Epidemiology, Fetus/Newborn Infant, Public Health

Ohio's Infant Mortality Problemby Dr Lydia Furman MD, Assistant Editor, Pediatrics

Ohio is a terrific place to live, but has major public health challenges. Itsinfant mortality rate and associated racial inequities are persistent and refractory. This week's Infant MortalitySummit in Cleveland, Ohio (https://www.odh.ohio.gov/odhprograms/cfhs/octpim/2016) sought to draw attentionto the problem and focus on solutions.  The Infant Mortality Rate (IMR) is the number of child deaths before one year of life per 1,000 births, and theHealthy People 2020 goal for the United States (https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives, MICH-1.3) is to reduce this number to 6.0.  Progresshas been made nationwide to a rate of 6.08. However, Ohio's all infant IMR in 2015 was 7.2, with a rate forwhite infants of 5.5, for Hispanic infants of 6.0, and for Black infants of 15.1. 

That is not a typographic error - it's a shocking vital statistic that has defied multiple public health initiatives. Dr.Arthur James is an Ohio obstetrician who has led our efforts to reduce infant mortality statewide and close thechasm between white and black babies' chances of surviving the first year of life. Ohio's racial disparity haspersisted for as long as records have been kept in our state, which is for 35 years.   

Dr. James points out that over the past 2 decades there has been a  51% improvement in white infant mortality,but only a 31% improvement in black infant mortality; in other words, the gap has widened, and now a blackbaby has a 2.75x greater chance of dying in year 1 than a white baby. More facts and figures are available fromthe Ohio Department of Health (ODH) (https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/cfhs/OEI/2015-Ohio-Infant-Mortality-Report-FINAL.pdf?la=en)

Race is a social determinant, and I hope none of us believe there is a biological difference between white andblack babies.  The Ohio Commission on Minority Health White Paper (Ohio Minority Commission Infant MortalityWhite Paper) accompanying the conference material eloquently states, "…key to understanding this issue is tofirst acknowledge the complex nature of race as a social construct and adverse reactions to race, which is in factracism…" Racism is a powerful social force that occurs at the personal, interpersonal and societal or structurallevels.  

Race is a risk factor that can transcend income, education, marital status, and impact women's pregnancyoutcomes via chronic stress generated through interpersonal racial discrimination.1   Others have similarlyshown that the experiences of a lifetime of stress, not just of 9 months of pregnancy, impact each infant'schances of being born at a healthy weight, specifically that perceived racism predicted birthweight.2  It's veryuncomfortable to acknowledge racism directly, and to bear witness to the role it has in weakening the fabric ofour society in so many ways, its impact on inequity in infant mortality just one example.

One of the most amazing small group sessions at the conference was called "Who' s Asking the Women? UsingDigital Storytelling to Include African American Women at the Table in a Community Based ParticipatoryResearch Project."3 In an academic-community partnership, a group of African-American women, and a couple

Copyright © 2016 American Academy of Pediatrics

Epidemiology, Fetus/Newborn Infant, Public Health

of men too, were recruited by Community Health Workers and a Certified Nurse Midwife to "circles of sharing" totell their stories, which they did through tears and honest words.  Photographs were taken of their homes andlives, from piles of laundry, to empty allies to convenience stores to loved family members caring for each other,and these were narrated with the stories the women told. 

How it felt to be in line at the grocery store and have those looks that go with getting out your WIC coupons, andwith being late for your prenatal appointment, and how hard it was to always be the one who cared for othersrather than for oneself. But the most telling moments were at the conclusion of the video when at least 4audience members separately asked, "OK, that was beautiful, but how does this video relate to infant mortality?" Wow. Here is an engaged and, one imagined, broad thinking audience, yet the concept of racism is not onthese individuals' radar at all as a direct cause of infant mortality. 

I believe we need more plain speaking on this topic, less political smoothing over, and more personal effort. Inmy own continuity clinic, located in inner-city Cleveland and serving predominantly African-American families, Iplan to directly address race and racism with my patients and families in any and every constructive way I canso I miss no opportunities to be a change-maker.

1. Collins JW, David RJ, Handler A, Wall S, Andes S. Very Low Birthweight in African American Infants: TheRole of Maternal Exposure to Interpersonal Racial Discrimination. American Journal of Public Health.2004;94(12):2132-2138.

2. Dominguez TP, Dunkel-Schetter C, Glynn LM, Hobel C, Sandman CA. Racial Differences in Birth Outcomes:The Role of General, Pregnancy, and Racism Stress. Health psychology: official journal of the Division of HealthPsychology, American Psychological Association. 2008;27(2):194-203. doi:10.1037/0278-6133.27.2.194.

3. from M. Cameron Hay, PhD, Miami University Jennifer Bailer, RN, MS, APHN-BC, Butler Co. Health Dept.,Co-Lead Butler County Partnership to Reduce Infant Mortality, Toni K. King, CNM, WHNP-BC, Butler CountyPartnership to Reduce Infant Mortality

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Reducing Perinatal Mortality in Nepal Using Helping Babies Breathe●

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