The infant mortality rate of African American newborns within the first year of life is more than twice that of white newborns and higher per 1,000 deaths than any other racial or ethnic group in the United States. Using social ecological model as the theoretical framework, the goal is to understand the causes of racially disparate infant mortality rates. This paper will present health disparities and related social inequities that may underlie these troubling outcomes for childbearing women and infants in the United States.
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Infant mortality rates are often used as a measure of a population’s general health status, socioeconomic conditions, and availability and access to quality health care. The decrease in the rate of infant death in the United States has been observed for births to both white and black mothers. Although there has been general improvement in infant survival, there has been widened gap in the racial disparity in infant mortality rates.
The ten leading causes of infant mortality in the United States are: 1) birth defects: 2) causes related to short gestation or low birth weight (LBW); 3) sudden infant death syndrome (SIDS); 4) maternal complications of pregnancy; 5) complications of placenta, cord, and membranes; 6) accidents; 7) respiratory distress of newborn; 8) bacterial sepsis of newborn; 9) diseases of the circulatory system; and 10) intrauterine hypoxia and birth asphyxia. Infants born to black mothers had the highest IFM due to prematurity and LBW.
Additionally, low birth weight and premature infants who survive the first year of life continue to face serious health problems and developmental problems. The social-ecological model has been chosen because it takes in account factors that influence disparate rate among black American infants. Disparities in infant mortality by race and class continue to be a national disgrace. The purpose of this study using the social ecological model will be: (1) discuss individual factors that influence infant mortality and (2) discuss multiple levels of factors that influence infant mortality rate.
The literature was searched using the databases of CINAHL, Pub Med (Medline), Eric, PsychInfo, Science Reference Center, and SocioIndex for the year’s 199-2010. The search terms included social ecological, black women, African American women, parenting, infant mortality, health, social inequalities. Inclusion criteria included a) original research; b) studies published in English; c) peer-reviewed journal; d) articles on black woman and infant mortality; and e) social ecological model. Of the 140 articles identified, only those studies with health, social determinants, black women, social ecological model, African American in the abstracts and full text articles were include (n=39).
Social Ecological Model
Vulnerable populations are at substantially greater risk of poor physical, mental and social health and have much higher rates of morbidity and mortality. Despite these greater health needs, they also typically face greater barriers to accessing timely and needed care and, even when receiving care, have worse health outcomes than others . The social ecological approach considers the nested arrangement of behavioral and environmental determinants of health. posits that concepts of health promotion require analysis of the health habits and lifestyles of participants, as well as constraints and resources present within participants’ environments. Secondly, the social ecological approach recognizes the importance of changing interpersonal, organizational, community, and public policy.Finally, the social ecological model has been chosen to analyze personal, community and societal institutions impact on infant mortality.
The intrapersonal resources include individual characteristics such as perceived lack of knowledge, attitudes, beliefs, health practices, age, race/ethnicity, income and education and employment status variables effect infant mortality .
In order to understand the individual interpersonal characteristics one needs to critically examine the mother’s knowledge regarding maternal education and health practices. Social inequities related to educational opportunities and social resources may influence health behaviors or practices that are associated with infant health. Compared with women who receive adequate prenatal care, those who do not seek a reasonable amount of care tend to be young, less educated, single, and/or to have other children . have documented the powerful association between a person’s socioeconomic status and mortality.
The gap in infant mortality based on mothers’ years of formal education has also widened significantly over time. Maternal education appears to be an increasingly important predictor of infant survival. Researchers observe that key risk factors for infant mortality, including smoking during pregnancy, delayed or no prenatal care, and lack of health care coverage, vary substantially with socio-economic status and maternal education .
Behavioral factors account for about half of premature mortality, and almost all vary by socioeconomic status. The greatest behavioral risk for premature mortality is tobacco use. In 2005, the IFM rate for infants of mothers who smoked was 74 percent higher than the rate for nonsmokers . Those with less education and less income are more likely to smoke. Smoking prevalence reflects likelihood of initiating smoking as well as of quitting, and different policies are relevant for those stages of smoking. However, the more educated were more likely to try and quit, and among those who tried to quit with higher incomes were more likely to succeed. This suggest that efforts to encourage quitting need to be geared more strongly to those with less education and that the means of quitting need to be made more accessible to the poor.
Breastfeeding has been shown to reduce rates of infant mortality in the United States and worldwide . However, the rates of initiation and maintenance of breastfeeding are less frequent among black women than white and Hispanic women,. Maternal education again is associated with substantial disparities: women with 9th-to 11th grade education are least likely to breastfeed to 6 months, whereas women with college degrees are most likely to do so as well as to report ever breastfeeding with the most recent birth .
Infant mortality rates vary with maternal age, with the highest 2005 death rates documented for infants of the youngest mothers those under age 15 (16.4 per 1,000 live birth), and oldest mothers- aged 40 and older (7.9 per 1,000 live births) . Among older mothers, especially those of low social economic status, infant mortality rates may be affected by pregnancy complications related to advanced maternal age, such as gestational diabetes mellitus and hypertensive disorders. Other contributing factors are black women’s higher rates of intra-uterine growth restriction, preterm premature rupture of membranes, placenta previa, preterm birth, very preterm birth, cesarean delivery, light vaginal bleeding, and heavy vaginal bleeding compared to the white population .
Chronic stress can affect health both directly and indirectly through its effects on health behavior. While people in all walks of life experience stress, lower-SES persons live and work in more stressful environments. Higher IFM among well- educated black women has been attributed to their cumulative experience of chronic stress over the life course, which causes wear and tear on their reproductive health over time. identified a number of factors that contribute to greater stress at lower SES levels, including economic strain, insecure employment, low control at work, and stressful life events.
determined that lifelong accumulated experiences of racial discrimination by black American women constitute an independent risk factor of preterm delivery. noted association between black American women’s exposure to chronic stress from interpersonal racism and infant, very low birth weight (VLBW). Black American women who were exposed to what they perceived as racial bias and internalized their responses to unfair treatment had a fourfold greater risk of hypertension as well. proposed the classic host (i.e., pregnant women), environment (i.e., chronic social stressors), and agent (i.e., immediate emotional stress or physical stressors) are ongoing stressors as well as social and cultural modifiers of stress may have influence on how particular stressors is experienced or what the physical response to it may be.
Researcher have also suggested that being a woman is a characteristic that cannot be neglected in the context of maternal stressors. Being a black woman produces a double effect of racial and gender discrimination and related stress which in turn impacts their health and the outcomes of subsequent pregnancies.
Interpersonal resources include culturally relevant social support as well as social norms that may facilitate behavioral capacity and health behavior change . Research has confirmed that loneliness is detrimental to health. Good health is positively correlated with involvement and satisfying relationships with other people. Studies show that married people live longer than unmarried people and that there are lower death rates among those who have lots of social support. A social network not only assists with instrumental assistance such as childcare, finances and housing, but it is a person’s major source of emotional support. A personal’s level of social support is one of the most potent indicators her degree of vulnerability .
Broken relationships create lifelong conditions of high stress and low support, which in turn pattern physiological, psychological, and behavioral responses that put the mother at risk for poor nutrition during pregnancy, and her baby at risk for fetal and infant deaths. Black American families are disproportionately affected by broken relationships, which contributes to disparities infant mortality . Infants born to unmarried mothers had higher IMR compared to those born to married mothers in 2002. However, the IMRs are significantly higher for married black American mothers than for unmarried black American mothers.
In a report, maternal grandmothers were more frequently nominated than other source of parenting help including spouses, current or former partners, relatives, friends and professionals. Grandmothers have a tremendous influence on a woman’s lived experiences. Maternal grandmothers tend to improve child survival rates, as do potential sibling helpers at the nest. In this study, researcher suggests that while help from family may be a universal feature of human child-rearing, who helps is dependent on ecological conditions of the family.
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Fathers can also have a tremendous influence on the health of mothers and their infants. Some fathers focused efforts are under way in the United State, including the “USDA’s Fathers Supporting Breastfeeding Program”, which uses a video, posters, and brochures designed to target Black men. Poor family and social support, negative attitudes of family and friends can pose a barrier to good health practices. , observed that there was an association of single motherhood and negative birth outcomes with single parent household, which occurred more often and longer than married or coupled households.
Community and Environmental Resources
The community resources and environmental resources may have a significant impact on individual characteristics of the mother, for instance, substandard housing, lack of transportation, and child -care problems can prohibit a mother from attending prenatal classes or obstetrical appointments. A key to reducing infant mortality is to address the barriers that stand between low-income women and adequate prenatal care. Racial and ethnic minorities tend to live in medically underserved areas, and many black American and Hispanic families lack a regular source of care, making do with outpatient clinics and hospital emergency rooms in times of crisis . According to a study by the Agency for Health Care Policy and Research, low-income pregnant women are more likely to seek and be satisfied with prenatal care if they can avoid long waiting time, see providers who explain procedures, and have access to ancillary services, especially substance abuse services and childbirth education. Health providers have also begun to understand the need for “culturally competent providers” and the availability of medical personnel who speak the patient’s primary language.
Exposure to damaging agents in the environment, including lead, asbestos, carbon dioxide, and industrial waste, varies with socioeconomic status. Those lower on the SES hierarchy are more likely to live and work in worse physical environments. Poorer neighborhoods are disproportionately located near highways, industrial areas, and toxic waste sites, since land there is cheaper and resistance to polluting industries, less visible. Housing quality is also poorer for low-SES families. As a result, compared with high-income families, both children and adults from poor families show a six fold increase in rates of high blood lead levels, while middle-income adults and children show a twofold increase
Economic differences do not fully explain the persistent high infant mortality rates of black American women and other minority groups. Several studies in the early 90’s examined the effect of racial residential segregation on the health outcomes of Black Americans and a positive association between black-white dissimilarity and black infant mortality rates was shown after controlling for metropolitan area poverty rates. After an initial focus on infant mortality, several authors examined the association between racial segregation and mortality in other age groups. Their general finding indicated that black mortality is positively associated with residential segregation and with residence in predominantly black areas.
Current research still indicates racial residential segregation as one of the fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mechanism of racism that was designed to protect whites from social interaction with blacks. The degree of residential segregation remains extremely high for most Black Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES was determined to remain a fundamental cause of racial differences in health.
The US sociological literature suggests that residential segregation along racial/ethnic lines is not primarily a result of the residential preferences of minority groups. National and metropolitan area surveys have shown that, on average, Black Americans and Hispanics would be more willing than Whites to live in relatively integrated neighborhoods. On the other hand, several studies, including audit studies involving experimental designs, have indicated that Black American and Hispanics continue to face discrimination in housing and mortgage markets even after income has been controlled. Discrimination prevents upwardly mobile members of minority groups from becoming more spatially integrated with Whites.
Organizational resources have a strong effect on the individual characteristics of mother. Lack of access, provider availability and geographic distance, quality of care, timeliness, and types of services creates health disparities for minority women. If a client lives 3 hours away from the regional medical center, the client will have an increased burden placed on her because of the lack of resources available in her own community. used the ecological model as a framework for applying social justice concepts to the care of childbearing women and families. They discovered by addressing health disparities exclusively on an individual level ignores the effect of social practices and institutions on the health of childbearing women and infants and serves as a barrier to achieving the goal of social justice. Although there are a number of mechanisms through which socio-economic status influences health, there is a distinctive link between utilization of health care services and health status. Prenatal care most often is associated with medical care, in which case it is an important factor in the prevention of poor birth outcomes, particularly prematurity and/or low birth weight and their associated neonatal mortality .
Typically, efforts to improve infant health in the United States have focused on timely, appropriate care during pregnancy and delivery. While these services remain the keys to giving babies a good start in life, they do not sufficiently address the maternal health problems that often underlie infant mortality. There is a growing consensus that prevention efforts need to begin well before conception, especially for those mothers at greatest risk for poor pregnancy outcomes. Several months of medical attention cannot overcome many years of disadvantage and poor health. Women, particularly minority women need good care between pregnancies.
Good maternal health requires diagnosis and management of chronic disease well before conception. But lack of health insurance keeps women from getting the care needed to maintain their own health and improve their chances for healthy pregnancies. Before pregnancy, women qualify for Medicaid only if they have extremely low incomes- well below the poverty line (68 percent of the Federal poverty line for working women, and under 41 percent for those who do not work). Once they become pregnant, women are held to a less stringent requirement (185 percent). As a result, many low-income women who qualify for Medicaid only after a confirmed pregnancy test often experience delays in enrollment and referral to a provider
suggests that disparities in neonatal mortality are primarily determined by not only the birthrate of extremely premature infants but access to specialized obstetrical and pediatric care. This analysis suggests that the epidemiology and social meaning of disparities in infant mortality are intensely dynamic and increasingly reflect the interaction between social forces and technical innovation. interviewed a total of 6, 2999 white, black American, Hispanic and Asian adults, to view their differences in perceptions of health care system. It was determined that bias and cultural competence are not fully explained by such factors as demographics, source of care, and patient-physician communication, but it may partially explain disparities in patient ratings of individual health care provider cultural competence. As such, interventions aimed at improving access to a regular source of care and enhancing patient-physician communication may improve patient ratings of interpersonal bias and cultural competence of physicians; however, such interventions alone are not likely to substantially improve ethnic minority patients’ perceptions of bias and cultural competence in the health care system as a whole.
Moreover, disparities in preterm births have proven very difficult to overcome. In 2005, the preterm-related infant mortality rate was more than three times higher for black mothers than for white mothers . Infants’ chances of survival often depend on technology and expertise available at local hospitals. Hospitals serving a high proportion of minority patients have higher than expected mortality rates for infants born at very low birth-weights .
In 1999, Congress requested in the Institute of Medicine (IOM) report, entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities,” in Healthcare, assess is the extent of racial and ethnic disparities in healthcare, the study concluded that although myriad sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.” From the IOM report, assuming that access-related factors- such as insurance status and the ability to pay for care are the same, the possibility that overt or subtle biases or prejudice on the part of healthcare providers might affect the quality of care for minorities; suggests the need for intervention strategies to improve access to quality health care .
The impact of social and environmental factors on the behavior and health of individuals and populations has been understudy for years. Addressing health disparities from an individual, community and organizational level is important to the social health of United States. Nationally, black infants have the worse birth outcomes than any other racial and ethnic group. By exploring the social ecological model a more comprehensive approach to acknowledging how individual challenges, environmental resources, and organizational structures influences the health behaviors of black women. Social inequities may contribute to differences in access to or quality of health care, which leads to less knowledge and skill in promoting personal and family health, thus results in poor health and birth outcomes.
To rekindle concern about infant mortality to the level of effective action, public health professionals must refocus the public’s attention on assuring that all women are provided adequate education and services to help them avoid unintended pregnancies, that all pregnant women receive services in appropriate facilities, and that the causes of preterm deliveries are discovered. Effective action in these areas would not only improve infant mortality overall; it would also reduce racial and ethnic disparities in infant health .
Implications for Research and Practice
In summary, prevention of an infant early death is not a health outcome, but rather a surrogate endpoint for optimum fetal, infant, and lifelong health. Racial and socio- economic disparities in rates of preterm birth and infant mortality area among the most widely recognized but, least understood aspects of infant and maternal health in this country. In particular, the persistent black/white differential requires intensive study. At any age, and at any income, education or socioeconomic level, an black American mother is more than twice as likely to lose her infant as a white woman. Given the complexity of the layered intrapersonal, interpersonal, local, and national contexts in which social justice operates, and realizing social justice is a work in progress; we can certainly help move nursing and medicine toward integrating concepts of social justice for the betterment of society, as a whole . Adoption of universal health-care coverage for women and children and providing optimum work policies for women is worthy goals. Additionally, new interventions designed with the social context of friends, family, and neighborhood associates, can be used to improve birth outcomes.
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