Despite appreciable improvement in the overall reduction of infant mortality in the United States, black infants are twice as likely to die within the first year of life as white infants, even after controlling for socioeconomic factors. There is consensus in the literature that a complex web of factors contributes to racial health disparities. This paper presents these factors utilizing the socioecological framework to underscore the importance of their interaction and its impact on birth outcomes of Black women. Based on a review of evidence-based research on Black–White disparities in infant mortality, we describe in this paper a missing potent ingredient in the application of the ecological model to understanding Black–White disparities in infant mortality: the historical context of the Black woman in the United States. The ecological model suggests that birth outcomes are impacted by maternal and family characteristics, which are in turn strongly influenced by the larger community and society. In addition to infant, maternal, family, community and societal characteristics, we present research linking racism to negative birth outcomes and describe how it permeates and is embedded in every aspect of the lives of African American women. Understanding the contribution of history to the various factors of life of Black women in the United States will aid in developing more effective policies and programs to reduce Black infant mortality.
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Alexander, G. R., Wingate, M. S., Bader, D., et al. (2008). The increasing racial disparity in infant mortality rates: Composition and contributors to recent US trends. American journal of obstetrics and gynecology, 198, e1–e9.
MacDorman, M. F., Martin, J. A., Mathews, T. J., et al. (2005). Explaining the 2001–2002 infant mortality increase in the United States: Data from the linked birth/infant death data set. International Journal of Health Services, 35, 415–442.
Frisbie, W. P., Song, S. E., Powers, D. A., et al. (2004). The increasing racial disparity in infant mortality: Respiratory distress syndrome and other causes. Demography, 41, 773–800.
Mathews, T. J., & MacDorman, M. F. (2007). Infant mortality statistics from the 2004 period linked birth/infant death data set. National Vital Statistics Reports, 55, 1–32.
MacDorman, M. F., Munson, M. L., & Kirmeyer, S. (2007). Fetal and perinatal mortality, United States, 2004. National Vital Statistics Reports, 56, 1–20.
Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7, 13–30.
Hogue, C. J., & Bremner, J. D. (2005). Stress model for research into preterm delivery among Black women. American Journal of Obstetrics and Gynecology, 192(5), S47–S55.
U.S. Department of Health and Human Services (DHHS). (2000). Healthy people 2010 (2 Vol., conference ed.). Washington, DC. Accessed June 4, 2008, Available at http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm#_Toc494699661.
Glanz, K., Rimer, B. K. (1995). Theory at a glance: A guide for health promotion practice. Bethesda, MD: National Cancer Institute publication NIH 97-3896. Accessed June 4, 2008, Available at http://oc.nci.nih.gov/services/Theory_at_glance/HOME.html.
McLeroy, K. R., Bibeau, D., Steckler, A., et al. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351–377.
Reifsnider, E., Gallagher, M., & Forgione, B. (2005). Using ecological models in research on health disparities. Journal of Professional Nursing, 21, 216–222.
Ashton, D. (2006). Prematurity–infant mortality: The scourge remains. Ethnicity and disease, 16(2), S3-58-62.
Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900–1999: Healthier mothers and babies. MMWR, 48, 849–858.
Centers for Disease Control and Prevention. (2002). Infant mortality and low birth weight among Black and White infants-United States, 1980–2000. MMWR, 51, 589–592.
Centers for Disease Control and Prevention. (2000). State-specific changes in singleton preterm births among Black and White women-United States, 1990 and 1997. MMWR, 49, 837–840.
Cnattingius, S., Haglund, B., & Kramer, M. S. (1998). Differences in late fetal death rates in association with determinants of small for gestational age fetuses: Population based cohort study. BMJ, 316, 1483–1487.
Centers for Disease Control and Prevention. (2004). Racial/ethnic trends in fetal mortality-United States, 1990–2000. MMWR Morbidity and Mortality Weekly Report, 53, 529–532.
Salihu, H. M., Chatman, L. M., Alio, A. P., et al. (2004). Single motherhood and neonatal survival of twins among blacks and whites. Journal of the National Medical Association, 96, 1618–1625.
Getahun, D., Ananth, C. V., Selvam, N., et al. (2005). Adverse perinatal outcomes among interracial couples in the United States. Obstetrics and Gynecology, 106, 81–88.
Headley, A. J. (2004). Generations of loss: Contemporary perspectives on black infant mortality. Journal of the National Medical Association, 96, 987–994.
Hamvas, A., Wise, P. H., Yang, R. K., et al. (1996). The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites. The New England Journal of Medicine, 334, 1635–1640.
Healy, A. J., Malone, F. D., Sullivan, L. M., et al. (2006). Early access to prenatal care: Implications for racial disparity in perinatal mortality. Obstetrics and Gynecology, 107, 625–631.
Yang, Q., Chen, H., Correa, A., et al. (2006). Racial differences in infant mortality attributable to birth defects in the United States, 1989–2002. Birth Defects Research. Part A, Clinical and Molecular Teratology, 76, 706–713.
Salihu, H. M., Aliyu, Z. Y., Pierre-Louis, B. J., Obuseh, F. A., et al. (2004). Omphalocele and gastroschisis: Black–White disparity in infant survival. Birth Defects Research. Part A, Clinical and Molecular Teratology, 70, 586–591.
Centers for Disease Control and Prevention. Linked birth/infant death, Wonder On-line Database. Accessed June 4, 2008, Available at http://wonder.cdc.gov.
Falcone, R. A., Jr, Brown, R. L., & Garcia, V. F. (2007). The epidemiology of infant injuries and alarming health disparities. Journal of Pediatric Surgery, 42, 172–177.
Mathews, T. J., & MacDorman, M. F. (2006). Infant mortality statistics from the 2003 period linked birth/infant death data set. National Vital Statistics Reports, 54, 1–29.
Byrd, D. R., Katcher, M. L., Peppard, P., et al. (2007). Infant mortality: Explaining black/white disparities in Wisconsin. Maternal and Child Health Journal, 11, 319–326.
Rowley, D. L. (1995). Framing the debate: Can prenatal care help to reduce the black-white disparity in infant mortality? Journal of the American Medical Women’s Association, 50, 187–193.
Scholer, S. J., Hickson, G. B., & Ray, W. A. (1999). Sociodemographic factors identify U.S. infants at high risk of injury mortality. Pediatrics, 103, 1183–1188.
Ventura, S. J., & Bachrach, C. A. (2000). Nonmarital Childbearing in the United States, 1940–1999. National Vital Statistics Reports, 48, 1–40.
Kiely, J. L., & Kiely, M. (2001). Epidemiology trends in multiple births in the United States, 1997–1998. Twin Research, 14, 131–133.
United States Census Bureau. Accessed June 4, 2008, Available at http://www.census.gov/population/socdemo/ms-la/tabch-3.txt.
Bennett, T. (1992). Marital status and infant health outcomes. Social Science and Medicine, 35, 1179–1187.
Jackson, F. M., Hogue, C. R., & Phillips, M. T. (2005). The development of a race and gender-specific stress measure for African-American women: Jackson, Hogue, Phillips contextualized stress measure. Ethnicity and Disease, 15(4), 594–600.
Kirchengast, S., & Hartmann, B. (2003). Advanced maternal age is not only associated with newborn somatometrics but also with the mode of delivery. Annals of Human Biology, 30, 1–12.
Phipps, M. G., Blume, J. D., & DeMonner, S. M. (2002). Young maternal age associated with increased risk of postneonatal death. Obstetrics and Gynecology, 100, 481–486.
Carolan, M. (2003). The graying of the obstetric population: Implications for the older mother. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, 19–27.
Reddy, U. M., Ko, C. W., & Willinger, M. (2006). Maternal age and the risk of stillbirth throughout pregnancy in the United States. American Journal of Obstetrics and Gynecology, 195, 764–770.
Rauh, V. A., Andrews, H. F., & Garfinkel, R. S. (2001). The contribution of maternal age to racial disparities in birthweight: A multilevel perspective. American Journal of Public Health, 91, 1815–1824.
Cottrell, B. H., & Shannahan, M. (2004). Maternal bacterial vaginosis and fetal/infant mortality in eight Florida counties, 1999 to 2000. Public Health Nursing, 21, 395–403.
Leitich, H., & Kiss, H. (2007). Asymptomatic bacterial vaginosis and intermediate flora as risk factors for adverse pregnancy outcome. Best Practice and Research. Clinical Obstetrics and Gynaecology, 21, 375–390.
Moutquin, J. M. (2003). Socio-economic and psychosocial factors in the management and prevention of preterm labour. BJOG, 110(Suppl 20), 56–60.
Chen, A., & Rogan, W. J. (2004). Breast feeding and the risk of postneonatal death in the United States. Pediatrics, 113, e435–e439.
Jones, G., Steketee, R. W., Black, R. E., et al. (2003). Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet, 362, 65–71.
Centers for Disease Control and Prevention. Breastfeeding: Data and statistics: Breastfeeding practices—Results from the 2004 National immunization survey. Accessed on June 4, 2008, Available at www.cdc.gov/breastfeeding/data/nis_data/data_2004.htm.
Bentley, M. E., Dee, D. L., & Jensen, J. L. (2003). Breastfeeding among low income, African-American women: Power, beliefs and decision making. The Journal of Nutrition, 133, 305S–309S.
Burke, J. G., Lee, L. C., & O’Campo, P. (2008). An exploration of maternal intimate partner violence experiences and infant general health and temperament. Maternal and Child Health Journal, 12, 172–179.
Huth-Bocks, A. C., Levendosky, A. A., & Bogat, G. A. (2002). The effects of domestic violence during pregnancy on maternal and infant health. Violence and Vicitims, 17, 169–185.
Boy, A., & Salihu, H. M. (2004). Intimate partner violence and birth outcomes: a systematic review. International Journal of Fertility and Women’s Medicine, 49, 159–164.
Murphy, C. C., Schei, B., Myhr, T. L., et al. (2001). Abuse: A risk factor for low birth weight? A systematic review and meta-analysis. Canadian Medical Association Journal, 164, 1567–1572.
Silverman, J. G., Decker, M. R., Reed, E., et al. (2006). Intimate partner victimization prior to and during pregnancy among women residing in 26 US states: Associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195, 140–148.
Berenson, A., Wiemann, C. M., Wilkinson, G. S., et al. (1994). Perinatal morbidity associated with violence experienced by pregnant women. American Journal of Obstetrics and Gynecology, 170, 1760–1769.
Coker, A., Fong, C., & Romans, M. (2004). Partner violence during pregnancy and risk of adverse pregnancy outcomes. Paediatric and Perinatal Epidemiology, 18, 260–269.
Rodrigues, T., Rocha, L., & Barros, H. (2008). Physical abuse during pregnancy and preterm delivery. American Journal of Obstetrics and Gynecology, 198(171), e1–e6.
Yost, N. P., Bloom, S. L., McIntire, D. D., et al. (2005). A prospective observational study of domestic violence during pregnancy. Obstetrics and Gynecology, 106, 61–65.
Webster, J., Chandler, J., & Battistutta, D. (1996). Pregnancy outcomes and health care use: Effects of abuse. American Journal of Obstetrics and Gynecology, 174, 760–767.
Berenson, A., Wiemann, C., Wilkinson, G., et al. (1994). Perinatal morbidity associated with violence experienced by pregnant women. American Journal of Obstetrics and Gynecology, 170(6), 1760–1769.
McFarlance, J., Campbell, J., Sharps, P., et al. (2002). Abuse during pregnancy and femicide: Urgent implications for women’s health. Obstetrics and Gynecology, 100(1), 27–36.
Rich-Edwards, J. W., & Grizzard, T. A. (2005). Psychosocial stress and neuroendocrine mechanisms in preterm delivery. American Journal of Obstetrics and Gynecology, 192, S30–S35.
Braveman, P., Cubbin, C., Marchi, K., et al. (2001). Measuring socioeconomic status/position in studies of racial/ethnic disparities: Maternal and infant health. Public Health Reports, 116, 449–463.
Sims, M., Sims, T. L., & Bruce, M. A. (2007). Urban poverty and infant mortality rate disparities. Journal of the National Medical Association, 99, 349–356.
Collins, W., & David, R. (1997). Urban violence and African-American pregnancy outcome: An ecologic study. Ethnicity and Disease, 7, 184–190.
Polednak, A. P. (1991). Black-white differences in infant mortality in 38 standard metropolitan statistical areas. American Journal of Public Health, 81, 1480–1482.
Pickett, K. E., Ahern, J. E., Selvin, S., et al. (2002). Neighborhood socioeconomic status, maternal race and preterm delivery: A case-control study. Annals of Epidemiology, 12, 410–418.
Schoendorf, K. C., Hogue, C. J. R., Kleinman, J. C., et al. (1992). Mortality among infants of black as compared with white college-educated parents. The New England Journal of Medicine, 326, 1522–1526.
McGrady, G. A., Sung, J. F. C., Rowley, D. L., et al. (1992). Preterm delivery and low birth weight among first-born infants of black and white college graduates. American Journal of Epidemiology, 136, 266–276.
New Jersey Department of Health and Senior Services (NJDOHSS). (1997). The blue ribbon panel report on black infant mortality reduction. Trenton,1–24.
Goza, F. W., Stockwell, E. G., & Balistreri, K. S. (2007). Racial differences in the relationship between infant mortality and socioeconomic status. Journal of Biosocial Science, 39, 517–529.
Gennaro, S. (2005). Overview of current state of research on pregnancy outcomes in minority populations. American Journal of Obstetrics and Gynecology, 192, S3–S10.
Kleinman, J. C., & Kessel, S. S. (1987). Racial differences in low birth weight: Trends and risks factors. The New England Journal of Medicine, 317, 749–753.
Alexander, G. R., Kogan, M. D., & Himes, J. H. (1999). Racial differences in birth weight for gestational age and infant mortality in extremely-low-risk US population. Paediatric and Perinatal Epidemiology, 13, 205–217.
Starfield, B., Shapiro, S., & Weiss, J. (1991). Race, family income and low birth weight. American Journal of Epidemiology, 134, 1167–1174.
Collins, J. W., & David, R. J. (1990). The different effect of traditional risk factors on infant birth weight among blacks and whites in Chicago. American Journal of Public Health, 80, 679–681.
Lee, R. E., & Cubbin, C. (2002). Neighborhood context and youth cardiovascular health behaviors. American Journal of Public Health, 92, 428–436.
Sexton, P. T., & Sexton, T. L. (2000). Excess coronary mortality among Australian men and women living outside the capital city statistical divisions. The Medical Journal of Australia, 172, 370–374.
Yen, I. H., & Syme, S. L. (1999). The social environment and health: A discussion of the epidemiologic literature. Annual Review of Public Health, 20, 287–308.
Gee, G. C., & Payne-Sturges, D. C. (2004). Environmental health disparities: A framework integrating psychosocial and environmental concepts. Environmental Health Perspectives, 112, 1645–1653.
Williams, D. R., & Collins, C. (2001). Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Reports, 116, 404–416.
Cubbin, C., Pickle, L. W., & Fingerhut, L. (2000). Social context and geographic patterns of homicide among US black and white males. American Journal of Public Health, 90, 579–587.
Geronimus, A. T., Bound, J., Waidmann, T. A., et al. (2001). Inequality in life expectancy, functional status, and active life expectancy across selected black and white populations in the United States. Demography, 38, 227–251.
Deaton, A., & Lubotsky, D. (2003). Mortality, inequality and race in American cities and states. Social Science and Medicine, 56, 1139–1153.
Culhane, J. F., & Elo, I. T. (2005). Neighborhood context and reproductive health. American Journal of Obstetrics and Gynecology, 192, S22–S29.
Bell, J. F., Zimmerman, F. J., Almgren, G. R., et al. (2006). Birth outcomes among urban African-American women: A multilevel analysis of the role of racial residential segregation. Social Science and Medicine, 63, 3030–3045.
Patrick, T. E., & Bryan, Y. (2005). Research strategies for optimizing pregnancy outcomes in minority populations. American Journal of Obstetrics and Gynecology, 192, S64–S70.
Farley, T. A., Mason, K., Rice, J., et al. (2006). The relationship between the neighbourhood environment and adverse birth outcomes. Paediatric and Perinatal Epidemiology, 20, 188–200.
Whitman, S., Silva, A., Shah, A., et al. (2004). Diversity and disparity: GIS and small-area analysis in six Chicago neighborhoods. Journal of Medical Systems, 28, 397–411.
O’Campo, P., Burke, J. G., Culhane, J., et al. (2008). Neighborhood deprivation and preterm birth among non-Hispanic Black and White women in eight geographic areas in the United States. American Journal of Epidemiology, 167, 155–163.
Papacek, E. M., Collins, J. W., Jr, Schulte, N. F., et al. (2002). Differing postneonatal mortality rates of African-American and white infants in Chicago: An ecologic study. Maternal and Child Health Journal, 6, 99–105.
Almond, D. V., Chay, K. Y., Greenstone, M. (2006). Civil rights, the war on poverty, and Black-White convergence in infant mortality in the rural south and Mississippi. MIT Department of economics working paper no. 07-04. Accessed on June 4, 2008 Available at SSRN. Available at http://ssrn.com/abstract=961021.
Shone, L. P., Dick, A. W., Klein, J. D., et al. (2005). Reduction in racial and ethnic disparities after enrollment in the state children’s health insurance program. Pediatrics, 115, e697–e705.
Smedley, B. D., Stith, A. Y., Nelson, A. R., eds. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care committee on understanding and eliminating racial and ethnic disparities in health care. Institute of Medicine.
Massey, D. S., & Denton, N. A. (1993). American apartheid: Segregation and the making of the underclass. Cambridge (MA): Harvard University Press.
Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Obstetrics and Gynecology, 90, 1212–1215.
Essed, P. (1991). Everyday racism. Claremont, CA: Hunter House.
Institute of Medicine. (2002). The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press.
David, R., & Collins, J. (2007). Disparities in infant mortality: What’s genetics got to do with it? American Journal of Obstetrics and Gynecology, 97(7), 1191–1197.
Hummer, R. A., Powers, D. A., Pullum, S. G., Gossman, G. L., & Frisbie, W. P. (2007). Paradox found (again): Infant mortality among the Mexican-origin population in the United States. Demography, 44(3), 441–457.
Buescher, P. A., & Mittal, M. (2006). Racial disparities in birth outcomes increase with maternal age: Recent data from North Carolina. North Carolina Medical Journal, 67, 16–20.
The study was funded by a grant from the Kellogg Foundation (Grant number: P0126278). The granting agency did not play any role in the study.
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Alio, A.P., Richman, A.R., Clayton, H.B. et al. An Ecological Approach to Understanding Black–White Disparities in Perinatal Mortality. Matern Child Health J 14, 557–566 (2010). https://doi.org/10.1007/s10995-009-0495-9