In Boston, a construction worker, ravaged by
burns, successfully underwent a total face transplant. In San Antonio, surgeons
have injected a glue-like substance that hardens and prevented the bursting of
a woman's brain aneurysm. And in my own institution, researchers have shown
that stem cells from a patient's own heart can help regenerate tissue and
repair damage caused by a heart attack.
Every day the headlines are filled with
breath-taking reports about the advances in American medicine. But even as it
leads the planet in medical and scientific accomplishments, the United States
also has some downright shameful disparities in its health care, and one of the
worst is in the area of infant mortality.
Every year about 30,000 babies in our nation,
a disproportionate number of them African Americans, die before reaching their
first birthday.
U.S.:
Laggards of industrial world
Last year, the infant mortality rate in the
United States was an estimated 6.06 deaths per 1,000 live births, just ahead of
Croatia, but lagging behind all of industrialized Europe and Asia.
For African Americans, the rate is worse. In
2007, the most recent year that a comparison is available, there were 13.3
deaths per 1,000 live births for African Americans, compared to 5.6 for whites.
Here, in California, public health officials
have campaigned to address infant mortality, an apparently successful and
commendable effort that has sent our rates to new lows with 4.9 deaths per
1,000 live births. Still, African Americans are plagued by a rate double that,
according to 2009 statistics.
African Americans nationwide also have a
stillbirth rate double that of whites. What's more, these unacceptable
disparities have persisted for a half century.
Research shows that women's and infants' health
are hugely affected by socioeconomic factors, such as family income, education,
a lack of access to adequate care and the environmental, physical and mental
conditions impacting both parents. Women who are obese or smoke, for example,
are more likely to experience issues that lead to delivery complications and an
unhealthy baby.
Still, these factors don't entirely explain
the persistent racial divide, as even African American women with graduate
degrees are more likely to lose a child in its first year than are white women
who did not finish high school.
Puzzling
the racial divide
To solve that part of the puzzle, researchers
are scrutinizing environmental concerns such as air quality, chronic stress,
genetics and even racism.
Among African Americans, as well as the
general population, preterm births (less than 37 weeks) and low birth-weight
(less than five pounds, six ounces) are leading causes of infant mortality. The
prevalence of preterm births in the United States is the chief reason we rank
so poorly compared to other wealthy countries. In Sweden, for instance, 6.3
percent of births were premature, compared with 12.4 percent in the United
States in 2005, the latest year for which international rankings are available.
In the past three years, overall preterm
births have declined in the United States. However, the number of preterm
births for African Americans babies has not. It remains substantially higher at
17.47 per 1,000 births.
The causes of preterm birth and low
birth-weight are vast and varied and some remain a mystery. The complexity and
interactions between them has made it a challenge to sort out what accounts for
the racial disparity. But one factor that we know plays a role is access to
prenatal care. African-American women are 2.3 times less likely than white
mothers to have seen a healthcare professional before their third trimester, or
to have received prenatal care at all.
The hurdles to prenatal care for some
African-American women may include their higher uninsured rates, their working
and living in areas with reduced access to medical facilities and their lesser
income and education. Some African-American women also have expressed fear
about mistreatment in the health care system.
To close the racial gap, quality health care
needs to be accessible to all and provide an approach that begins before
conception and follows the woman through her prenatal and post-delivery times
-- and beyond. Even the number of births and the length of intervals between
pregnancies can affect outcomes for babies and moms, so access to high quality,
knowledgeable care is very important.
Infant mortality related to congenital
anomalies is 38% higher in African Americans. Though the cause of most birth
defects is unknown, preventive measures (such as folic acid intake, access and
use of prenatal ultrasonography and chromosomal analysis) can help in some
cases to increase the chances that a woman delivers a healthy baby.
Care also must continue after delivery,
including screening for post-partum depression and education about
breastfeeding. In California, research recently showed that at 22 hospitals
more than 75% of mothers were supplementing their infants with formula at the
time of discharge. Many of these hospitals serve the poorest families.
The benefits of breastfeeding have been well
documented for years, [see my earlier post on this] yet nationwide, 65% of all
black infants were breast fed versus, 79% of white infants, according to a
2005-2006 study.
Once babies go home, follow-up care must be
part of the plan. SIDS, the unexplained sudden death of infants, has declined
by more than 50% since 1990 among the general population. But rates for
African-American infants remain 1.9 times higher than for whites.
Though the cause of SIDS is unknown, several
factors have been identified to decrease its risks. These include: putting infants
to sleep on their backs, getting them a firm mattress, removing from their
cribs the clutter of stuffed toys and loose bedding and keeping the room
temperature right and not overheating them with excessive blankets or clothes.
Preterm and low birth weight babies and those, whose mothers smoked during
pregnancy, are also at higher risk.
New research also suggests that the brains of
infants who die of SIDS produce low levels of serotonin, a brain chemical that
conveys messages between cells and plays a vital role in regulating breathing,
heart rate and sleep. Researchers theorize that this newly discovered serotonin
abnormality might reduce infants' capacity to respond to breathing challenges,
such as low oxygen levels or high levels of carbon dioxide. These high levels
may result from re-breathing exhaled carbon dioxide that accumulates in bedding
while sleeping face down.
Maryland and South Carolina have driven down
infant mortality rates at least 10% from 2008 to 2009 by relentlessly preaching
the basics of safe sleep and having nurses visit new mothers at home.
What
can be done
To close the racial gap, programs must address
all aspects of women's lives, especially those unique to African-American
women. In 2008, the Association of Maternal and Child Health Programs and the
National Healthy Start Association (NHSA), created the Partnership to Eliminate
Disparities in Infant Mortality to explore the effects of racism and other
disparities on infant mortality.
Recent research suggests, for example, that
African Americans who live in segregated neighborhoods, face racism, lack
paternal support and live near freeways and congested roads breathing unhealthy
air are likelier to have their babies prematurely, putting them at risk.
In a recent article, my colleague Calvin J.
Hobel, MD, an expert on the effects of stress on preterm birth, explains that
chronic stress, precipitated by such factors as poverty, living in a dangerous
neighborhood or racism, may trigger the release of a hormone called
corticotrophin-releasing hormone. CRH, produced by the brain and the placenta,
is closely tied to labor. It prompts the body to release chemicals called
prostaglandins, which help trigger uterine contractions.
Researchers hope to learn more about these and
other factors, including genetics, child rearing and exposure to chemicals,
through the National Children's Study, an ambitious undertaking in which
researchers are examining the lives of more than 100,000 children from before
birth to age 21. The Southern California coordinating center is at UCLA in
collaboration with Cedars-Sinai, The Charles R. Drew University of Medicine and
Science, the University of Southern California, the Los Angeles Department of
Public Health, the Research Triangle Institute, the Rand Corporation and
several Ventura County organizations.
To be sure, some programs already are targeted
to assist African-American mothers, such as Los Angeles' Black Infant Health
Program. It offers steps-in 10 sessions prenatally and 10 postpartum-designed
to empower and support women with crucial information and skills.
In Milwaukee, the Health Department and the
Nurse Family Partnership have joined forces so nurses visit at-risk women in
the poorest neighborhoods weekly during pregnancy and every other week for two
years after the baby is born. The healthcare pros offer suggestions for healthy
lifestyle changes, finding safer housing and coping with stress.
To slash infant mortality, of course, we in
the U.S. also must tackle teen pregnancy prevention programs, family planning,
full coverage of prenatal care and child health. We also need to step up our
efforts to get pregnant women to stop smoking and abusing drugs.
Since the sixties, the United States has
become a beacon for the world in seeking to eliminate inequality in its
society. Now we need to ensure that the inequities surrounding infant mortality
get fixed so we can be proud of not only our headline-grabbing, world-class,
scientific and medical advances but also the health of each and every American
newborn.
Glenn D. Braunstein, M.D.
HuffPost Los Angeles
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