Tiny casualties: Closing the black-white infant mortality gap
Macomb County possesses a wealth of assets but its black infant mortality rate has been relative to that of a poor community in Romania.
"The persistent racial disparity in which women of color experience two times the risk of an infant death compared to white mothers is unacceptable," said Macomb County Health Department Director Bill Ridella.
Part of Ridella's responsibility as community health director is to track data related to infant mortality rates (IMR), as it is a key indicator of population health.
Historically, Michigan has seen a drop in overall rates.
"In 1970, the infant death rate was 20.3 deaths per 1,000 live births; and this rate declined to 10.7 in 1990 and then again to 7.1 deaths per 1,000 live births in 2010," according to a recent study by the Michigan Department of Health and Human Services (MDHHS). "Since 1970, these declines were primarily due to advances in neonatal medicine, artificial lung surfactants, folic acid supplementation, and numerous public health interventions."
Ridella said health care improvements have done a lot and if the decline remains constant, the overall infant mortality rate could drop to 6.3 by 2020 and as low as 5.0 by 2030.
In contrast to this has been the persistent and widening gap of infant mortality rates between women of color and whites.
Roughly 12 of every 1,000 black infants born in Macomb County won't live to see their first birthday, more than twice the 5.2% mortality rate for white babies.
In 2013, the white IMR in the U.S. was five per 1,000 live births resembling economically advanced nations such as New Zealand but the black IMR for the U.S. was 11.2 (11.1 in Macomb County), which is a rate closer to that of lower income nations such as Romania, Grenada and Thailand.
It's a disturbing statistic but nothing that Ridella has not seen before.
"The disparity has been there for a long time but unfortunately we're seeing a widening of the gap," Ridella said, adding some of the number has to do with changes in the county's population.
Still, that does not answer why there's such a gap between the races.
"That's a question that the medical community and researchers are still trying to figure out," Ridella said.
Preterm births and low birth weights are two of the leading causes of infant mortality across all races, according to the Centers for Disease Control and Prevention in Atlanta. A healthy pregnancy is often the best defense against those complications.
But what makes a population more susceptible to preterm births isn't an easy answer, said Dr. Anissa Mattison, residency program director for obstetrics and gynecology at St. Joseph Mercy Oakland Hospital in Pontiac.
There are several risk-factors that affect all pregnant women's chances for a preterm birth. They include:
• Age, teen pregnancies and those 35-years or older
• Weight, obesity or lack of nutrition during pregnancy
• Substance use such as drugs or tobacco
• Access to health care.
Preeclampsia is also a condition that can lead to early deliveries and black women are at higher risk for this condition, said Dr. Linda Karadsheh, an obstetrics and gynecology physician at McLaren Macomb hospital in Mount Clemens.
"It's important to identify any patient who could be at risk for preterm delivery or any other pregnancy complication. Recent research on preeclampsia and other causes of early deliveries has allowed us to provide patients with some preventative tools," said Karadsheh. "Simple interventions such as a baby aspirin from early pregnancy has shown to slow down onset of preeclampsia and has been very effective in our practice. Early cervical ultrasounds on patients who are at risk for incompetent cervix and placement of cerclage when indicated has also been helpful. Ultimately, patients that are coming and receiving care are much more likely to have better outcomes and we see this on a regular basis."
Unfortunately, while 89% of white women receive prenatal care from the first trimester, only 75% of African American women do the same, according to the March of Dimes.
Access to proper prenatal care is not just a matter of health insurance. Research on infant mortality rates show there are a myriad of factors that not only impact birth outcomes among African American mothers but also maternal health, such as a lack of socio-economic equality, unreliable transportation, safe housing, racism and chronic stress.
Perceived discrimination, especially over the course of a lifetime, has been linked to causing chronic stress, according to a 2018 report from Duke University's Samuel DuBois Cook Center on Social Equity and the Inside Center for Community Economic Development. Chronic stress can lead to a host of health complications, including high blood pressure and levels of inflammation.
"Black women who acquire protective factors like higher socioeconomic status and educational attainment do reduce their individual likelihood of preterm birth and infant mortality, but, regardless of the personal efforts made by individual black women, the difference in outcomes between black and white women persists," said the authors of the Duke study. "Eradicating this disparity requires structural change that improves outcomes at the population level."
Eradicating the gap
Macomb County has between 9,200 and 9,300 births a year and the goal of the county health department is to ensure positive outcomes for all of them.
"We have 40 to 50 public health nurses who work in a variety of areas but eight are dedicated to maternal health. They do home visits for pregnant women," said Ridella.
The county's Nurse-Family Partnership is an evidence-based program that has seen great results among first-time mothers nationally and locally. The program features nurses who meet with women and not only support them through their prenatal, pregnancy and delivery, be it for guidance, information, referrals or just a shoulder to lean on, but until the baby is 2 years old.
"The nurse and the mother pair as early as possible in order to build a relationship," said Cheryl Woods, director of the Macomb County health department's family health services division. "The nurses in the program have a lot of education and are specialists."
That means they know about the research and how socioeconomics and chronic stress can impact maternal health and birth outcomes. They work to help reduce those risk-factors.
"That could be helping the mother find access to prenatal care, ways to continue her education or helping her find a good job," Woods said.
Since the nurse and mother meet early in the women's pregnancy and maintain a relationship after the baby is born there is a better chance of building a trusting relationship that leads to better outcomes overall.
Among the cities in the county to benefit from the program is Warren, which has an IMR of 9.4%, an increase of 4.9% since 2014-16.
"It's a very wonderful program," Woods said. "We knew we were getting these disparities so we knew it was important to try and reach out to populations impacted by it."
One rate that has shown great improvement in the county, and one that impacts the number of preterm births and low birth rates is teen pregnancies.
Macomb County has seen a 26% decline in the number of teens becoming young moms.
Ridella believes this is partially due to evidence-based programs such as Title X Family Planning. The federal grant program is dedicated to providing individuals with comprehensive family planning and related preventative health services in order to promote positive birth outcomes and healthy families.
He also believes credit should be given to the county's adolescents (15-19) who are really making an effort to prevent unintended pregnancies.
Michigan is also currently in the process of transitioning from its 2016-19 Infant Mortality Reduction Plan to the new Mother Infant Health & Equity Improvement Plan.
Physicians such as Karadsheh, who make prenatal care accessible to more women, will also have an impact.
"Our office takes all insurances, including most forms of government insurance," said Karadsheh. "There are a lot of areas in the U.S. that have restricted access to quality medical care for the underserved. Without appropriate care from the beginning of pregnancy, patients are already at risk for preterm deliveries and other medical conditions that affect the timing of delivery."
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