FINALInfant Mortality Rate Disparities in America2 (1)

Infant Mortality Rate Disparities in
America:
A Closer Look at infant loss in the African American
Population
Presented by: 1LT Rickenbach, Alecia

Objectives
• Define infant mortality, neonatal mortality, and post
neonatal mortality
• Compare international infant mortality rates (IMR)
and explore racial disparities in IMR in the US
• Analyze factors that predispose the African
American population to increased infant mortality
• Discuss nursing interventions that promote wanted
pregnancies, term gestation, infant survival and
wellness

Definition of Terms
• Infant Mortality Rate
• Fetal Mortality Rate
• Neonatal Mortality
Rate
• Post-Neonatal
Mortality Rate
• Pre-Term Birth
• Very Pre-Term Birth
• Low Birth Weight
• Very Low Birth
Weight
Kim & Saada, 2013

Finland
KuwaitCuba
Japan
Russia
International Infant
Morality Rates

Preterm Birth Rates among OECD
Nations
CDC, 2014

Causes of Infant Loss in the U.S.
CDC, 2013
CDC, 2015

Causes of Infant Deaths
Neonatal Post-Neonatal
• Congenital defects
• Complications of preterm
birth
• Maternal Health Conditions
• Complications of Labor
and Delivery
• Lack of Care Access
• Injury
• Infection
• Complications of surviving
preterm infants
• Sudden unexpected infant
death (SUID)
▫ ASSB
▫ SIDS
▫ Ill-defined deaths
CDC, 2013
CDC, 2015

What country’s infant mortality
rate is closest to the infant
mortality rate in the African
American population?

The Republic of Palau: 11.46/1000
Non-Hispanic Blacks in the US: 11.22/1000
CIA, 2014

IMR Disparities Among U.S. Racial Groups
African Americans Non-Hispanic Whites
IMR 11.22/1000 live births IMR 5.07/1000 live births
Preterm Birth Rate 16.6% Preterm Birth Rate 10.2%
CDC, 2013
Cole-Lewis, et al., 2014

Infant Mortality Rates by State
MacDorman, Hoyert & Mathews, 2013

Are Genetics to Blame?
• African women
immigrants = IMR of
American Caucasians
• Second generation
black women = IMR of
American-born black
women
Kramer, Hogue, Dunlop, & Menon, 2011)

What is Happening to non-
Hispanic black Women in
America?

Socioeconomic Status
• Low SES = IMR
• 1/3 of African
Americans live below
the national poverty
line
Bravemen, et. al, 2015
Collins, Rankin, Rankin, & David, 2011
Kim & Saada, 2013

IMRs in African Americans with
increased SES
• Retrospective study of 10,400
black and white women
▫ Increased SES = Improved
preterm birth (PTB) rate for
white women
▫ Increased SES = no change
for PTB rate for black
women
• Retrospective study of 11,265
black women and their infants
▫ Increased SES = no change in
PTB rate if mother had been
a low birth weight infant
Bravemen, et al., 2015
Christopher & Simpson, 2014
Collins, et al., 2011
David & Collins, 2014
Kramer, et al., 2011
Porter, 2010

PTB Rate in African Americans with
increased SES (Theories)
• Experience race specific
workplace stressors
▫ Minority in workplace
▫ Pressure to overcome
racial biases
• More likely to be
supporting family in low
SES categories
▫ Emotional & Financial
Stress
Bravemen, et al., 2015
Christopher & Simpson, 2014
Collins, et al., 2011
David & Collins, 2014
Porter, 2010

Residential Segregation
Kim & Saada, 2013

History of Residential Segregation in
America
• Racially restrictive
covenants 
concentrated urban
poverty
▫ Utilized until 1960’s
Gotham, 2000
McFarland & Smith, 2011

Residential Segregation Remains an
Issue Today
• White-majority housing
▫ More valuable in real
estate markets
• Realtor audits
▫ Racial discrimination
▫ Non-minority
applicants favored
Gotham, 2000

Impact of Residential Segregation on
Infant Outcomes
• Segregated white populations
▫ No impact on infant
outcomes
• Segregated black populations
▫ Increased IMR and LBW
• Segregated Hispanic
populations
▫ Protective for infant
outcomes
▫ “Hispanic Paradox”
Shaw & Pickett, 2013

The Hispanic Paradox
• Residential segregation
protective against infant
death, despite low SES
▫ Strong Kin Networks
▫ Value Mothers &
Families
▫ Traditions of healthy
behaviors
• Hispanic density improves
infant outcomes for all races
in that area
▫ #powerofsocialcohesion
Kim & Saada, 2013
Shaw & Pickett, 2013

Pregnancy Intention
• 1/3 of pregnancies in the U.S. are unintended:
▫ Slightly mistimed: pregnancy was wanted within two
years
▫ Grossly mistimed: pregnancy was wanted, but not
within 2 years
▫ Unwanted
Kost & Lindberg, 2015

Pregnancy Intention
• An analysis of surveys results of 4,297 women’s
pregnancy intentions found:
▫ Unwanted & grossly mistimed pregnancies
 Occurred more frequently among African American
women
 Delayed entrance into prenatal care
 decreased breastfeeding rates
▫ Unwanted pregnancies
 increased PTB and LBW risk
 62% were third order or higher birth order infants

Pregnancy Intention
• Study involving 282
low SES, majority black
women who received
inadequate prenatal care
▫ 93% unwanted
pregnancies
▫ 22% admitted had not
used contraceptives
Katz, et al., 2011

Maternity Leave
• World Health Organization
Recommends 16 weeks
• Benefits
▫ Bonding
▫ Infant growth
▫ Maternal recovery
▫ Longer breastfeeding
duration
▫ Higher infant
immunization rate
▫ More well-child visits
Shepherd-Banigan & Bell, 2014
Vahratian & Johnson, 2009

Kim & Saada, 2013
Shepherd-Banigan, Megan & Bell, 2013
Vahratian & Johnson, 2009

Maternity Leave In the United
States
• Family & Medical
Leave Act of 1993
▫ 12 weeks unpaid
maternity leave if:
▫ >50 employees
▫ >1,760 hours worked
in last year
• Low SES Mothers more
likely to take less leave
Guendelman, Goodman, Kharrazi, & Lahiff, 2014
Shepherd-Banigan, et al., 2013
United Census Bureau, 2013

Epigenetics & Allostatic Stress Load
CDC, 2011

Martini & Nath, 2009
Smith & Vale, 2006

Hypothalamic-Pituitary-Adrenal (HPA) Axis
Smith & Vale, 2006

Effects of Glucocorticoids &
Catecholamines
Glucocorticoids Catecholamines
• Increased glucose &
glycogen synthesis
• Increased utilization of
lipids peripherally
• Anti-inflammatory effects
• Decreased immune
response
• Increased glycogen
breakdown
• Increased blood sugar
• Elevated lipid release
• Increased heart rate and
contractility
• Increased blood pressure
Smith & Vale, 2006

HPA Axis and the Placenta
• Normal amount of CRF
▫ Adequate placentation
• Elevated CRF
▫ Release of
catecholamines
▫ Vasoconstriction
 Reduced blood to
uterus/placenta
 Placenta releases even
more catecholamines
▫ Uterine contractions
Bonis, et al., 2012
Smith & Vale, 2006

Preconception Stress Theory #1:
Early Life Programming of Chronic Disease
Smith & Vale, 2006
Stressful experiences in
utero and early
childhood
Hypersensitive HPA
axis
Preterm labor

Early Life Programming of Chronic
Disease—Supporting Evidence
• Prior preterm birth
▫ 3.8X risk for another
preterm birth
• HPA dysfunction in
baby rats with:
▫ Poor mothering
▫ Injected maternal
stress hormones
• Dutch Famine
▫ Lower birth weights Collins, Rankin, & David, 2011

Preconception Stress Theory # 2:
The Weathering Hypothesis
Chronic Exposure to
Stressors
Wearing of body’s stress
response
Permanent Immune &
Vascular Dysfunction
Preterm Labor Kramer, et al., 2011
Smith & Vale, 2006

The Weathering Hypothesis: U-Curve
Prime Child Bearing Age
Black Mothers: 20-25
Prime Child Bearing Age
White Mothers: 25-35

Preconception Stress Theory # 3:
Psychosocial Responses to Stressors
Chronic Stressors
Unhealthy Coping
Mechanisms
Preterm Labor

International GDP Expenses
U.S . Healthcare
expenses exceed
other OECD
Nations, while Social
Service expenditures
are far less
Bradley, Elkins, Herrin & Elbel, 2011

National Efforts to Improve
Infant Outcomes

Pregnancy Risk Assessment Monitoring
System (PRAMS)
• Surveillance program used
to identify geographic
specific pregnancy & infant
care education needs
• Has led to successful
interventions:
▫ “Tobacco Free Pregnancy
Initiative”
▫ “Infant Safe Sleep
Campaign”
CDC, 2013

Home Visitation Programs
• Paraprofessionals or Nurses
visit homes of high risk
families to provide teaching
& improve safety
▫ Infant care
▫ Parenting Skills
▫ Home Environment
▫ Parent-child interaction
▫ Reduce Abuse/Neglect
▫ Connect w/ Community
Resources
Azzi-Lessing, 2013
Katz, et al., 2011
Kothari, et al., 2014

Home Visitation Programs
Pros Cons
• For Highly Engaged
Families:
▫ Improved Home
Environments:
 Increased safety
 Developmentally
appropriate
▫ Better mothering skills
▫ Improved perception of
support
▫ Reduce child abuse &
neglect
• Expensive
• Time Intensive
• Minimal overall benefits
• No improvements in
preterm birth rates or
gestational age
• Failure to engage highest
risk population
Azzi-Lessing, 2013
Katz, et al., 2011
Kothari, et al., 2014

Challenges of Home Visitation
Programs
• Overwhelming life
stressors
• Mistrust of federal/state
programs
• Inadequate skill level of
paraprofessionals
Azzi-Lessing, 2013

What is Centering Pregnancy?
• Group Prenatal Care
▫ 8 to 12 women
• Ten Sessions during
pregnancy
▫ 1 to 1.5 hours each:
 30-40 min. Individual
Assessment w/ provider
 1 hour Group Teaching
Rotundo, 2011

Centering Pregnancy
• Empowers women to be
active care participants
▫ Take their own vitals
▫ Calculate their gestational
age
• Teaching Session
▫ Discussion based
▫ Encourages knowledge
exchange
• Increased Social Capital
▫ Groups remain consistent
throughout their
pregnancies
Rotundo, 2011

Benefits of Centering Pregnancy
• Increased Patient
Satisfaction
• Increased Breastfeeding
Rates
• Improved Birth
Outcomes
• Increased Educational
Time with Providers
Catling, 2015
Ickovics, et al., 2011
Rotundo, 2011
Tanner-Smith, Steinka-Fry, & Lipsey, 2013
Thielen, 2012

Supporting Evidence for Centering
Pregnancy (CP)
• Retrospective study of 651
CP patient statistically
matched with traditional
prenatal care
▫ Did not improve preterm
birth rate
▫ Preterm infants were 2.5
weeks older & 300g
heavier at delivery
▫ Decreased risk of fetal
demise
Catling, 2015
Tanner-Smith, Steinka-Fry, & Lipsey, 2013

Nursing Implications: Prevention of
Unwanted Pregnancies
• Pathways
▫ Indifference
▫ Inaccurate information to
pregnancy prevention
▫ Lack of access to adequate
birth control
• Contraceptive Education
▫ access
• Pregnancy Spacing
▫ 18 to 23 months between
pregnancies recommended Katz, et al., 2011
Nabukera, et al., 2009
Thomas, 2012
Wendt, Gibbs, Peters & Hogue, 2012

Nursing Implications: STI Prevention
• Identify at risk patients
▫ Assess for risky sexual
life style
• Importance of STI testing
for partners
• Education of adverse effects
on pregnancy and infants
▫ Fetal Demise
▫ Preterm Birth
▫ Low Birth Weight
▫ Opthalmia, pneumonia,
mental delays,
Fontenot & George, 2014

Nursing Implications: Nutrition
• 60% of African American
women are obese
• Education on pregnancy &
infant risk factors associated
with obesity
▫ Gestational Diabetes
▫ Preeclampsia
• Nutrition Counseling
▫ Diet composition
▫ Appropriate pregnancy
weight gain
▫ Caloric consumption per
trimester American Psychological Association, 2014
Marshall, Guild, Cheng, Caughey, & Halloran, 2014
Lowdermilk, et al., 2015

Nursing Implications: Substance Abuse
• Education on negative
effects of substance use
• Greater risk for African
Americans who smoke
▫ Preeclampsia
▫ Fetal Demise
• Evaluate for Intention to
Quit
▫ Provider referral to
cessation/rehab programs
▫ Self-help resources
▫ If unwilling to quit, see if
they’ll cut back

Nursing Implications: Social Support
• Assess for adequate
social support
• Ask provider if
Centering Pregnancy is
a good option
Rotundo, 2011
Tanner-Smith, et al., 2014
Thielen, 2012

Nursing Implications: Depression
Screening
• Low SES women with low
social support = risk
• Ensure 100% of patients are
screened
• Screening Tools
▫ Edinburgh Postnatal
Depression Scale
▫ Two question screening tool
• Times to Screen
▫ Every Prenatal Appointment
▫ Prior to discharge from
hospital
▫ 4 weeks post partum Bansil, et al., 2010
Lefkovics, Baji, Rigo, 2014

Nursing Implications: Promotion of
Breastfeeding
• Educate women on the
benefits of
breastfeeding
▫ Decreased SIDS risk
▫ Decreased Infection
risk
▫ Improved bonding
• African American
women have lowest
breastfeeding rates Ahluwalia, Morrow, D’Angelo & Li, 2012
Chen & Roger, 2004

Summary
• Defined relevant terms related to fetal and infant
mortality
• Compared international infant mortality rates and
maternity leave policies to the United States
• Racial infant mortality disparity in the United States was
explored
• Reviewed effectiveness of some interventions to reduce
infant mortality & reduce the racial disparities in America
• The role of nurses in improving outcomes for women and
infants, especially in vulnerable socioeconomic
populations

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