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Racial disparities in infant deaths draw attention

State’s infant mortality rate among African-Americans is among worst nationally.

January 11, 2013
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LANSING — While the infant mortality rate in Michigan is one of the highest in the nation, experts say the disparity in racial and ethnic groups is equally alarming.

“The clearest issue to us is the huge difference in the health disparity by racial and ethnic groups,” said Paulette Dunbar, the manager of the Maternal, Infant and Family Health section at the Department of Community Health.

According to the department, for every 1,000 babies born in Michigan, approximately five Caucasian and seven Hispanic babies die, compared to 14 African-American babies who die before their first birthday. The state average is 7.1.

Dunbar said in the late 1990s, the department started to identify what groups of residents were contributing to the infant mortality rate more than others.

Dunbar said Michigan’s infant mortality rate among African-Americans is higher than the country’s average, and one of the worst nationally. “The black infant mortality rate contributes a great deal to the overall state infant mortality rate,” she added.

She said low income affects housing and access to care and quality food.

Kim Jaffee, an associate professor and Master of Social Work Program coordinator at Wayne State University, said, “There are economic and environmental policies that tend to create conditions in poor neighborhoods that make it harder for people to have healthy outcomes. You can relate that to disparities in health across a lot of different diseases and chronic illnesses.”

Racism is one social aspect that can affect infant mortality, Dunbar said. “We are looking at what the impact is of racism and the stress it causes to family and physical stress.”

Community Health is looking inside the department to identify any institutional racism, Dunbar said.

“We have a new project called “Practices for Reducing Infant Mortality through Equity” to see if there is something that we are doing that may continue or support these differences, unknowingly.”

The department focuses on women in large urban areas such as Wayne County, Genesee County and Kalamazoo, she said.

Kimberlydawn Wisdom, M.D. is the senior vice president of Community Health & Equity for Henry Ford Health System and the founding chair of the Sew Up the Safety Net for Women and Children (SUSN) project that aims to lower the infant mortality rate in Detroit.

Wisdom said Detroit has one of the highest infant mortality rates in the country, exceeding the national average of 6.6.

The project focuses on the Brightmoor, Chadsey/Condon and Osborn neighborhoods in Detroit, she said, where community health workers will recruit 1,500 at-risk women and link them to resources.

The neighborhoods were selected as part of the project because they are part of the Skillman Foundation’s “Good Neighborhoods” initiative that focuses on six Detroit neighborhoods’ development and growth. Skillman, a private non-profit organization, set up a 10-year, $100 million program for the six neighborhoods.

High infant mortality rates indicate the health of the population, Wisdom said. “So what we’re doing by linking women to resources is helping identify where people can access fresh fruits and vegetables, find safe environments to exercise and get a complete education.”

In particular, the Brightmoor neighborhood’s urban farming initiative works to provide fresh fruits and vegetables to residents of the community.

And, with SUSN’s program goal to connect women to other programs and resources, Wisdom said there is a possibility of a future partnership with the gardening efforts.

Wisdom said they have already seen trends in transient women. “We’re finding that some of these women are ‘couch-homeless’ and move from couch to couch within their community.” Because these women don’t have an address, tracking them is difficult.

Most of these women are young and into cell phones and texting but they also need a trusted person they can go to for guidance.

Wisdom said SUSN focuses on a “high-touch and high-tech” strategy that places a high priority on interpersonal interaction as well as connecting through social media and cell phones.

“I think the combination of the high touch and high tech is what makes us really different.”

Jaffee said economic and environment conditions contribute to infant mortality in poorer neighborhoods. “There are fewer physicians for the population in poor neighborhoods, which can create difficulty for people to get into prenatal care as early as they might attempt to.”

However, she cautioned against suggesting that women aren’t being responsible and getting prenatal care early enough, she said, “when in fact it’s neighborhood economic conditions that indirectly impact their ability to get into prenatal care.”

“We’re not trying to identify where the stressors are,” Wisdom said. “We are where these stressors exist — in lower income neighborhoods with women who are unemployed and don’t have a high school diploma.

A high level of violence and high levels of substance use and drug dealing exist in some neighborhoods, Jaffee said.

“There’s a fear of being outside and a fear that creates less opportunities to get exercise, which is important when you’re pregnant. But even more important is that high levels of stress can be viewed medically because they influence your immune responses which, when you’re pregnant, are very important to the infant,” she said.

Jaffee said research linked racism and poor birth outcomes in two ways.

“Racism can create economic conditions and environments that are really toxic to good health. There is also the individual subjective sense of being treated differently than another group of people.”

In addition, Rosemary Fournier of the Fetal-Infant Mortality Review said sleep-related deaths are a problem. “If we were to eliminate just those preventable sleep-related deaths, we could drop the state’s infant mortality rate by nearly an entire percentage.”

Dunbar said most teen mothers have a higher rate of infant death. Rates go down for women in their 20s and 30s, and then back up in for those 40 and older.

“What we’re seeing in the black community is that the infant mortality rate is almost as high in the 20-30 year old woman as teens,” she said. “Black women who are educated could still potentially have poorer pregnancy outcomes than a white woman who has not finished high school.”

Fournier said FIMR helped shape the department’s infant mortality strategic plan.

FIMR is a surveillance system, started as a way for communities to identify factors contributing to infant death and to find solutions to improve care and services for infants and families, she said.

FIMR has included a voluntary maternal interview as part of the process for every case.

Fournier said, “We make every attempt to go out and talk to the mom and say, ‘Can you tell us what kind of care and services you did or didn’t get, or what were your encounters with the health care system like?’ We’re really trying to get the woman’s story and her voice, and we’re not guessing.”

Although social and environmental factors contribute to infant mortality, there are also preventive measures that can be taken, medically.

Sonia Hassan, associate dean for Maternal, Perinatal and Child Health at Wayne State’s School of Medicine, said the two main causes of infant mortality are preterm birth and congenital anomalies, “and preterm births are the more preventable one.”

Hassan conducted an international study that found that performing cervical ultrasounds in all pregnant women and treating those with a short cervix with vaginal progesterone reduces preterm births and neonatal complications.

The most accurate way for a woman to find out if she has a short cervix is to get it measured by a trans-vaginal ultrasound, Hassan said.

The procedure is minimally invasive, she said. “It is safe in pregnancy and takes 10 minutes at the most.” It should be done in the mid-trimester, around 20 weeks.

A shorter cervix is more common in areas with high rates of preterm birth, Hassan said.

“Detroit had the highest rate of short cervix of any of the centers in our trial. We believe it certainly contributes to the high rates of preterm birth. “

There might be some genetic factors that cause a short cervix, Hassan said. “We’re looking into those factors that make women more prone to having a short cervix.”

The state’s Infant Mortality Reduction Plan incorporates vaginal progesterone for high-risk women, Hassan said, and to ensure its implementation, “we need education for physicians and patients and we’re still working with the hospitals.”

The state has done a good job with the insurance companies, but there’s still more to do to make sure that every woman who is pregnant gets that measurement and gets the progesterone if her cervix is short.”

The protocol has already been implemented around the country and beyond, Hassan said.

Lawrence Reynolds, president of Mott Children’s Health Center in Flint and past president of the Michigan chapter of the American Academy of Pediatrics, said, “The communities that are most successful are those that recognize that prevention of premature and low birth rate doesn’t start or end in the physician’s office.”

Dunbar said the Women, Infants & Children program shows that a baby’s weight is a marker for survivability, and the program focuses on supplying healthy supplemental food to pregnant women, infants and mothers.

She said women can have access to home visiting services that provide a social worker and nursing support to help them understand services available to them.

“As we’ve been evaluating the home visiting program, we’ve made a major redesign and feel like it will contribute greater to improving outcomes. We’ll be evaluating the newer strategies shortly and see what we need to tweak,” Dunbar said.

Dunbar said Michigan is watching how other states handle similar problems.

“But in terms of infant mortality disparity, states have varying populations and no one has found the magic bullet for how to address that.

“It is clear that we have to take a comprehensive approach and look at all the factors relating to a healthy pregnancy,” such as women’s health before getting pregnant, chronic health problems and social issues.

Dunbar said, “Infant mortality is one of those issues that many people don’t realize is a crisis. When you’re looking at 800-900 babies dying every year due to low birth weight or prematurity, we have to do something.”

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