Infant Mortality Inequities Based on Race/Ethnicity, and Income

Infant Mortality Inequities Based on Race/Ethnicity, and Income

West Virginia

In West Virginia, black and white women live within and under the same social and physical environment, rule of law, institutions, systems, policies and practices. Yet these two groups of women suffer the loss of their infants at different and disproportionate rates with a black infant having almost twice the chance of dying than a white infant. The question is what circumstances in their lives constitute shared and different traumatic events that might account for changes in the reproductive systems of these women and explain differences in birth outcomes for white and black infants?

One of the biggest myths about these racial ethnic disparities in infant mortality is that people believe the disparities are the consequences of racial differences in socioeconomic status. However, consider, infant mortality among white American women with a college degree or higher is about four deaths per thousand births.  Alternatively, among African American women with the same level of education, infant mortality is about ten per thousand births. This is almost three times higher. In fact, African American mothers with a college degree have worse birth outcomes than white mothers without a high school education.

A life course approach combined with the concept of embodiment, and adverse circumstances  posits that external physical and social aspects of the environment in which we live accumulate across the life, get under the skin, and are expressed in human biology (Bailey et al.; Krieger, 1994, 2001, 2005, 2008, 2015; Lu et al., 2010; Petteway, Mujahid, & Allen, 2019).

Adverse circumstances are defined as discrimination, humiliation, abuse, loss of opportunities, and actual and perceived loss in social standing and self-worth due to race/ethnicity and/or economic deprivation. A growing body of perinatal research has focused on maternal psychosocial and sociodemographic stress (i.e., adverse circumstances) and their biological pathways as possible explanations for adverse birth outcomes(McEwen, 1998; Sapolsky, 2005; Wallace et al., 2013). Public health emphasis is being placed on the accumulated, multisystem physiologic dysfunction resulting from chronic or severe stress that could ultimately lead to disease and detrimental changes in the reproductive systems of women, e.g., traumatic life events, spousal abuse, discrimination, neighborhood level crime and violence, unemployment, child maltreatment. The question is what circumstances in the lives of black and white women in West Virginia  who live under similar conditions based on social status constitute shared and different traumatic events that might account for changes in the reproductive systems of these women and explain differences in birth outcomes?

To explore this question Dr. Andress has established The Infant Mortality Qualitative Research Study. Read the full story at WVU Today.

Illustration by Aira Burkhart.

WVU Public Health researcher studying racial disparities in infant mortality in West Virginia

MORGANTOWN, W.Va. — Black infants die at almost twice the rate of white infants in West Virginia, a statistic nursed by racism and other adverse circumstances not only in the state, but across the nation. West Virginia University School of Public Health professor Lauri Andress is studying how chronic stress from living with racism and discrimination can lead to poorer health outcomes for Black mothers and their babies.

In West Virginia, white women experience higher infant mortality rates than the national average, which is only compounded for Black women. From 2015 to 2017, the March of Dimes reported there were 13.1 Black infant deaths for every 6.9 white infant deaths in West Virginia.

“The gap has been consistent across time and space,” Lauri Andress said. “What has changed is our thinking about why that gap exists.”

Nearly two decades after she initially became interested in infant mortality, Andress, as as executive director of the Louisville Center for Health Equity, observed generally that access to prenatal care for Black women was better, but there were no significant improvements in infant death rates. She also found research indicating that even Black women with higher levels of education and mid-level incomes or higher were not experiencing better outcomes in infant and maternal health.

“This research is astounding because normally, in the case of almost every illness, income and education are protective factors acting to mitigate or decrease the likelihood that the group will experience that disease state,” Andress said. “Imagine what it’s like to live feeling constantly threatened, insignificant, excluded, stressed or made to feel you’re on the bottom. Chronic stress can come from racism and discrimination, which can lead to the increase of certain hormones, such as cortisol, which creates the flight or fight response.”

She said normally, these circumstances and the body’s response starts and ends, giving the body a rest.

“However, living under the adverse circumstances imposed by experiences of racism 24/7 with no respite within the body’s regulatory system can cause physiological changes in the body.”

While the quantitative data already highlights the disparities, Andress is taking a qualitative approach to her research. She’ll be listening to the stories of Black and white women in West Virginia to learn more about their experiences and the circumstances in which they live.

“It’s presumably a side-by-side comparison,” Andress said. “Black and white women both experience poverty in West Virginia, but what are the differences for Black and white women living in poverty? Is the experience of racism for Black women different enough to create a Black and white gap in the infant death rate?”

Many underlying structural factors throughout the years have led to a variety of poorer health outcomes for people of color. For much of the 1900s, for example, segregation promoted the intentional development of white communities, which led to inferior access to resources and opportunities, such as medical care, for Black communities. Also, racial myths and implicit biases from healthcare providers persist and have been shown to lead to improper or inadequate care.

Andress also points to Adverse Childhood Experiences, or ACEs, which can include physical or emotional abuse, having a parent who is incarcerated or witnessing substance use. Andress argues that experiencing racism, too, should be considered among ACEs.

She plans to collect and catalogue the stories this year, then analyze her findings for publication in summer 2021.

Citations

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. Structural racism and health inequities in the USA: evidence and interventions. The Lancet, 389(10077), 1453-1463. doi:10.1016/S0140-6736(17)30569-X

Krieger, N. (1994). Epidemiology and the web of causation: has anyone seen the spider? Social Science & Medicine, 39(7), 887-903.

Krieger, N. (2001). Theories for social epidemiology in the 21st century: an ecosocial perspective. International Journal of Epidemiology, 30(4), 668-677.

Krieger, N. (2005). Embodiment: a conceptual glossary for epidemiology. Journal of Epidemiology & Community Health, 59(5), 350-355.

Krieger, N. (2008). Proximal, Distal, and the Politics of Causation: What’s Level Got to Do With It? American Journal of Public Health, 98(2), 221-230. doi:10.2105/AJPH.2007.111278

Krieger, N. (2015). Public health, embodied history, and social justice: Looking forward. International journal of health services, 45(4), 587-600.

Leimert, K. B., & Olson, D. M. (2020). Racial disparities in pregnancy outcomes: genetics, epigenetics, and allostatic load. Current Opinion in Physiology, 13, 155-165.

Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the black-white gap in birth outcomes: A life-course approach. Ethnicity & disease, 20(1 0 2), S2.

McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840(1), 33-44.

Petteway, R., Mujahid, M., & Allen, A. (2019). Understanding Embodiment in Place-Health Research: Approaches, Limitations, and Opportunities. Journal of Urban Health, 1-11.

Sapolsky, R. M. (2005). The influence of social hierarchy on primate health. Science, 308(5722), 648-652.

Wallace, M., Harville, E., Theall, K., Webber, L., Chen, W., & Berenson, G. (2013). Neighborhood poverty, allostatic load, and birth outcomes in African American and white women: Findings from the Bogalusa Heart Study. Health & Place, 24, 260-266. doi:http://dx.doi.org/10.1016/j.healthplace.2013.10.002