By Karim Mikhail
Mortality.
For most, this word elicits the vision of old age, the slow withering-away that awaits us all. We find comfort in this thought; mortality lies at the opposing end of the life spectrum, its reach distant from us. But what if our conceptualization of mortality is backward?
Just as mortality fills our visions of the future, so too does it corrupt the very start of life: infancy. This burden, however, is unequally shared. In particular, African American communities have long suffered the brunt of infant mortality.
In 2018, for every 1,000 live births of Black babies, 10.75 died. Among white communities, the number rests at 4.63 per 1,000. Little has changed in these disparate statistics even after quite some time, and so the question naturally becomes why. Why do African Americans suffer disproportionate infant mortality, and why do we have no substantial progress to speak of? Dr. Colm Travers, a neonatologist at the University of Alabama at Birmingham, is one doctor who tries to fill in these gaps.
Dr. Travers came to UAB in 2014 to complete his fellowship in neonatal and perinatal medicine. He garnered a faculty position in 2019, and since then his practice has driven him to seek explanations for neonatal-perinatal disparities.
“The leading cause of infant mortality in African American communities in the United States is the preterm birth rate,” says Travers. “Specifically, the extreme preterm birth rate among African Americans.”
According to Travers, preterm birth refers to cases where babies are born too early, prior to the 37-week mark of pregnancy. Such cases are commonly fatal, as they disturb the normal growth and development that babies must undergo prior to birth. Without the final weeks needed for brain, lung and liver development, preterm infants are at a significantly higher risk of death and disability.
For Travers, preterm birth prevention emerges as a foremost objective.
“It’ll take a multifaceted approach,” says Travers. “Before conception, making sure that the mother has good health care and is in good health is essential.”
One recommendation he makes is prenatal vitamins, which he suggests all women of childbearing age should take regardless of their intentions to become pregnant.
High-quality health care must be available as early as the “first trimester, so that we [the health care team]can identify women at highest risk of adverse pregnancy, particularly to prevent preterm birth,” says Travers.
Finally, according to Travers, postpartum (after birth) care must be offered to “target causes of infant mortality that disproportionately affect the African American community, specifically SIDS.”
SIDS, or sudden infant death syndrome, refers to the unexpected death of a child less than 1 year old. SIDS is usually associated with sleep, requiring around-the-clock preventative efforts. These deaths, Travers adds, are especially pervasive in the Black community between 28 and 65 days after birth.
“The African American community is disproportionately represented among the babies in the NICU,” says Travers, reflecting on his own experiences in UAB’s Neonatal Intensive Care Unit. “It’s important to involve this community in our research efforts to identify targets for intervention — drawn right from the knowledge of the community.”
However, there are some questions that medicine alone can’t answer.
The heightened prenatal birth rate uncovers one layer of the multidimensional infant mortality puzzle, but it alone cannot guide preventative efforts. Dr. Grant Moody, a medical sociologist at UAB, is helping the research community understand the structures underlying the African American experience before, during and after pregnancy.
Originally trained at the University of Kentucky and a founding affiliate for its Center for Health Equity Transformation, Moody gradually became interested in studying racism as a social stressor and how it can impact the health of Black people overtime. Drawing on this background, he explains the social underpinnings of the disproportionate infant mortality rate.
“Having the knowledge and social network that an education affords for making right, healthy decisions,” he says, “and having resources like … healthy food, gas and insurance — all of that costs money.”
Moody also says that when it comes to racism’s reach, medicine is no exception.
“When you [a Black individual]go into a doctor’s office, you’re less likely to be treated by folks from your background. So they may not understand the cultural factors that contribute to your health.”
According to Moody, various studies have found that when people of color enter health care settings, their concerns are less likely to be listened to. Rather, these individuals are more likely to be talked down to — creating a patient-physician disconnect that exacerbates health disparities.
“They [people of color]are less likely to be treated as agents of their health outcomes. It can be pretty off-putting to people who come from a history of unethical research practices.”
Moody stresses that people of color unceasingly endure these racism-related stressors, which affects health outcomes. Devastatingly, preterm births are one way in which this disparity manifests.
“For Black women with higher levels of education and who make pretty good money, they still tend to have worse birth outcomes compared to their white women counterparts with far less education,” states Moody. “What we’ve been saying all along is that racism, as an added burden, plays a huge role.”
And we know this thanks to the research done on Black patients who find themselves in the hands of Black physicians.
A study published in the Proceedings of the National Academy of Sciences analyzed a data set of 1.8 million births in Florida between 1992 and 2015. The authors found that when the caring physician for Black babies was also Black, infant mortality for Black newborns relative to white newborns halved.
Dr. Moody believes that improving Black representation in medicine will be a critical step forward to ameliorating the issue of infant mortality — and one that will require structural change.
“As individuals, I think it’s great that we want to be better. But we’ve been talking about the same stuff for over a hundred years now,” Moody says. “If we want to see change, it’s the structures that have to change.”
