Infant Mortality Among Black Americans

The recent slowing in the rate of decline in infant mortality and the disparity in the risk of infant death between racial and ethnic subgroups have attracted considerable attention (3,4). In 1984, infant mortality for blacks was 18.4 deaths/1,000 births; this was approximately twice that for whites, which was 9.4 deaths/1,000 births (5). A twofold disparity in infant mortality between black and white infants existed for the time period 1960-1984, and there was a 59% reduction in the infant deaths/1,000 live births over that time for both blacks and whites (5,6). From 1960 to 1984, declines in the neonatal mortality rate* were greater for whites than for blacks (64% compared with 58%), whereas the reduction in the postneonatal mortality rate** was greater for blacks than for whites (60% compared with 43%) (Figure 1).

Analysis from the National Infant Mortality Surveillance (NIMS)S project, a tabulation of data from linked birth and infant death certificates for live births occurring among U.S. residents in 1980, provides a more complete description of the disparity in infant mortality risk (IMR)P between blacks and whites (7). This is the most recent year for which linked birth and infant death data are available for the United States. Although the race-specific risk for infant death varied among states, within states the IMR for blacks was generally two times the risk for whites. In one analysis, the lowest state-specific IMR for single-delivery black infants (12.5) was higher than the highest mortality risk for whites (10.1) (8). There were also differences in the race-specific risk of infant death between U.S. census regions, with IMRs for blacks ranging from 16.5 to 20.7 and for whites, from 8.8 to 9.8. In all regions, however, the IMR for blacks was approximately twice that for whites (9).

Analysis of NIMS data revealed three factors contributing to the difference between the IMRs for black and white infants. First, blacks have a higher percentage of low birthweight births than whites. Black infants in this study had approximately three times the risk that white infants had of being born weighing 1,500g (2.1% compared with 0.7%); they had over two times the risk of having a birthweight of 1,500-2,499g (9.2% compared with 4.2%). Low birthweight is the most important determinant of infant survival, and infants with low birthweights suffer the highest mortality risks (10). A recent comprehensive review has provided an inventory of factors that increases the risk of low birthweight (11). These include demographic, medical, and behavioral risk factors, many of which are more prevalent among black Americans than among white Americans.

The other two factors contributing to the elevated IMR among blacks are neonatal deaths among infants with birthweights greater than or equal to 2,500g and postneonatal deaths among infants in all birthweight categories (12). Black infants with birthweights 2,500g had a lower neonatal mortality risk (NMR)** than white infants, but blacks with birthweights greater than or equal to 2,500g had a higher NMR than whites with comparable birthweights. Black neonatal survivors experienced a higher postneonatal mortality risk (PNMR)**** in all birthweight categories (Table 1 (12)).

To describe the causes of death among black compared with white infants, the international classification of disease codes, ninth revision, was aggregated into seven categories (Table 2 (13)). Except for congenital anomalies, the overall NMRs among blacks, for all causes of death, were approximately twice those among whites. During the postneonatal period, black infants were at higher risk of dying from all causes, including those that are preventable and those that are subject to intervention efforts.

If black infants born in 1980 in the United States had experienced the same birthweight distribution and birthweight-specific mortality risk as white infants, there would have been 5,526 (51%) fewer single-delivery black infant deaths. Of this total, 75% occurred among infants with birthweights 2,500g (59% in the neonatal period and 16% in the postneonatal period), and 25% occurred among infants with birthweights greater than or equal to 2,500g (7% in the neonatal period and 18% in the postneonatal period) (Figure 2). Reported by Pregnancy Epidemiology Br, Research and Statistics Br, Div of Reproductive Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The reduction of the disparity in IMR between black and white infants is a major public health objective (3). Accomplishing this goal will require intervention strategies aimed at reducing the frequency of low birthweight births, of neonatal mortality among infants with birthweights greater than or equal to 2,500g, and of postneonatal mortality among infants in all birthweight categories. This report highlights the importance of low birthweight in contributing to the disparity in infant mortality between blacks and whites. In the NIMS study, 75% of the excess deaths experienced by single-delivery black compared with white infants occurred among black infants with birthweights 2,500g. In addition, 18% of these excess deaths occurred during the postneonatal period among black infants with birthweights greater than or equal to 2,500g; many of the causes of these deaths are subject to current intervention efforts.

Research has shown that much of the disparity in pregnancy outcomes among racial and ethnic groups is mediated by factors such as socioeconomic status; maternal education; health insurance coverage; and access to prenatal, infant, and other health care services (3,4,10). As recommended by the Secretary's Task Force on Black and Minority Health and by the American Academy of Pediatrics, future intervention strategies include new and expanded programs in pregnancy and family planning, prepregnancy care, prenatal care, and postnatal and pediatric care as well as financial provisions that will improve access to care (3,4).

Race-specific state and regional differences in the risk for infant death suggest that substantial improvements in the mortality of black infants are achievable. Although there have been major improvements in infant mortality for both blacks and whites during the past two decades, the reduction of the continued elevated risk for black compared with white infants remains a major public health objective.

References

1. U.S. Department of Health and Human Services. Report of the Secretary's task force on black and minority health--volume I: executive summary. Washington, DC: U.S. Department of Health and Human Services, 1985.

2. CDC. Report of the Secretary's task force on black and minority health. MMWR 1986;35:109-12.

3. U.S. Department of Health and Human Services. Report of the Secretary's task force on black and minority health--volume 6: infant mortality and low birthweight. Washington, DC: U.S. Department of Health and Human Services, 1986.

4. American Academy of Pediatrics, Task Force on Infant Mortality. Statement on infant mortality. Pediatrics 1986;78:1155-60.

5. National Center for Health Statistics. Advance report of final mortality statistics, 1984. Hyattsville, Maryland: National Center for Health Statistics, 1986; DHHS publication no. (PHS)86-1120. (Monthly vital statistics report; vol. 35, no. 6, supplement 2).

6. National Center for Health Statistics. Vital statistics of the United States, 1960--volume 1: natality. Hyattsville, Maryland: National Center for Health Statistics, 1962.

7. CDC. National birthweight-specific infant mortality surveillance: preliminary analysis--United States, 1980. MMWR 1986;35:269-73.

8. Marks J, Buehler JW, Strauss LT, Hogue CJR. Variations in state-specific infant mortality risks. Public Health Rep (in press).

9. Allen DM, Buehler JW, Hogue CJR, Strauss LT, Smith JC. Regional differences in birthweight-specific infant mortality. Public Health Rep (in press).

10. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, 1980:17.

11. Institute of Medicine, National Academy of Sciences. Preventing low birthweight. Washington, DC: National Academy Press, 1985.

12. Hogue CJR, Buehler JW, Strauss LT, Smith JC. Overview of national infant mortality surveillance (NIMS) project--design, methods, results. Public Health Rep (in press).

13. Buehler JW, Strauss LT, Hogue CJR, et al. Birthweight-specific causes of infant mortality, United States, 1980. Public Health Rep (in press).

*Neonatal mortality rate = Deaths occurring among infants from 0 to 28 days of age per 1,000 births in a calendar year. **Postneonatal mortality rate = Deaths occurring among infants from 28 days to 1 year of age per 1,000 live births in a calendar year. SSupported in part by health departments from all 50 states, New York City, and the District of Columbia; the Association for Vital Records and Health Statistics; the Demographic and Behavioral Sciences Branch, Center for Population Research; the National Institute of Child Health and Human Development; the Division of Maternal and Child Health,

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