Santiago de Tunja (Boyacá)

PPOR Fetal-Infant Cohort Death Map, 2004 - 2008

500-1,499 g Maternal Health/Prematurity = 131

Fetal Neonatal Infant

47 63 21

Black 37 Black 48 Black 20

White 10 White 15 White 1

>1,500 g Total Maternal Care, Newborn Care,

Infant Health = 174

Maternal Care Newborn Care Infant Health

76 33 65

Black 69 Black 24 Black 53

White 7 White 9 White 12

Exploring Racial Disparity in St. Louis City Fetal-infant Death

The majority of deaths for both occurred within the ma- ternal health/prematurity risk period. PPOR excess mortality calculations determined that maternal health/prematurity and maternal care remained the two classifications with the highest rates of excess fetal-infant deaths across both periods for Blacks in St. Louis. Whites continued to experience excess fetal-infant deaths during the maternal health/prema- turity period across both temporal periods. Analysis demon- strated improvement in birth outcomes for Whites during the 2004 -2008 period in the categories of maternal care and newborn care; however, White birth outcomes markedly worsened during the infant health category.

Multiple logistic regression was performed to determine if Low Birth Weight (LBW) was influenced by the variables of gestational age, educational attainment, marital status, maternal age, maternal race, Medicaid status, multiple pregnancy, prenatal care, and smoking status. The status for Women, Infants, and Children (WIC) and food stamp vari- ables were excluded, as they are considered co-linear with Medicaid. In Missouri, if a woman with a child under one year of age qualifies for Medicaid coverage, she would also qualify for WIC and food stamps.

Preterm babies were, of course, more often of low birth weight. This finding aligns with current knowledge that recognizes the importance of carrying a fetus to 40 weeks or nine calendar months (CDC, 2014b. Additionally, preterm birth has been associated with insufficient prenatal care particularly among African American women (CDC, 2014). While the p - value associated with affirmative Medicaid status was not significant, the results of p = .054 were sug- gestive and consistent with research findings that having Medicaid is not necessarily a protective factor for the fetus. Women may still not access adequate prenatal care (Meikle, Orleans, Leff, Shain, & Gibbs, 1995; Milligan et al., 2002; York et al., 1999).

Discussion

Black women in St. Louis City experienced higher rates of death in the womb or the death of an infant within the first year of life when compared to their White cohorts. For Whites, the category with the highest fetal-infant deaths was during the maternal health/prematurity period, with a rate of 5.7/1000, double the referent group of non-Hispanic

Whites nationwide. There is no clear evidence as to why White cases experienced outcomes worse than the national referent group of White women. St. Louis, like other metro- politan areas, has experienced a growing biracial population, increasing from 1.9% in 2000 (United States Census Bureau [USCB], 2000) to 2.4% in 2010 (USCB, 2010). Consistent with data collection, the mother’s race was used as a proxy for infant race; White mothers either pregnant with a bira- cial child or parenting a biracial infant may be vulnerable to similar challenges that Black women face, thus contributing to adverse birth outcomes.

White populations in St. Louis demonstrated healthier birth outcomes across both the 1999 - 2003 and the 2004 - 2008 periods when compared to Blacks. Additionally, Whites in St. Louis did not make comparable gains across temporal periods when compared to the Black cohort. Even with Whites failing to make strides in decreasing fetal- infant death, the mortality gap between Blacks and Whites increased slightly.

Findings indicated that Black cases fared worse in educational attainment status, marital status, and poverty as indicated from higher utilization of government subsi- dies, including WIC, food stamps, and Medicaid at higher rates than Whites. Black women conceived at younger ages when compared to White women. Nearly 50% of the Black study population fetal-infant deaths were attributed to Black women in the 18 - 24 age groups, whereas less than 15% of the White fetal-infant deaths were in this age group. This is consistent with research that indicates social determinants of health shape health inequities, including adverse birth outcomes (Berg, Wilcox, & D’Almada, 2001; Collins, David, Simon, & Prachand, 2007; WHO, 2011).

Research has unearthed many structural and personal barriers such as the cost of care, staff treatment of patients, overburdened clinics that are unwilling/unable to provide flexible appointments, denial of the pregnancy, actively de- siring termination of the pregnancy, and personal problems such as domestic violence, substance abuse, and homeless- ness that may impede Blacks from obtaining prenatal care (Meikle et al., 1995; Milligan et al., 2002; York et al., 1999). Not all reasoning for delayed or unsought prenatal care can be defined as structural or personal barriers. Many identified barriers such as cost of care or lack of adequate and afford- able healthcare can be viewed as both a system failure and a personal responsibility, rendering the need for comprehen- sive solutions. The findings of this study provide context for

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Exploring Racial Disparity in St. Louis City Fetal-infant Death

disparate birth outcomes between Black and White women in St. Louis.

Minority urban populations experience barriers to re- ceiving prenatal care, which aligns directly with the maternal care and prematurity risk periods. This finding allows for the development of interventions and targeted resources for childbirth educators, community members, and policy- makers to further explore mechanisms affecting limited or inadequate maternal care for minority women residing in St. Louis. Specifically, childbirth educators and other profession- als that interact frequently with low-income Black women receiving governmental subsidy services (WIC, food stamps) have an opportunity, with the support of community leaders and policy makers, to counteract obstacles that impede early prenatal care from acting as a full protective factor for Black fetal-infants.

References

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Journal, 5, 75-84

Burns, P. (2005). Reducing infant mortality rates using the perinatal periods of risk model. Public Health Nursing, 22(1), 2-7. http://dx.doi.org/10.1111/ j.0737-1209.2005.22102.x

Cai, J., Hoff, G. L., Dew, P. C., Guillory, V. J., & Manning, J. (2005). Peri- natal periods of risk: Analysis of fetal-infant mortality rates in Kansas City, Missouri. Maternal and Child Health Journal, 9(2), 199-205. http://dx.doi. org/10.1007/s10995-005-4909-z

Centers for Disease Control and Prevention. (2014a). Infant mortality. Retrieved September 1, 2014, from http://www.cdc.gov/reproductivehealth/ MaternalInfantHealth/InfantMortality.htm

Centers for Disease Control and Prevention. (2014b). Planning of preg- nancy. Retrieved November 5, 2014, from http://www.cdc.gov/preconcep- tion/planning.html

Centers for Disease Control and Prevention. (2014). Reproductive Health. Preterm Birth. Retrieved February 25, 2015 from http://www.cdc.gov/ reproductivehealth/maternalinfanthealth/pretermbirth.htm Citymatch. (n.d.). What is PPOR. Retrieved November 5, 2014, from http://www.citymatch.org/perinatal-periods-risk-ppor-home/what-ppor Collins, J. W., David, R. J., Simon, D. M., & Prachand, N. G. (2007). Preterm birth among African American and White women with a lifelong residence in high-income Chicago neighborhoods: An exploratory study.

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Dominguez, T., Dunkel-Schetter, C., Glynn, L., Hobel, C., & Sandman (2008). Racial differences in birth outcomes: the role of general, preg- nancy, and racism stress. Health Psychology, 27(2), 194-203. http://dx.doi. org/10.1037/0278-6133.27.2.194

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MacDorman, M. F., & Mathews, T. J. (2008). Recent trends in infant mortal- ity in the United States (NCHS data brief, no. 9). Hyattsville, MD: National Center for Health Statistics. Meikle, S., Orleans, M., Leff, M., Shain, R., & Gibbs, R. (1995). Women’s reasons for not seeking prenatal care. Birth,

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Milligan, R., Wingrove, B., Richards, L., Rodan, M., Monroe-Lord, L., Jackson, V., … Johnson., A. (2002). Perceptions about prenatal care: Views of urban vulnerable groups. BMC Public Health, 2(25), 1-9. http://dx.doi. org/10.1186/1471-2458-2-25

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Dr. Marie Peoples obtained her undergraduate degree in Crimi- nal Justice Administration from Columbia College, a master’s degree in Sociology and Criminal Justice from Lincoln Univer- sity, and both a master’s degree and PhD in public health from Walden University. As a health practitioner who has worked in many correctional and public health systems with a variety of populations, her passion and area of expertise is in maternal and child health with the goal of empowering women of all demo- graphics to live equitable, healthy, and fulfilling lives. Dr. Peoples also is a Certified Advanced Facilitator for the University of Phoenix and adjunct faculty for Northern Arizona University.

Dr. Hadi Danawi was trained in Public Health with a PhD in Epidemiology from the University of Texas at Houston and a master’s degree in Environmental Health from the American University of Beirut, Dr. Danawi has had international exposure to various public health issues in the U.S., Middle East, and Af- rica. Dr. Danawi worked on bettering the health and wellbeing of women and children in West Africa and is passionate about creating positive social change in underserved communities. Dr. Danawi currently serves as full-time faculty at Walden Univer- sity, College of Health Sciences, teaching and mentoring doctoral dissertations.

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The Role of Ultrasound