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

Central Intelligence Agency (CIA), 2014

Preterm Birth Rates among OECD Nations

CDC, 2014

Causes of Infant Loss in the U.S.

CDC, 2013CDC, 2015

Causes of Infant DeathsNeonatal 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, 2013CDC, 2015

What country’s infant mortality rate is closest to the infant

mortality rate in the African American population?

The Republic of Palau: 11.46/1000Non-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, 2013Cole-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, 2015Collins, Rankin, Rankin, & David, 2011Kim & 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., 2015Christopher & Simpson, 2014Collins, et al., 2011David & Collins, 2014Kramer, et al., 2011Porter, 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

StressBravemen, et al., 2015Christopher & Simpson, 2014Collins, et al., 2011David & Collins, 2014Kramer, et al., 2011Porter, 2010

Residential Segregation

Kim & Saada, 2013

The Great Migration

History of Residential Segregation in America•Racially restrictive

covenants concentrated urban poverty▫Utilized until 1960’s

Gotham, 2000McFarland & 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, 2000McFarland & Smith, 2011

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”

McFarland & Smith, 2011Shaw & 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, 2013McFarland & Smith, 2011Shaw & 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

Kost & Lindberg, 2015

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, 2014Vahratian & Johnson, 2009

Kim & Saada, 2013Shepherd-Banigan, Megan & Bell, 2013Vahratian & 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 leaveGuendelman, Goodman, Kharrazi, & Lahiff, 2014Shepherd-Banigan, et al., 2013United Census Bureau, 2013

Epigenetics & Allostatic Stress Load

CDC, 2011

Kramer, et al., 2011Martini & Nath, 2009 Smith & Vale, 2006

Hypothalamic-Pituitary-Adrenal (HPA) Axis

Kramer, et al., 2011 Martini & Nath, 2009 Smith & Vale, 2006

Kramer, et al., 2011Martini & Nath, 2009Smith & 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

pressureKramer, et al., 2011Martini & Nath, 2009Smith & 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., 2012Smith & Vale, 2006

Preconception Stress Theory #1:Early Life Programming of Chronic Disease

Kramer, et al., 2011Smith & 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, 2011Kramer, et al., 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., 2011Smith & Vale, 2006

The Weathering Hypothesis: U-Curve

Kramer, et al., 2011

Prime Child Bearing AgeBlack 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

Kramer, et al., 2011

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

ResourcesAzzi-Lessing, 2013Katz, et al., 2011Kothari, et al., 2014

Home Visitation ProgramsPros 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, 2013Katz, et al., 2011Kothari, 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, 2015Ickovics, et al., 2011Rotundo, 2011Tanner-Smith, Steinka-Fry, & Lipsey, 2013Thielen, 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, 2015Tanner-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

Kost & Lindberg, 2015Nabukera, et al., 2009Thomas, 2012Wendt, 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, 2014Marshall, Guild, Cheng, Caughey, & Halloran, 2014Lowdermilk, 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

Lowdermilk, et al., 2015

Nursing Implications: Social Support

•Assess for adequate social support

•Ask provider if Centering Pregnancy is a good option

Rotundo, 2011Tanner-Smith, et al., 2014Thielen, 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, 2014Lowdermilk, et al., 2015

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, 2012Chen & 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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QUESTIONS?