/magazine-22751415 Lefkovics, E., Baji, I., Rigo, J. (2014). Impact of maternal depression on pregnancies and on early attachment. Infant Mental Health Journal, 35(4), 354-365. http://dx.doi.org/10.1002/imhj.21450 Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2015). Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier MacDorman, M., Hoyert, D., & Mathews, T. (2013) Recent declines in infant mortality in the United States, 2005-2011. Center for Disease Control and Prevention NCHS Data Brief No. 120. Hyattsville, MD: National Center for Health Statistics.
  • 23. 23 MacDorman, M., & Mathews, T. (2011) Understanding racial and ethnic disparities in U.S. infant mortality rates. Center for Disease Control and Prevention NCHS Data Brief No. 74. Hyattsville, MD: National Center for Health Statistics. Marshall, N., Guild, C., Cheng, Y., Caughey, A., & Halloran, D. (2014). Racial disparities in pregnancy outcomes in obese women. The Journal of Maternal-Fetal & Neonatal Medicine, 27(2), 122-126. http://dx.doi.org/10.3109/14767058.2013.806478 Martini, F., & Nath, J. (2009). Fundamentals of anatomy and physiology. (8th ed.). San Francisco, CA: Pearson Education Inc. McFarland, M., & Smith, C. (2011). Segregation, race, and infant well-being. Population Research and Policy Review, 30, 467-493. http://dx/doi.org.10.1007/s11113-010-9197-7 Nabukera, S., Wingate, M., Owen, J., Salihu, H., Swaninithan, S., Alexander G., & Kirby, R. (2009). Racial disparities in perinatal outcomes and pregnancy spacing among women delaying initiation of childbearing. Maternal Child Health Journal, 13, 81-89. http://dx.doi.org/10.1007/s10995-008-0330-8 Porter, G. (2010). Work ethic and ethical work: distortions in the American dream. Journal of Business and Ethics, 96, 535-550. http://dx.doi.org.10.1007/s10551-010-0481-6 Rotundo, G. (2011). Centering pregnancy: the benefits of group prenatal care. Nursing for Women’s Health, 15(6), 510-516. http://dx/doi.org. 10.1111/j.1751-486X.2011.01678.x Shaw, R., & Pickett, K. (2013). The health benefits of Hispanic communities for non-Hispanic mothers and infants: another Hispanic paradox. American Journal of Public Health, e1- e6. http://dx.doi.org.10.2105/ALPH.2012.300985 Shepherd-Banigan, Megan & Bell, Janice. (2013). Paid leave benefits among a national sample of working mothers with infants in the United States. Maternal and Child Health Journal, 18, 286-295. http://dx/doi.org.10.1007/s10995-013-1264-3 Smith, S., & Vale, A. (2006). The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues in Clinical Neuroscience, 8(4), 383-393. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181830/ Tanner-Smith, E., Steinka-Fry, K., & Lipsey, M. (2014). The effects of CenteringPregnancy group prenatal care on gestational age, birth weight, and fetal demise. Maternal & Child Health Journal, 18, 801-809. http://dx.doi.org/10.1007/s10995-013-1304-z Thielen, K. (2012). Exploring the group prenatal care model: a critical review of the literature. Journal of Perinatal Education, 21(4), 209-218. http://dx.doi.org/10.1891/1058- 1243.21.4.209 Thomas, Adam (2012). Three Strategies to prevent unintended pregnancies. Journal of Policy Analysis and Management, 31(2), 280-311. http://dx.doi.org/10.1002/pam.21614
  • 24. 24 United States Census Bureau. (2013). Poverty status in the past 12 months. Retrieved From: http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_1 3_1YR_S1701&prodType=table Vahratian, A., & Johnson, T. (2009) Maternity leave benefits in the United States: today’s economic climate underlines deficiencies. Birth: Issues in Perinatal Care, 36(3), 177- 179. Ward, T., Mazul, M., Ngui, E., Bridgewater, F., & Harley, A. (2013). Maternal and Child Health Journal, 17, 1753-1759. http://dx.doi.org.10.1007/s10995-012-1194-5 Wendt, A., Gibbs, C., Peters, S., & Hogue, C. (2012). Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatric & Perinatal Epidemiology, 23, 239- 258. http://dx.doi.org. 10.1111/j.1365-3016.2012.01285.x Zhang, S., Cardarelli, K., Shim, R., Ye, J., Booker, K., & Rust, G. (2013) Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients. Maternal and Child Health Journal, 17, 1518-1525. http://dx.doi.org.10.1007/s10995-012-1162-0