Contradicting Assumptions About Infant Mortality Rates: How Far Upstream?
Posted November 04, 2014 by Charles J. Homer, MD, MPH
Learning often begins when facts contradict our assumptions. While attending the kickoff summits of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN) in July, I became aware of at least two facts that contradicted my previous assumptions: (1) that infant mortality rates for non-Hispanic blacks are higher in the upper Midwestern states than they are in the deep South and (2) that the declines in infant mortality in several southern states over the past decade have been steeper than anywhere else in the country. We need to learn more about the “why” behind these results so we can apply these lessons elsewhere to reduce disparities and improve overall outcomes.
I was not surprised to learn at the summits that two states—Washington State and my home Commonwealth of Massachusetts—are successfully narrowing the chasm between non-Hispanic black and white infant mortality rates. However, they are still far from achieving the aim that was made so forcefully at the summits by Arthur James, MD, from Ohio: that we need to eliminate, not narrow, this divide. These observations were reinforced when the Boston Globe reported in late August that non-Hispanic black infant mortality rates declined sharply in Boston over the past three years, from 13.8 in 2008 to 6.5 in 2012. Although still more than double the rate of white babies (3.0), this improvement is remarkable, one that then Boston Public Health Commissioner Barbara Ferrer attributed to a broad focus on maternal health during the pre-and post-conception period and to ongoing support for women and their children up to the age of five.
But another fact contradicted my well-founded belief that social inequality is a major driver of infant mortality. A report released in September indicated worsening income inequality in Boston during the same time period as the reduction in infant mortality and disparities, with Boston having one of the most unequally distributed incomes of all U.S. cities and Massachusetts having one of the most unequal of all the states. What can we learn from this? These findings make me want to know more about the relative contribution of income inequality versus absolute levels of social disadvantage.
Massachusetts, for example, has a reasonable safety net, so perhaps most disadvantaged women in this state don’t have the level of extreme material deprivation that may occur elsewhere and lead to the dire outcome of infant mortality. Perhaps targeting the provision of healthcare services to low-income and minority women before and after pregnancies, as Commissioner Ferrer suggests, can mitigate the impact of adverse socioeconomic conditions—through identifying and treating medical conditions (e.g., hypertension, substance abuse); through enabling effective family planning; or by providing a portal to broader social services (e.g., emergency housing).
Abraham Jacobi, a 19th century founder of pediatrics in the U.S., and Jack Geiger, a more recent founder of the community health center movement, both emphasized that we who care about health need to directly address the upstream social conditions that shape health. As has often been reported, Geiger sought to include funding for a tractor in his Mississippi-based health center’s budget so that the poor and malnourished people in that area could farm the land and produce food to feed themselves and others. At the same time, both of these giants also recognized that healthcare services themselves play a critically important role. Addressing upstream social conditions and providing healthcare services should be a “both/and,” not an “either/or.”
NICHQ and our partner organizations are working with public health leaders and their partners from 31 states and nine territories/jurisdictions to help them reduce infant mortality and eliminate disparities over the next three years. Choosing what to do is not abstract—they need to set priorities and commit resources to get results. For their first pass, the teams have preliminarily prioritized five strategies to work on together over the next 18-24 months: safe sleep practices, perinatal care interventions, reproductive health and other health services, smoking cessation and improved treatment of health risks for women (including substance abuse and mental health). Cross-cutting these priorities were several themes such as building more effective and timely data systems, strengthening family capacity and, yes, tackling social determinants and keeping equity front and center. The state, jurisdiction and territory teams and the Maternal and Child Health Bureau of the Health Resources and Service Administration in the U.S. Department of Health and Human Services, the initiative’s funder, will reflect on and refine this list. Each team will then choose up to three of the strategies and get to work.
If together we can sustain the type of learning that challenges our assumptions, the type of learning that has begun in the IM CoIIN, I am fully confident that together we will succeed in having more infants—regardless of race or income—living to celebrate their first birthday.