The Black Commentator - RE-PRINT Persistent Peril

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Sophie Womack, 48, was surprised when in 1985 her first child, Brandi, was born three weeks shy of her due date and six ounces below normal birth weight. The Detroit mother had received timely prenatal care and was in good health throughout her pregnancy. Yet her baby was premature. Then, two years later, Sophie's second child, Ashley, also entered the world too small and too early. "In spite of the fact that I ate well and otherwise was healthy, I still had two relatively small children," she recalls.

This pattern seemed particularly odd since Sophie was a neonatalogist, a type of doctor who specializes in the development of newborns. As a physician, she knew a great deal about how to prepare for pregnancy and childbirth. She just didn't fit the profile of a mom of low birth weight children: She wasn't too young. She wasn't poor. She was educated and had medical care. Yet Sophie had one key risk factor that seemed to cancel out all the positives: She was black.

African American women have long had higher rates than whites of low-birth weight and preterm babies, the leading causes of infant mortality or death in the first year of life. This fact does not seem extraordinary considering the long list of other well-documented health disparities, including life expectancy and various disease incidence rates. But a recent study published in the Journal of the American Medical Association reported that one particular disparity - the gap in black-white baby deaths - has not just persisted but actually grown in recent years despite federal efforts to eliminate the difference. As the journal authors noted, that long-standing inequality is not readily explained by a mother's age, education or income.

While many ob/gyns and health experts point to causes like the timing of prenatal care or unequal health insurance access, others are asking broader questions about race, racism, and health. These more complex questions may begin to explain why in a country with one of the most advanced health care systems in the world black babies remain the most vulnerable, and such racial health disparities simply refuse to go away.

Medical mystery

An infant's survival and long-term health is influenced by many factors, including the mother's age, health status and behavior during pregnancy. The two most significant determinants of a young baby's health and development, however, are birth weight and gestational age at birth. Infants born at or before 37 weeks, or under 2,500 grams (5 lbs., 8 oz.), are at greater risk of medical problems, disability, and death before their first birthday. Compared with women from various ethnic groups in the United States (Hawaiian, American Indian, Puerto Rican, Filipino, Mexican, Cuban, Japanese, Chinese and non-Hispanic white), black mothers have the highest percentage of low birth weight and preterm births. In 2000, more than one in ten black infants was born too small and nearly one in five was born before the ideal time.

This disparity has long been the case. Historically, while African-American moms have been stereotyped as "fertile Myrtles," they've had consistently poorer birth outcomes, including more low birth weight babies, very low birth weight (at or less than 3 lbs. 5 oz.) babies and infant mortality. In 2000, the rate of infant death for blacks stood at 13.6 per 1,000 live births - double the rate for the general population, and almost triple the rate for whites. (Even the group with the next highest infant mortality rate - Hawaiians with a 9 per 1,000 baby death rate - fare far better than blacks.) [Infant mortality rate rankings by nation]

However, the usual explanations for the disparity-income, education, late prenatal care-don't come close to identifying why even professional, middle-class black mothers like Sophie continue to experience the two to threefold higher risk of having a small baby than white moms. Research has debunked the notion that socioeconomic status and related factors are the source of the problem. Consider these facts:

College- and graduate-school educated black mothers have a higher infant mortality rate than white moms who didn't finish high school

Black women who get prenatal care in the first trimester have double the infant mortality rate of white mothers with first-trimester care

Black women with similar levels of prenatal care as Hispanic women (generally less educated and with lower incomes than blacks) have higher rates of low birth weight, preterm deliveries, and infant mortality.

According to Dr. Michael Lu, assistant professor of obstetrics and gynecology and public health at UCLA, researchers have found that even when they control for such varied factors as poverty, housing, employment, medical risk, abuse, social support and so on, 90 percent of the differences in birth weight between black and white moms remains unaccounted for. "Most studies have looked at black-white differences during pregnancy, for example, differences in prenatal care utilization or maternal behavior," he says. "What we're finding is that these differences really explain very little of the disparities in birth outcomes."

Even genetics fail to provide answers. To test the hypothesis, Dr. James W. Collins, Jr., associate professor of pediatrics at Northwestern University Medical School, compared birth outcomes of African American and Africa-born mothers in Illinois over a 15-year period. He assumed if there was something about African genes that caused poor birth outcomes, the statistics for African-born women might actually be worse. But Collins and his colleagues found that the babies of African-born women had birth weights similar to those of white American women and higher than those of black American women.

A different paradigm

To probe the underlying cause of excess black infant mortality some experts are beginning to look beyond individual women's risk factors at the time of pregnancy to a more complete, long-term perspective on women's health. "Healthy women beget healthy children," says Lu. "So when you start to talk about the health of the mother, you have to really look at her life course experiences, and some of that actually depends on the health of her mother."

It's known, for example, that a child is more likely to be born low birth weight if her mother was also born that way. If the cause is not a shared gene, perhaps it's a shared experience. For instance, the immune system begins to develop in utero and matures over time. During certain critical periods of development, Dr. Lu points out, the immune system can be adversely affected by certain experiences and exposures, such as repeated infections or undue stress. These exposures may pattern the immune system in a particular way that sets the stage for increased risk to poor health and poor birth outcomes. A mother with less than optimal immune response may give birth to a baby with less than optimal immune response and so on.

Chronic emotional stress results from many factors, including physically demanding jobs and a lack of control in the workplace, single parenthood, and financial worries - all problems experienced disproportionately by women of color. Discrimination is also a documented source of harmful stress. One study found that women who gave birth to very low birth weight babies were more likely to have experienced racial discrimination than women who had normal weight babies.

Sophie Womack acknowledges that the related issues of discrimination and stress may explain, in part, why even she and many of her fellow black physician friends all gave birth to small babies despite their education and higher incomes. "As a black woman going into the field of medicine and stepping out into the world, we're constantly trying to accomplish and do well because we're afraid if we don't do well that we may be discriminated against," she says. "I'm sure that plays some role in the amount of stress that we have during the time that we're in training and trying to develop our careers. It's just not very easy. And those things do factor into what happens in our pregnancies."

While women of color and their health advocates can't undo centuries of discrimination or the stress it causes, they can begin to recognize the complexity of the problem. "For about 20 years, our model of prenatal care says if only we can give women universal access to early and adequate prenatal care, if we get them to the doctor's office, if we can enhance quality of prenatal care that they get, somehow we improve the birth outcomes," says Dr. Lu. "But to expect that one visit once a month to once a week, in less than nine months, to reverse all the cumulative disadvantages and inequities over their life course is probably expecting too much of prenatal care."

Closing the gap

To counter low birth weight, prematurity, and infant mortality among blacks and other women of color, the health care system must go beyond narrow messages about prenatal vitamins and visits. Doctors can talk to women about preconceptual health and the importance of identifying and treating medical conditions, such as hypertension and diabetes, prior to pregnancy. The medical community also needs to confront the now-proven pattern of bias in medical care. While the Institute of Medicine uncovered discrimination in such areas as cardiac care, less well-publicized studies have found discrepancies in prenatal care and high-risk obstetrics. White mothers in preterm labor and white newborns with life-threatening conditions such as respiratory distress syndrome by and large receive better care.

Public health providers can take a cue from successful programs, such as the Black Infant Health Program (BIH). Based in San Diego, BIH helps women with whole-life issues such as applying for health insurance, accessing transportation to their doctor's office, and finding drug treatment programs. From the time a woman enters the program and through the first year after birth, she can expect home visits from nurses and services such as support groups. By assisting women with a range of issues, including housing, child custody, marital and work problems, the program has seen a small but demonstrable increase in the birth weight and viability of black newborns in San Diego.

Another key area is culture. Research by Dr. Collins and others has shown that while some foreign-born women (specifically African and Mexican women) have babies with better birth weights, the birth outcomes of their daughters show a decline. The same is true of Native American women who leave reservations. While women of color in the U.S. may gain from certain aspects of living in mainstream American society, they may also miss out on some of the protective effects of culture and close familial and community ties that serve as a buffer to stress and racial discrimination.

RaceWire Home Page: http://www.arc.org/C_Lines/racewire/index.html

Colorlines Home Page: http://www.arc.org/C_Lines/ArcColorLines.html

Infant mortality rate rankings by nation: http://www.geographyiq.com/ranking/ranking_Infant_Mortality_Rate_aall.htm

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