Infant Mortality: Putting solutions in your hands
By Asia Ingram, PhD Student
High pregnancy rates often indicate the makings of a healthy society. A growing population suggests both safety and resources are abundant. With the overturning of Roe v. Wade, politicians have made it clear that population growth is a central goal. But in a country where racial demographics can determine your access to quality healthcare and even your value to American society, Black mothers and their infants are receiving the short end of the stick. However, parents still have decisions to make regarding breastfeeding, vaccination status, and maternal care which largely impact the health and wellbeing of the infant and with community support and postpartum Doula care, the best option for infant care becomes accessible to more Black and Brown parents.
From 1915 to 1950 the creation of antiseptic processes, the effective use of vaccines and the implementation of Medicaid caused a major shift in mortality for everyone in high-income countries [1]. Infant mortality dropped from an estimated 100 deaths per 1000 births in 1915 to 10 deaths per 1000 births in 1950 during that 35-year span [1]. Since 1933, the National Vital Statistics System (NVSS) has recorded infant mortality data and since the 1950s the overall infant mortality rate continues to drop however disparities between white and Black infant outcomes have continued to rise [1,2]. In the 1960s, trends showed that Black neonates (0-28 days) were 1.62 times more likely to die [2]. The Black post-neonatal mortality rate was nearly 2.89 times that of the white outcomes [2]. By 1988, Black infants were 2.08 times more likely to die overall compared to white infants and Congenital anomalies, Sudden Infant Death Syndrome, Respiratory Distress, and Short Gestation/ Low Birth weight accounted for these deaths [3]. Today Black infants are 1.9x more likely to experience death and for many of the same reasons found in 1988 (birth defects, preterm birth, low birthweight, complications with maternal pregnancy, sudden infant death syndrome, and injuries.[3]).
Even with recent technology to ensure fertility and embryo formation such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), outcomes for Black patients remain lower. Black women show significantly lower clinical pregnancy rates, lower live-birth rates and higher spontaneous-abortion rates when seeking fertility treatments [4,5]. Specifically, mortality for Black infants is about 4x as high as white infants for women seeking fertility treatments whereas, Black infants conceived naturally have a mortality rate that is double that of white infants [5]. While Black women seeking IVF may have complex issues affecting fertility, negative stereotypes of increased fertility and delayed egg retrieval may play a role in negative outcomes since more Black women receiving these procedures are older than 35 years of age on average [4]. Additionally, Black women are also more likely to be hypertensive and more likely to have diabetes when seeking these treatments, suggesting maternal complications contribute to poor outcomes [4]. However, it is important to recognize that Black women are the least likely to seek IVF treatments, the most likely to discontinue treatment, and Black women experience more psychological stress during these treatments [4,5]. Regardless, the infant mortality disparity remains no matter the method of conception.
Empowering Parents: Breastfeeding, Vaccinations and Maternal Nutrition
In recent years, we have seen an uptick in campaigns to change attitudes for public breastfeeding and initiatives to promote healthy child-rearing behaviors. The Baby Friendly Hospital Initiative (BFHI) launched by the World Health Organization in 1991, is a global initiative promoting healthy breast-feeding clinical practices such as uninterrupted skin to skin contact and exclusive breastfeeding for 6 months, etc. [6]. Breastfeeding is associated with lowered outcomes for inner ear infections, infant intestinal infections and overall decreased incidences of sudden infant death syndrome (SIDS), asthma, and type I diabetes [6,7]. Black women have the highest infant mortality at 10.8 deaths per 1000 live births and show the lowest breastfeeding initiatives [6]. Asian women in America have the lowest infant mortality at 3.6 deaths per 1000 births and the highest overall breastfeeding initiatives [6]. This same study showed a 17% reduction in infant mortality for Black infants associated with breastfeeding initiation compared to a 49% reduction in infant mortality for Asian infants but does not consider the length of breastfeeding nor the exclusivity of breastfeeding as confounding factors [6]. In addition, breastfeeding was also associated with higher income, higher education, private healthcare and marriage, which also suggests a highly supportive environment for child-rearing [6,7]. A large barrier to breastfeeding includes limited support or limited resources for pumping and proper storage of the milk while away from the child due to labor requirements. Breastfeeding (chestfeeding) remains a controversial topic because of the stigmas placed upon those who use formula or public breastfeeding however, infant nutrition is vital and utilizing the best resource for your lifestyle is the best option.
Like breastfeeding, vaccinations are also a controversial topic of discussion regarding infant mortality. Negative associations with vaccinations and autism in the early 90s, led to social campaigns to warn mothers of the harm that vaccinations can cause. Today, the global impact of immunizations is said to be positive especially in developing countries [8]. However, Goldman et al 2023 show positive correlations between infant mortality and increased vaccinations for developed countries [9]. However, research that shows positive associations between infant mortality and vaccines cannot show that vaccines directly cause these deaths even when death may be within days of vaccine administration [10]. Additionally, research suggesting associations between vaccine implementation and SIDS indicate that many infant deaths are misclassified and assessing this information remains difficult [10,11]. While there are no direct mechanisms found that may explain how infant mortality and vaccinations are associated, autopsies from infant deaths within 10 days of vaccinations show increased inflammation and cytokine expression associated with these cases [8,10]. However, the CDC remains in support of vaccinating infants and suggests that there is no association between SIDS and vaccination administration [12].
Maternal nutrition is vital and certain deficiencies in minerals such as Folate or Iodine, can cause serious issues like neural tube defects and developmental abnormalities [11]. Maternal infections and health complications like diabetes and hyperthermia can have major consequences in the infant outcomes and have lifelong consequences [11]. This fact emphasizes the importance of maternal nutrition and the significance of adequate prenatal care. Birth defects remain the largest contribution to infant mortality accounting for more than 20% of all infant deaths. Genetic and idiopathic (without a known cause) birth defects are complex disorders rarely with clinical solutions other than pregnancy termination or potential long-term health issues and disability for the growing fetus. Currently, non-invasive prenatal testing helps to identify possible genetic disorders as early as 10-weeks’ gestation because fetal DNA circulates in the maternal blood and can be sequenced for genetic issues and viability [13]. This provides expecting parents with a choice based on expected risks of the pregnancy using the fetal DNA. However, the accuracy of the test depends on the concentration of the circulating fetal DNA which is inversely related to maternal weight [13]. Thus, this test has limited outcomes for obese mothers [13].
While topics for infant mortality can be left up to debate like immunization timing efficacy and toxicity, other behaviors like exclusive breastfeeding remain in the hands of the mother meaning with adequate support we can provide infants with a fighting chance of survival. The underlying impact of these choices can be the deciding factor between life, death, and even disability. Discussing the discrepancy between white and Black outcomes reminds us that we must be fierce advocates for ourselves, our children and everyone in our community. Doula organizations are tasked with serving both pregnant people and infants by providing advocacy, education and physical support to clients on an individual basis. Time and time again we see the positive impact of community support from organizations independent from hospital institutions. Doula assisted pregnancies saw decreased low birth weight and increased breastfeeding initiation, which has been shown to dramatically decrease infant mortality [14]. Additionally, doulas have been shown to make the greatest impact for mothers who are socially disadvantaged, low-income, unmarried and experience language barriers [14]. It is clear that empowering parents means increasing access to Doulas.
References:
[1]Bhatia, A., Krieger, N., & Subramanian, S. V. (2019). Learning From History About Reducing Infant Mortality: Contrasting the Centrality of Structural Interventions to Early 20th-Century Successes in the United States to Their Neglect in Current Global Initiatives. The Milbank quarterly, 97(1), 285–345. https://doi.org/10.1111/1468-0009.12376
[2] MacDorman, M. F., & Rosenberg, H. M. (1993). Trends in infant mortality by cause of death and other characteristics, 1960-88. Vital and health statistics. Series 20, Data from the National Vital Statistics System, (20), 1–57.
[3] Jang, C. J., & Lee, H. C. (2022). A Review of Racial Disparities in Infant Mortality in the US. Children (Basel, Switzerland), 9(2), 257. https://doi.org/10.3390/children9020257
[4] Ghidei, L., Wiltshire, A., Raker, C., Ayyar, A., & Brayboy, L. M. (2021). Factors associated with disparate outcomes among Black women undergoing in vitro fertilization. F&S reports, 3(2 Suppl), 14–21. https://doi.org/10.1016/j.xfre.2021.12.002
[5]Lisonkova, S., Ukah, U. V., John, S., Yearwood, L., Muraca, G. M., Razaz, N., Sabr, Y., Yong, P. J., & Bedaiwy, M. A. (2022). Racial and Ethnic Disparities in the Perinatal Health of Infants Conceived by ART. Pediatrics, 150(5), e2021055855. https://doi.org/10.1542/peds.2021-055855
[6] Walsh, A., Pieterse, P., Mishra, N., Chirwa, E., Chikalipo, M., Msowoya, C., Keating, C., & Matthews, A. (2023). Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review. International breastfeeding journal, 18(1), 22. https://doi.org/10.1186/s13006-023-00556-2
[7] Li, R., Ware, J., Chen, A., Nelson, J. M., Kmet, J. M., Parks, S. E., Morrow, A. L., Chen, J., & Perrine, C. G. (2022). Breastfeeding and post-perinatal infant deaths in the United States, A national prospective cohort analysis. Lancet regional health. Americas, 5, 100094. https://doi.org/10.1016/j.lana.2021.100094
[8] Moro, P. L., Arana, J., Cano, M., Lewis, P., & Shimabukuro, T. T. (2015). Deaths Reported to the Vaccine Adverse Event Reporting System, United States, 1997-2013. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 61(6), 980–987. https://doi.org/10.1093/cid/civ423
[9] Goldman, G. S., & Miller, N. Z. (2023). Reaffirming a Positive Correlation Between Number of Vaccine Doses and Infant Mortality Rates: A Response to Critics. Cureus, 15(2), e34566. https://doi.org/10.7759/cureus.34566
[10] Miller N. Z. (2021). Vaccines and sudden infant death: An analysis of the VAERS database 1990-2019 and review of the medical literature. Toxicology reports, 8, 1324–1335. https://doi.org/10.1016/j.toxrep.2021.06.020
[11] Institute of Medicine (US) Committee on Improving Birth Outcomes; Bale JR, Stoll BJ, Lucas AO, editors. Improving Birth Outcomes: Meeting the Challenge in the Developing World. Washington (DC): National Academies Press (US); 2003. 7, Reducing Mortality and Morbidity from Birth Defects. Available from: https://www.ncbi.nlm.nih.gov/books/NBK222106/
[12] Centers for Disease Control and Prevention. (2020, August 14). Sids and vaccines. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccinesafety/concerns/sids.html#rel
[13] Pös, O., Budiš, J., & Szemes, T. (2019). Recent trends in prenatal genetic screening and testing. F1000Research, 8, F1000 Faculty Rev-764. https://doi.org/10.12688/f1000research.16837.1
[14] Gruber, K. J., Cupito, S. H., & Dobson, C. F. (2013). Impact of doulas on healthy birth outcomes. The Journal of perinatal education, 22(1), 49–58. https://doi.org/10.1891/1058-1243.22.1.49