Challenging Dogma

...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

Reducing Infant Mortality Disparities: How Public Health Fails to Value Women’s Health Outside of Prenatal Care-Briane Accius

The infant mortality rate (IMR) in the country has been on the decline for over a decade, yet disparities persist when it comes to African Americans (1). The IMR includes all infant who died prior to the first birthday. The IMR is the leading indicator of a nation’s health, making this a problem in desperate need of resolution. The IMR disparity is an example of an area that needs further study to “eliminate health disparity in segments of the population,” according to the goals set forth in Healthy People 2010 (2). In 2000 the goal was to reduce the infant mortality rate to 7 per 1000 live births, which has now changed to 4.5 per 1000 live births in Healthy People 2010 (1, 2, 8). Progress has been made with the national average at 6.8 deaths per 1000 live births. However, the IMR for African American infants remains more than twice that of White infants (8). Public health has failed to value women’s health outside of prenatal care, making this intervention inadequate to resolve a complex problem as infant mortality rate disparities.

Historically, prenatal care has focus only on women’s health in regards to the life of her unborn child. According to the Maternal and Child Health Bureau timely, the movement to organize prenatal care began in Boston in 1909 as a mean to reduce the IMR (10). Women were expected to attend prenatal care visits throughout their pregnancy to promote a healthy birth outcome. New programs were later established to help in reducing the IMR disparity, but the focus remains on prenatal care. The March of Dimes (created in 1938 in response to polio epidemic) and Healthy Start (created in 1991) are two programs that are committed to reducing the IMR disparity. However, heavy reliance on prenatal care has failed to consider: 1) Maslow’s Hierarchy of Need for African American women, 2) Influence of lifetime social condition on birth outcome and 3) The relationship between the health care system and African American women.

Maslow’s Hierarchy of Needs and Prenatal Care

The reason for focusing public health efforts in prenatal to reduce IMR for almost a century is based on the premise that every expectant mother will behave ‘rationally’. A healthy baby is then contingent on a mother behaving ‘rationally’ by having the recommended prenatal care visits. However, human beings have a tendency to behave irrationally. There must be an explanation as to why providing services to women only during pregnancy does not have a significant impact on lowering the IMR. According to the Maslow’s Hierarchy of Needs, a person cannot become self-actualized if the basic physiological, safety, love/belonging needs are not met (3). A woman who is self-actualized has the ability to express ideas freely, resolve problems with an objective view of reality and independent of prejudice. This is only possible after the basic fundamental needs are met.

A woman lacking food, water and sleep for herself which are all basic physiological needs is nowhere near being self-actualized. As a result, attending a prenatal care visit may not be at the forefront of her thought. Prenatal care education provides information to women about negative and positive behaviors influencing birth outcome. Women are advised to avoid environmental stressors. For African American women, this task can prove to be difficult. African Americans have the lowest rate of ever been married (35 percent) and highest rate of never been married (39 percent) (11). A disproportionate number of African American women may fall into this category and thus lack the financial, emotional and physical support of a partner which are all necessary to be self-actualized. About half (48.34 percent) of African American children live in a household headed by a women. Compounded with poverty among African American women, these factors can lead to stress affecting physiological responses negatively. As a result, even after adequate prenatal care visits an African American woman has an increased risk of having a poor birth outcome. This can undermine her sense of autonomy and confidence when it comes to making choices important to a positive birth outcome. Anytime before or after the birth of the child, the woman returns to her invisible existence. If Maslow’s Hierarchy of Needs is applied effectively, prenatal care will be incorporated into initiatives equal emphasis on fulfilling basic physiological, safety, love and belonging, esteem and self-actualizing needs.

Fundamental Causes of Infant Mortality Disparity

Prenatal care does not address social conditions in the environment the women may reside. Health is affected and influence by numerous social factors which are not examined in the process. African American women are likely to experience racism, lack social support, and reside in neighborhoods without resources that are conducive to a healthy pregnancy (1, 5, 9, 11). This serves to further widen the gap in the IMR regardless of prenatal care visits. The experience of the African American women has been different in several aspects in society.

One area which gives further background into this issue is residential segregation. Residential segregation remains one of the contributing factors health disparities not addressed by public health. An example of inequality at is worst supported by our own government. The system is so enclave into this system that years after the Civil Rights Act of 1968 was signed making it illegal to discriminate in the sales or renting of housing, discrimination persist (5). Eliminating segregation would require 66% of blacks to move according to the index of dissimilarity which measures segregation. The IMR for African American infant is higher in cities that are highly segregated (9). The effect of residential segregation can be seen by the neighborhoods in the Boston area. Black communities usually contain more check cashing store, liquor store, and mini-convenient stores (charging higher for poor quality food) and are less likely to have a grocery store, employment opportunities. The lack of social capital and support makes a poor birth outcome inevitable given the circumstances. The Health of Boston 2007, recently released by the Boston Public Health Commission (BPHC), demonstrates this phenomenon with a report on the IMR for each of the 16 neighborhoods (12). In the report, the highest IMR were in Mattapan (12.3), Roxbury (10.6), South Dorchester (9.7) and Hyde Park (7.6) which are neighborhoods highly populated by African Americans and other minority groups. The lowest IMR were in South Boston (4.3), Back Bay, Charlestown and the North End which are neighborhoods mainly inhabited by Whites. (Some neighborhoods did not include an IMR because the number of infant deaths were too small to include in the final analysis (12)).

Lifetime Access to Health Care

African American women have a negative history in their relationship with the health care system. Concerning issues of access and quality to services rendered. In various levels in the health care system the disparities exist; from analgesic utilization, cardiac care, cancer to prenatal care advice (9, 11). Research has shown that the content of prenatal care differs when addressing African American women (4, 9). Advice concerning health behaviors for smoking and alcohol cessation during pregnancy is less likely to be given to African American women during prenatal care visits (9).

In a study conducted by van Ryn and Burke looking at physician’s perception of patients, blacks were rated as “less intelligent and educated than whites (9).” This remained significant after controlling for other factors such as SES, race and level of education. Stereotyping patients is detrimental to the reception of quality care by African American women as well as the health system relationship with the African American community. The population of health providers does not represent the proportion of the groups receiving health services (13, 14). Prevailing perception about patients resulting in a lack of adequate care by African American adversely affect current and future birth outcomes.

A holistic approach is necessary to help reduce the disparity in infant mortality. It is not enough to implement changes targeting behavior, a comprehensive initiative assessing all aspect of the individual’s life and experiences will result in a better birth outcome. The outcome will serve not only to improve health but empower individuals and having in place a system that one can be proud of and respect. A better dialogue will develop with more social capital reducing some of the mistrust that exists between the races that also contribute to disparities.

Lu and Halfon proposed the life-course perspective to addressing health disparities that combines two different existing models (6). This new combination of the early programming model and the cumulative pathways model encompass the entire life irrespective of pregnancy. The early programming model describes the experiences of a developing fetus during critical periods, after conception, that have negative health manifestation later in life. This may result at anytime during an individual’s lifetime. The cumulative pathways model, however, describes poor health outcomes resulting from “wear and tear” of the body. As a result, the life-course perspective includes life in uterus, childhood, adolescence, preconception, prenatal, postpartum care until death.

This model is fitting for reducing the excess infant mortality experienced by African American women. Thus far, public health interventions targeting only time frame prior, during or postpartum have failed to show promising result. The profession should embrace this new model, even if with skepticism. The result of innovation is unknown until after it is put to the test. Besides, this new approach does not call for the abandonment of current initiatives like prenatal or preconception care, only for continuity of care.


Prenatal care serving as the catalyst to reduce infant mortality disparities continue to fail and will prevail if public health does not take the necessary measures to change the approach. As indicated by Maslow’s Hierarchy of Needs, the African American women health is affected by other experiences during her lifetime that can negatively affect birth outcome. Prenatal care only addresses the health care needs without accounting for physiological, safety, esteem and self-actualizing needs which exist throughout the life course.

Social conditions such as racism, discrimination and segregation are overarching in daily life. The impact of residential segregation is alive and well today, explained by the disparity in the IMR by neighborhoods based on racial/ethnic distribution (12). The lack of social capital and the burden of poverty and environmental hazards in those neighborhoods contribute to the inability of prenatal care to resolve the problem.

The need for new and better research and policy is what drives this profession known as public health to effectively serve its community. Certainly a woman has the possible of becoming self-actualized, as described in Maslow’s Hierarchy of Needs. The need for food, water, shelter, safety, love and self-esteem are all within the life-course perspective. “The death of any infant is always a tragedy. But the death of an infant from preventable causes is always unjust” (7).

There will be those who oppose the change toward a new direction. Policy changes must occur and funding which is an important aspect for continuity of care in any health care system must be provided. The investment is for a life time because every infant life is important to the health of society.


1.Crum, L., Hogan, V., Chapple, T., Browne, D and Greene, J. Disparities in Maternal and Child Health in the United States, in Kotch JB. Maternal and Child Health: Programs, Problems, and Policy in Public Health. Boston: Jones and Bartlett Publishers, 2005, pp.299-346.

2.U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

3.Wikipedia. Maslow's Hierarchy of Needs. Retrieved March 1, 2007.'s_hierarchy_of_needs.

4.Kogan, M.D., Kotelchuck, M., Alexander, G.R. and Johnson, W.E. Racial disparities in reported prenatal care advise from health care providers. American Journal of Public Health, 1994; 84: 82-88.

5.Williams, R.D. and Collins, C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports, 2001; 116: 404-416.

6.Lu, M.C. and Halfon, N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Maternal and Child Health J, 2003; 7: 397-414.

7.Wise, P.H. The anatomy of disparity in infant mortality. Annual Review of Public Health, 2003; 24:341-362.

7.Centers for Disease Control and Prevention. Racial/Ethnic Disparities in Infant Mortality -- United States, 1995--2002. MMWR, 2005; 54(22); 553-556.

8.LaVeist, T.A. Race, Ethnicity, and Health: A Public Health Reader. San Francisco, CA: Jossey-Bass, 2002.

9. Maternal and Child Health Bureau. MCH Timeline: History, Legacy and Resources for Education and Practice. Washington, DC: HRSA, DHHS.

10.LaVeist, T.A. Minority Population and Health: An Introduction to Health Disparities in the United States. San Francisco, CA: Jossey-Bass, 2005.

11.Boston Public Health Commission. The Health of Boston, 2007. Boston, MA: Research Office, 2007.

12.Frist, W.H. Overcoming Disparities in U.S. Health Care. Health Affairs, 2005;24(2); 445-451.

13.Kennedy, E.M. The Role of the Federal Government in Eliminating Health Disparity. Health Affairs, 2005;24(2); 451-458.

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